Definition/Introduction

Drug Utilization Review (DUR) is an ongoing, systematic quality-improvement activity constructed to ensure the effective and appropriate use of medicines. It can also be considered a formulary system management technique. It comprises a comprehensive review of a patient's health and medication history before, during, and after dispensing medicines to optimize patient outcomes. As a result, it provides quality assurance, prescriber feedback, corrective action, and additional evaluations. Hence, DURs performed by pharmacists improve the quality of patient care, enhance therapeutic outcomes, prevent adverse drug reactions, and reduce inappropriate pharmaceutical expenditures, reducing overall healthcare costs.[1]

Although distinctions have been made among the terms drug-use evaluation, drug-use review (DUR), and medication use evaluation (MUE), they all refer to the systematic evaluation of medication use employing standard, observational quality-improvement methods. The Centers for Medicare & Medicaid Services (CMS) promotes the term DUR for the Medicare Part D prescription drug benefits.[2] The Academy of Managed Care Pharmacy refers to DUR as the most common designation for the retrospective, concurrent, or prospective medication review process in the healthcare marketplace. The American Society of Health-System Pharmacists (ASHP) currently utilizes the nomenclature of medication use evaluation (MUE).[3]

MUE encompasses the goals and objectives of drug use evaluation (DUE) in its broadest application, emphasizing improving patient outcomes. MUE, rather than DUE, emphasizes the need for a more multifaceted approach to improving medication use. However, MUE has a common goal with the pharmaceutical care it supports: to improve the quality of life of an individual patient by achieving predefined, medication-related therapeutic outcomes. Through its focus on the medication use system, the MUE process helps to identify actual and potential medication-related problems, resolve actual medication-related problems, and prevent potential medication-related problems that could interfere with achieving optimum outcomes from medication therapy.

MUEs and DURs fall into three categories: prospective, concurrent, and retrospective. In a prospective review, evaluating a therapeutic intervention is planned and takes place before the medication is dispensed.[1] In a concurrent review, the review is ongoing, and drug therapy is monitored during treatment. Finally, in a retrospective MUE, the evaluation and review of the therapy occur after the patient has received the medication.[4]

DUR is a performance improvement method that evaluates and improves medication-use processes to optimize patient outcomes. Specific elements addressed in each medication use evaluation are:

• Define the purpose, focus, and priorities
• Develop the usage criteria to be evaluated
• Collect the usage data; review and evaluate the data collected
• Develop and implement actions to improve medication usage
• Assess the actions that were implemented
• Document the results
• Report the results to other healthcare professionals.

The success of each medication usage evaluation should be reviewed within a specific timeframe, whether it be three months, six months, or a year.[5][6] Pharmacists routinely perform prospective DUR by evaluating the dose, directions, and duration of a prescription medication therapy while reviewing patient health records for possible prescription duplication or adverse drug reactions. Computerized algorithm-generated alerts support addressing key contraindications with the patient's disease state or condition, drug interactions, and therapeutic duplications.

Drug dose adjustments, inappropriate duration of drug treatment, therapeutic interchange, or generic substitution are often addressed during prospective DURs. Other important issues addressed include identifying misuse, abuse, drug-drug interactions, drug-disease contraindications, and drug-patient precautions (specific patient population of age, allergies, pregnancy status, etc.)[7] Concurrent DUR identifies over and underutilization of medicines.

Issues commonly addressed by retrospective DUR include appropriate generic medicine use, use of formulary medications whenever appropriate, inappropriate duration of treatment, incorrect drug dosage, clinical misuse or abuse, drug-disease contraindications, drug-drug interactions, over and underutilization, therapeutic appropriateness, and duplication.

Steps in the DUR Process

1. Identification of Optimal Use: The established criteria define the optimal use of drugs, which focus on relevant patient health outcomes and are in scope for DUR. Medicine use is monitored for optimal use in advance.
2. Measurement of Actual Use: The precise use of medications can be acquired from medical, prescription, or electronic health records.[8]
3. Assessment: This step involves using a computerized algorithm, identifying members who meet the DUR criteria, and comparing optimal and actual use. It helps identify and evaluate discrepancies and, if appropriate, intervene.
4. Intervention: This corrective action is implemented if any targeted areas of concern are identified in the previous steps, i.e., economic considerations, prescribing patterns, and adverse drug reactions.[9]
5. Evaluate the DUR Program: Evaluation of the effectiveness of the DUR program is performed to evaluate the outcomes and document reasons. Appropriate alteration to the DUR program and persistent surveillance should be conducted.
6. Report the DUR Findings: This is the final step; reporting the results to the pharmacy and therapeutics committee and clinician when appropriate.

Issues of Concern

A recent study examined the perception of drug utilization review (DUR) in 742 physicians from different specialties. The study indicated that DUR impacts treatment decisions by physicians and results in additional resource use by patients. Additionally, the survey suggested that the DUR policy may misalign with clinical practice guidelines. Further studies are required to address queries raised by this survey. [10]

MUE can be simply informative, such as collecting data to guide decision-making or measuring the effect of interventions, such as adding a new agent to the formulary or implementing a new medication use policy. MUE activities can focus on any dimension of the medication-use process (from medication acquisition to patient monitoring), presenting an opportunity for improvement. While MUE often focuses on problem-prone, high-risk, or high-cost medications, MUE can be used to examine any aspect of medication use that is problematic to the institution conducting the evaluation.  

A systematic plan to monitor, evaluate, and improve medication use should be established within the organization. Such a plan is an accreditation requirement for many organizations, such as the Joint Commission. MUE should be a part of the overall quality-improvement program of the organization. MUE activities should be conducted to examine the effect of medication use policy decisions, particularly those made without convincing evidence from the biomedical literature. Still, they can also be undertaken to inform decision-making, particularly when making policy decisions under conditions of uncertainty. Specific projects to evaluate medication use can involve assessing how an individual medication is used or evaluating medication management of a given disease state. All steps of the medication-use process should be assessed over time. The Pharmacy and Therapeutics Committee, or its equivalent, should be involved in the MUE process.

Many government agencies, including CMS and NCQA, mandate that DUR be performed to ensure appropriate drug therapy. In the community pharmacy setting, DUR is mandated by Federal Law (OBRA-90) for those patients receiving drugs through Medicaid. A review for preventable problems (pro-DUR) is a required component of this process. In addition, there are federal mandates for resources to be used in creating the criteria. In this setting, the state agency administering Medicaid is also mandated to perform the quality review discussed above, called retro-DUR. DUR programs play a key role in helping managed healthcare systems understand, interpret, and improve medication prescribing, administration, and use.

Employers and health plans find DUR programs valuable because the results foster more efficient use of scarce health care resources. Pharmacists play a key role in this process because of their expertise in pharmaceutical care. DURs allow the managed care pharmacist to identify trends in prescribing within groups of patients, such as those with asthma, diabetes, hypertension, or depression.[11] Collaborating with other healthcare team members, pharmacists can initiate action to improve drug therapy for individual patients and covered populations.[2][1]

The specific process addressed in medication use evaluation is based on the FOCUS-PDCA model as per ASHP.[3] Steps in this method include:

• Find the process which requires improvement.
• Organize the healthcare team that comprehends the process.
• Clarify current knowledge with team members.
• Understand the causes of process deviation.
• Select process improvement.
• Plan and design a solution.
• Do execute improvements.
• Check and assess the results.
• Act on the modifications required and implement the changes.

Clinical Significance

DUR programs play an important role in serving healthcare systems to understand the prescribing, administration, and drug utilization process. Employers and health care plans have found DUR programs valuable and used the results to foster efficient use of health care resources.

Pharmacists performing DUR play an important role in this process, as their main expertise is medication therapy management. The pharmacist uses the DUR to evaluate prescribing trends of clinicians within a specific patient population by medicine-specific criteria or disease state (i.e., hypertension, asthma, diabetes, depression).[11][12] In collaboration with prescribers, pharmacists can initiate actions to optimize drug therapy for patients.

Concurrent evaluation, collecting data during care delivery and sometimes as a component of the care process, is usually preferred over retrospective methods. Concurrent evaluation allows organizations to select relevant outcomes for collection rather than rely on outcomes routinely documented within patient medical records. For example, quality-of-life measures remain an infrequently documented measure in medical records. Only through concurrent evaluation can that outcome measure be reliably captured.

Medications recently added to the formulary should be evaluated, especially if there is the potential for inappropriate use or concerning adverse effects. This review should occur 6 to 12 months after their addition to the formulary. High-cost, high-use, and problem-prone medications also are good candidates for evaluation.

Nursing, Allied Health, and Interprofessional Team Interventions

Applying MUE to patient care is an interprofessional team activity; it cannot occur within disciplinary "silos." For MUE to be effective, it requires communication and coordination among the various healthcare team members, where clinicians, specialists, pharmacists, and nurses all have input and access to all data regarding medication use. Each team member must be empowered to contribute to the process, and the latest studies and data should apply in the decision-making process. Clinicians must be open to input from pharmacists and nursing staff so that optimal medication use and procurement can lead to optimal patient outcomes. [Level 5]

Prospective DUR 

This approach places accountability on the health care practitioner to review the prescription when presented for filling and proactively resolve potential problems related to drug therapy. It allows the pharmacist and other health care practitioners to communicate with patients and the health care team to optimize the treatment plan for each patient. In institutional and retail setups, a pharmacist can evaluate the prescription order when dispensing and, utilizing clinical data from the patient's medical and pharmacy records, determine the appropriateness of the prescribed drug therapy. If the pharmacist identifies possibilities for improved patient care, they can communicate with the prescriber to discuss the treatment alternatives.[13]

Concurrent DUR 

The pharmacists have the responsibility in the concurrent DUR process to evaluate the ongoing treatment of the patient. If needed, pharmacists should provide input to revise the treatment plan. Case managers can become actively involved in managing the patient's condition, particularly in patients with multiple diseases. Through interaction with the prescriber, pharmacists can better comprehend the treatment plan. In addition, healthcare practitioners can counsel patients on the appropriate use of medications.

Retrospective DUR

Pharmacists play a leading role in clarifying the relationship between drug use and patient outcomes using retrospective DUR due to their expertise in drug therapy management. Managed care pharmacy professionals have an important role in planning, organizing, and implementing DUR. Pharmacists can collaborate with other healthcare professionals regarding medication use and actively participate in decision-making within the context of the Pharmacy and Therapeutics Committee. Pharmacists are members of DUR committees where input regarding drug policy development is necessary. 

Conclusion

The process of DUR is still evolving. Pharmacists can recognize prescribing trends and commence corrective measures by utilizing DUR data. In addition, rapidly improving information systems and artificial intelligence will provide a strategy for matching medical and pharmacy data with patient outcomes. Drug utilization review education by simulated clinical decision-making ensures competency in pharmacists.[14] As more healthcare professionals (e.g., nurse practitioners, physician assistants, podiatrists, optometrists) across the different states are involved in prescribing medications, DUR will require an interprofessional team approach.[15][16] DUR evolution will improve the utilization of healthcare resources and optimize patient outcomes.