Drug utilization review 1

Pharmacoepidemiology
Drug utilization review
Presented to: dr.Hina Raza
Presented
by:
Kaynat
Fatima
101-M-16
3rd proff
(morning)

DUR is an ongoing, systematic
process designed to maintain the
appropriate and effective use of
medications. It involves comprehensive
review of patient’s medication and
health history in following three steps:
Before dispensing
During dispensing
After dispensing
Drug utilization review

Continued…..
 Pharmacists participating in DUR programs can directly
improve the quality of care for patients, individually and as
population, by striving to prevent the use of unnecessary or
inappropriate drug therapy, prevent adverse drug reactions
and improve overall drug effectiveness.
 DUR allows the Pharmacist to document and evaluate the
benefit of pharmacy intervention in improving therapeutic
and economic outcomes.
 DUR programs play a key role in helping managed health
care systems.

IMPORTANCE
 Understand, interpret , evaluate and improve the
prescribing, administration and use of medications.
 Pharmacist play a key role in this process because of
their expertise in area of medication therapy
management.
 DUR affords managed care Pharmacists the
opportunity to identify trends in prescribing in
patients with asthma, diabetes or high blood
pressure, or by drug specific criteria.

CLASSIFICATION OF DUR
Prospective DUR
Concurrent DUR
Retrospective DUR

PROSPECTIVE DUR
 Prospective review involves evaluating a patient’s
planned drug therapy before a medication is
dispensed.
 This process allows the pharmacist to identify and
resolve problems before the patient has received the
medication.
 Prospective DUR often relies on computerized
algorithms to perform key checks including drug
interactions, duplication or contraindications with
patient’s disease state or condition.

ISSUES ADRESSED BY
PROSPECTIVE DUR
• Clinical abuse/misuse
• Drug-disease contraindications
• Drug dosage modification
• Drug-drug interactions
• Drug-Patient Precautions
• Formulary substitutions
• Inappropriate duration of drug treatment
EXAMPLE:-
A patient being treated with warfarin to prevent blood clot if prescribed
new drug used to treat arthritis then patient may complains of internal
bleeding. Upon reviewing the prescription, the pharmacist would note
possible drug interaction before dispensing and contact the prescriber to
alert him/her about the problem.

CONCURRENT DUR
 Concurrent DUR is performed during the course of treatment
and involves the ongoing monitoring of drug therapy to foster
positive patient outcomes.
 It presents pharmacists with opportunity to alert prescribers
about potential problems and intervene in areas such as drug-
drug interactions, duplicate therapy, over or underutilization
and excessive or insufficient dosing.
 An important component of DUR will require complete and
current drug and allergy records of patient.

ISSUES COMMONLY
ADDRESSED BY
CONCURRENT DUR
• Drug-disease interactions
• Drug dosage modifications
• Drug-patient precautions
• Over and underutilization
• Therapeutic Interchange
Example:-
Concurrent DUR often occurs in institutional settings, where patients
often receive multiple medications. Periodic review of patients records
can detect actual or potential drug-drug interactions or duplicate
therapy. It can also alert pharmacist to need for change of medications,
such as antibiotics, or need for dosage adjustment based on laboratory
test results.

RETROSPECTIVE DUR
 A retrospective DUR reviews drug therapy after the
patient has received the medication.
 A retrospective review aims to detect patterns in
prescribing, dispensing or administering drugs.
 Based on current patterns of medication use,
prospective standards and target interventions can be
developed to prevent recurrence of inappropriate
medication use or abuse.
 Outcomes of this review may aid prescribers in
improving care for their patients, either individually
or within certain target population.

ISSUES COMMONLY
ADDRESSED BY
RETROSPECTIVE DUR
• Clinical abuse/misuse
• Drug-disease contraindications
• Appropriate generic use
• Inappropriate duration of treatment
• Incorrect drug dosage
• Use of formulary medications whenever appropriate
• Over and underutilization
• Therapeutic appropriateness/duplication
.

Example:-
An example of retrospective DUR may
be the identification of a group of patients
whose therapy does not meet approved
guidelines. For example, a pharmacist
may identify a group of patients with
asthma, who according to their medical
and pharmacy history, should be using
orally inhaled steroids. Using this
information, the pharmacist can then
encourage prescribers to utilize the

COMPONENTS OF DRUG USE
FOR DUR CRITERIA
• Uses: appropriate indication for drug, absence of
contraindications
• Selection: appropriate drug for clinical condition
• Dosing: indication-specific dosing, interval and
duration of treatment
• Interactions: absence of interactions-drug- drug,
drug-food, drug laboratory
• Preparation: steps involved with preparing a drug
for administration

Continued…….
• Administration: steps involved in administration,
quantity dispensed
• Patient education: drug and disease –specific
instructions given to patient
• Monitoring: clinical and laboratory
• Outcome: decreased blood pressure, blood glucose,
asthma

STEPS IN ESTABLISHING A BASIC HOSPITAL
DUR PROGRAM(PHASE 1-PLANNING)
STEP1
Form the DUR
committee
STEP 2
Write policies and
procedures
STEP 3
Define all areas of
hospitals where
drugs are used
STEP 4
Identify drugs
for possible
inclusion in the
program
STEP 5
Assess resources
available for
criteria
development
STEP 6
For each drug
select aspect
(indication, dosing
, dosage etc)
STEP 7
Select criteria and
establish
performance
threshold
STEP 8
Establish
methodology for
data collection,
evaluation and
create a schedule
STEP 9
Educate hospital
staff about DUR
program and
current criteria

PHASE 2: DATA COLLECTION AND
EVALUATION
STEP 10
Collect Data
STEP 11
Evaluate data and determine if drug use problem
exist

PHASE 3: INTERVENTION
STEP 12
Disseminate
results to
hospital staff
STEP 15
Disseminate
results of re-
evaluation
STEP 13
If a drug use
problem is
found , design
and implement
interventions
STEP 14
Collect new data
on problem drug
to determine if
drug use has
improved as a
result of
intervention

PHASE 4: PROGRAM
EVALUATION
STEP 16
Evaluate all DUR program
activities at end of evaluation
year, and plan program
activities for the next year.

PHASE 1: PLANNING
STEP 1: Form the DUR committee
 In a hospital setting, the body responsible for planning and
implementing a drug utilization review program is the DUR
committee.
 Regardless of the structure, the body responsible for DUR
should be compose of professionals with an interest in
improving drug therapy in hospital and have ready access to
experts in medicines,sugery and all major hospital
specialties
 The most critical task of DUR committee is development or
selection of criteria that will serve as basis for monitoring,
evaluation and interventions .
 The committee is responsible for initial establishment of
DUR policies and procedures, and planning and
implementing all DUR activities.

Continued……
STEP 2: Write policies and procedures
 Prior to monitoring and evaluation, the committee should draft and
approve the policies and procedures that will govern its work.
 Inclusion of a clear statement of goals and major activities of committee
are important.
 Below are key elements recommended for inclusion in DUR policies and
procedures.
• Designation as a “ program’’
• Mission statement
• Committee makeup
• Frequency of meeting
• Program cycle ( Planning, Data collection and evaluation,
interventions, program evaluation)

Continued………
STEP 3: Define all areas or department where
medicines are used
 As a starting point in designing a comprehensive DUR
program, the committee should identify all areas or
departments of the hospital where drugs are used(e.g.
emergency room,ICU, radiology, surgical department and
medical department)
 Some departments such as medicine, surgery and
Pediatrics, will be involved in DUR program in every cycle .
 Other department, such as radiology , where drug use is not
extensive, may be included only every three or four years.

Continued………..
STEP 4: Identify drugs for possible inclusion program
 The DUR committee must define priority drugs, where
improvement in use will result in the greatest clinical and
economic impact. These can be drugs with the following
characteristics:-
• High cost, high volume, clinically important drugs(identified
and selected by performing ABC/VEN analyses or reviewing
procurement documents);
• Used in high-risk patients(elderly, Intensive care,pedriatics)
• Significant side effects, narrow therapeutic index
• Used in most common diagnoses
• Under consideration for formulary addition
• Recently added to formulary

Continued….
STEP 5: Assess resources available for criteria development,
data collection, and evaluation, and choose drugs to be
included in program
 The final plan will ultimately be determined by criteria
development, data collection and evaluation.
 The committee may develop criteria itself, utilize hospital
specialists and clinical staff, or used established criteria from
unbiased drug reference literature.
 Data collectors should be chosen carefully, and should be
familiar with how information is arranged in patient’s
history, since data are often collected from case history.

Continued……….
STEP 6: For each drug, Select aspects(Indications,
Dosing ,Dosage form chosen etc)of Drug use to
Monitor and Evaluate
 It is impossible to monitor and evaluate all drugs
used in hospital. It is impossible to address all
aspects of use for each drug finally selected.
 The main aspects of drug use to consider are listed
below:
• Indications
• Contraindications
• Side effects/adverse effects
• Management of overdose
• Dosing
• Duplicate Therapy

Continued…….
• Preparation
• Administration
• Drug-drug and drug food interactions
• Monitoring/laboratory tests
• Patient education/instructions
• Anticipated results of therapy
• Cost of course of therapy
For example, a committee may have selected ceftazidime,
heparin, and salbutamol for evaluation.

Continued……….
STEP 7: Select criteria and establish performance
threshold
 A hospital DUR committee may use one or more of the
following methods to develop criteria for its program:
• Use existing criteria sets, such as Standard Treatment
Guidelines, WHO guidelines for treatment of common
diseases, or American Society of Health System Pharmacists
criteria for drug use evaluation.
• Adapt existing criteria sets according to needs of hospital
• Select its own criteria, based on hospital -developed standard
treatment guideline.
• Below is an example of how a hospital may select criteria for
NSAIDS.In hospital, arthritic and inflammatory rheumatic
conditions are amongst the most common diagnosis and
many of its patients are on chronic therapy.ABC analysis
revealed that the following drugs comprised 15% of the total
drug budget:

Continued………….
 Acetylsalicylic acid
 Diclofenac
 Flurbiprofen
 Ibuprofen
 Naproxen
 Piroxicam
 The medical staff knows that improper prescription of
drugs in this class can lead to complications. As it’s
impossible to evaluate all aspects of drug use, the
committee limited criteria to contraindications and
interactions.
 The committee did not have access to existing criteria sets
and developed the following criteria based on scientific
literature available in hospital and experience of chief
rheumatologist.

Continued…………
• Contraindications: chronic renal insufficiency,
hypersensitivity to acetylsalicylic acid and NSAIDs,ulcer and
erosive gastrointestinal disease ,CHF, pregnancy etc
STEP 8: Establish Methodology for data collection,
Evaluation and create a schedule
 Before the actual monitoring and evaluation of drug begins
,the DUR committee must establish methodology for data
collection including:-
• Data elements(prescriber name, prescriber specialty, drug
name, drug dose, amount prescribed, duration of therapy)
• Data source(patient history, laboratory records, pharmacy
records)
• Forms designed to organize the data for final analysis
• Person responsible for collecting, organizing and reporting
the data
• Sample size

Continued……….
STEP 9:Educate hospital staff about DUR program and current
criteria
 Prior to data collection in first program cycle, it is important to
educate the medical and pharmacy staff about objectives of DUR
program, and build support for program.
 Physicians/Pharmacists education may best be accomplished by
disseminating all or part of DUR program’s policies and
procedures.
 Before subsequent DUR cycles, distribution of monitoring
schedule and criteria may be sufficient but the medical staff
should always be informed about changes in DUR policies and
procedures.

PHASE 2: DATA COLLECTION AND
EVALUATION
STEP 10: Collect Data
 The method of data collection will vary greatly with
approaches(prospective, concurrent or retrospective).In all
cases, forms will be necessary for documenting files.
• Prospective DUR:-
In prospective DUR, “data collection” usually requires a
review of physicians orders and comparison to criteria prior
to administration of the drug. How this is accomplished, or if
it is even feasible, will vary greatly between hospitals.
• Concurrent DUR:-
• Concurrent DUR data collection is similar to prospective in
that it may be done in the pharmacy, or on the wards.

It differs from prospective in that the data collection does not
have to occur prior to administration of a first dose. This
method of data collection is most suitable when staffing
permits a daily review of case histories.
• Retrospective DUR:-
Retrospective DUR presents the fewest problems with data
collection, and therefore is often the method of choice in new
programs. Since almost all required data elements are
contained in case histories, data collectors typically work in
cooperation with the medical records department.

STEP 11: Evaluate data and determine if drug
use problems exist
 Data evaluation is one of the critical steps in a DUR program.
 Conclusions drawn from data analysis could result in changes
in hospital policies, formulary additions or deletions,
prescribing restrictions, and counseling of hospital staff.
 Whenever feasible , a DUR committee member should
review the data collection forms for completeness , verify
questionable data with case history , or other hospital records.
 If threshold set at 100%is met(indicating complete
compliance with criteria) , it is usually sufficient to simply
report the results of DUR committee.

Continued…….
 If a threshold set at less than 100%(e.g.95%) is not actually
exceeded(e.g.98%) , the DUR committee should decide if it
is necessary to review those cases that were met in
compliance with criteria.
 The main purpose of any such review is to determine if
there was a justifiable reason for non-compliance.
 In this case, they may decide to change the criteria prior to
re-evaluation of drug.
 If non-compliance is determined to be justified, a
recalculation of threshold percentage should be done.

PHASE 3: INTERVENTION
STEP 12: Disseminate results to hospital staff
 As DUR data analyses are completed, the results should be
reported to physicians and other relevant staff such as
pharmacists and nurses. Results can be disseminated using
any of the following mechanisms.
• Weekly prescribers conference
• Dissemination of written DUR committee meeting minutes
• Newsletter
• Ad hoc meetings
• Posting results in meeting places such as nurses station on
each ward

Continued……..
STEP 13: If a drug use problem is found,
design and implement interventions
 Interventions can be educational or operational, and can
target groups, or only those individuals whose performance
was not in compliance with drug use criteria.
Choose one or more interventions that will
result in improved drug use
a. Educational interventions can include the following:
• In –service /continuing education program
• Informal and formal counseling
• Letters to the physicians

Continued………
b. Operational intervention can include:
• Development of drug order forms
• Changes in hospital policies and procedures
• Formulary additions and deletions
• Prescribing restrictions
• Implementing or revising standard treatment guidelines
• Purchasing new equipment
• Staffing changes

Continued…….
STEP 14: Collect data on problem drug to
determine if drug use has improved as a result
of intervention
 Monitor physician prescribing to determine effectiveness of
interventions.
 The re-evaluation is done six to twelve months after the
intervention was put in place, and should involve collecting
the same data as in original DUR evaluation.
 If a comprehensive evaluation with multiple criteria revealed
a small number of problems, the committee may decide to
narrow the focus of the re-evaluation to problematic criteria.

Continued……….
STEP 15: Disseminate results of re-evaluation
 Disseminate results of the re-evaluation DUR to medical
staff as per Step 12.

PHASE 4: PROGRAM
EVALUATION
STEP 16: Evaluate all DUR program activities at the
end of evaluation year and plan Program activities
for the next year
 At the end of evaluation cycle, the DUR committee should
perform an evaluation of the DUR program, and if necessary
make policy and procedural changes to reflect actual
practices, or to facilitate desired changes. Other
considerations when evaluating the program are:
• Were appropriate drug chosen for inclusion?
• Were important aspects of care addressed by the program?
• Were criteria developed according to hospital policy?
• Were threshold appropriate?
• Were problems identified ?

• Were interventions appropriate?
• Were drug use problems solved/did drug therapy improve?
• Did DUR have an impact on incidence of adverse drug
reactions, drug-drug interactions, or medication
administration errors?
• Were results disseminated according to policy?
• Did the DUR program have financial impact on hospital?

ESTABLISHED DUR CRITERIA ON
DATA COLLECTION FOR AMIKACIN

REFERENCES
• WHO Essential Medicines And Health Products
Information Portal
• Drugs And Therapeutics Committees – A Practical
Guide
• ASHP Guidelines On Medication-Use Evaluation
• Guidelines For Implementing Drug Utilization Review
Programs In Hospitals

Drug utilization review 1

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