Drug Utilization Review & Drug Utilization Evaluation: An Overview

1. Drug Utilization Review & Drug Utilization Evaluation:An Overview Presentation Developed for theAcademy of Managed Care Pharmacy Updated: February 2016

2. Learning Objectives Differentiate between the terms Drug Utilization Review (DUR) and Drug Utilization Evaluation (DUE) Explain the role of a pharmacist in a DUR program Provide an example for each of the three types of DUR’s: prospective, concurrent, and retrospective Describe the key stakeholders vested in a successful DUR/DUE program

3. Definition of DUR and DUE Drug Utilization Review (DUR): An authorized, structured, ongoing review of health care provider prescribing, pharmacist dispensing, and patient use of medication. Drug Utilization Evaluation (DUE): A qualitative evaluation of drug use, prescribing, and member fill patterns to determine the appropriateness of drug therapy. AMCP. Glossary of Managed Care Terms. http://www.amcp.org/ManagedCareTerms/

4. Goals of DUR and DUE Improve quality of care and overall drug effectiveness Prevent adverse drug reactions Encourage the practice of evidence-based, clinically appropriate, cost-effective drug use Reduce drug misuse and abuse Reduce costs related to inappropriate drug use

5. Pharmacist Role in DUR & DUE Identifies opportunities for quality improvement Participates in efforts to improve: Patient outcomes Quality of programs Promotes appropriate drug use to reduce overall health care costs and improve access to care Carries out ethical and professional responsibility

6. A Model DUR Program Access to member drug utilization data Qualified pharmacists with authority to review Knowledge of population served and delivery system Availability of established standards for comparison Measurement of utilization review outcomes

7. Prospective DUR A screening method by which a health care provider reviews the necessity of drug therapy beforeit is dispensed or administered Electronic DUE programs at retail pharmacies Prior authorization (PA) programs Drug-drug and drug-disease interactions Dosing appropriateness Drug-patient precautions (due to age, allergies, gender, pregnancy, etc.) Medication directions Formulary substitutions (e.g., therapeutic interchange, generic substitution) Inappropriate duration of drug treatment AMCP. Glossary of Managed Care Terms. http://www.amcp.org/ManagedCareTerms/

8. Concurrent DUR • A screening method by which a health care provider reviews the necessity of drug therapy at the timeof dispensing or during treatment • Case management • Review of patient records • Research projects that follow patients in randomized, controlled trials • Real-time system edits at the point of service • Over or underutilization of medication • Excessive or insufficient dosing • Drug-drug interactions • Drug-disease interactions • Drug dosage modifications AMCP. Glossary of Managed Care Terms. http://www.amcp.org/ManagedCareTerms/

9. Retrospective DUR A screening method by which a health care provider reviews the necessity of drug therapy afterit has been dispensed or treatment has started Review of medical charts, electronic medical records and/or claims data to assess appropriate drug use Review provider prescribing patterns Quality assurance analyses Developing standard guidelines to achieve target outcomes at a population level Appropriate generic use Use of formulary medications whenever appropriate Therapeutic appropriateness and/or duplication AMCP. Glossary of Managed Care Terms. http://www.amcp.org/ManagedCareTerms/

10. The DUR Process Determine criteria The criteria should focus on relevant outcomes within a delineated scope for DUR and identify the relevant drugs to be monitored for optimal use Collect data Measure the actual use of medications Compare the data to established criteria Involves applying the algorithm, identifying members who meet the DUR criteria and the comparison between optimal or appropriate and actual use Perform intervention Action should be targeted to areas of concern such as prescribing patterns, medication misadventures, and quality of drug therapy or economic consideration.

11. The DUR Process Analyze results Evaluate the outcomes and document reasons for positive and negative results Document DUR Report the findings to the appropriate team within the organization (e.g., the pharmacy & therapeutics committee) and/or individual prescribers when appropriate Re-evaluate the program (on-going)

12. Who Benefits from DUE/DUR? Accrediting bodies/Government National Committee for Quality Assurance Joint Commission on Accreditation of Healthcare Organizations Omnibus Budget Reconciliation Act 1990 Plan member Health care provider Pharmacist Health care system

13. Example "This asthma is really slowing me down.  This prescription isn't helping much." Example Scenario: Tim's asthma is not well controlled, and he uses his inhaler multiple times a day.  Tim's therapy should most likely be increased to prevent further medical complications. Pharmacist Interaction: A pharmacist conducted concurrent DUR at the health plan and noticed that Tim was only prescribed an as-needed inhaler.  With the pharmacist's recommendation to the prescriber, derived from evidence-based guidelines, Tim was prescribed a maintenance asthma medication. Benefit: Although another medication was added, the patient and the health plan have an overall cost savings.  The added prescription vastly decreases Tim's likelihood of a costly emergency room visit for a severe asthma attack and enhances Tim's quality of life.

14. Conclusion A pharmacist performs DUR/DUE to improve overall access and quality of care, and to reduce costs Each type of DUR represents an important step in ensuring that the member receives the most appropriate, cost-effective medication A successful DUR/DUE program benefits all health care players, including the member

15. Thank you to AMCP member Alvah Stahlnecker for updating this presentation for 2016.