Drug Utilization Review (DUR)

Drug utilization review (DUR) is defined as an authorized, structured, on-going review of prescribing, dispensing and use of medication. DUR encompasses a drug review against predetermined criteria that results in changes to drug therapy when these criteria are not met. It involves a comprehensive review of patients' prescription and medication data before, during and after dispensing to ensure appropriate medication decision-making and positive patient outcomes. As a quality assurance measure, DUR programs provide corrective action, prescriber feedback and further evaluations.

DUR programs play a key role in helping managed health care systems understand, interpret, evaluate and improve the prescribing, administration and use of medications. Employers and health plans find DUR programs valuable since the results are used to foster more efficient use of scarce health care resources. Pharmacists play a key role in this process because of their expertise in the area of medication therapy management.

DUR affords the managed care Pharmacist the opportunity to identify trends in prescribing within groups of patients whether by disease-state such as those with asthma, diabetes or high blood pressure, or by drug-specific criteria. Pharmacists can then, in collaboration with prescribers and other members of the health care team, initiate action to improve drug therapy for patients.

DUR is classified into three categories:
  1. Prospective: evaluation of a patient's drug therapy before medication is dispensed
  2. Concurrent: ongoing monitoring of drug therapy during the course of treatment
  3. Retrospective: review of drug therapy after the patient has received the medication

1. Prospective DUR
A 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. Pharmacists routinely perform prospective reviews in their daily practice by assessing a prescription medications dosage and directions while reviewing patient information for possible drug interactions or duplicate therapy. When part of an online claims adjudication process, prospective DUR often relies on computerized algorithms to perform key checks including drug interactions, duplications or contraindications with the patient’s disease state or condition.

Issues Commonly Addressed by Prospective DUR:
  • Clinical abuse/misuse
  • Drug-disease contraindications (when a prescribed drug should not be used with certain diseases)
  • Drug dosage modification
  • Drug-drug interactions (when two or more different drugs interact and alter their intended effects, often causing adverse events)
  • Drug-patient precautions (due to age, allergies, gender, pregnancy, etc.)
  • Approved by AMCP Board of Directors November 2009
  • Formulary substitutions (e.g., therapeutic interchange, generic substitution)
  • Inappropriate duration of drug treatment

Identification of drug-drug interactions is a common outcome of a prospective DUR. For example, a patient being treated with warfarin to prevent blood clots may be prescribed a new drug by another specialist to treat arthritis. If taken together, the patient could experience internal bleeding. Upon reviewing the patient's prescriptions, the pharmacist would note the potential drug interaction and contact the prescriber to alert him/her to the problem.

2. Concurrent DUR
Concurrent review is performed during the course of treatment and involves the on-going monitoring of drug therapy to foster positive patient outcomes. It presents pharmacists with the opportunity to alert prescribers to potential problems and intervene in areas such as drug-drug interactions, duplicate therapy, over or underutilization and excessive or insufficient dosing. This type of review allows therapy for a patient to be altered if necessary.

As electronic prescribing becomes more widely adopted, the concurrent DUR process may be performed by the prescriber at the time of prescription transmission to the pharmacy, allowing interventions before the drug is dispensed. An important component of DUR will require complete and current drug and allergy records for the patient, as well as knowledge of appropriate therapeutic interchanges for individuals. As a safety net, pharmacists will perform a similar role as prescribers on the dispensing side of these transactions.

Issues Commonly Addressed by Concurrent DUR:
  • Drug-disease interactions
  • Drug-drug interactions
  • Drug dosage modifications
  • Drug-patient precautions (age, gender, pregnancy, etc.)
  • Over and underutilization
  • Therapeutic Interchange

Concurrent DUR often occurs in institutional settings, where patients often receive multiple medications. Periodic review of patient records can detect actual or potential drug-drug interactions or duplicate therapy. It can also alert the pharmacist to the need for changes in medications, such as antibiotics, or the need for dosage adjustments based on laboratory test results. The key prescriber(s) must then be alerted to the situation so corrective action can be taken.

3. 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 the care of their patients, either individually or within a certain target population (e.g., patients with diabetes, asthma, or high blood pressure).

Issues Commonly Addressed by Retrospective DUR:
  • Appropriate generic use
  • Clinical abuse/misuse
  • Drug-disease contraindications
  • Drug-drug interactions
  • Inappropriate duration of treatment
  • Incorrect drug dosage
  • Use of formulary medications whenever appropriate
  • Over and underutilization
  • Therapeutic appropriateness and/or duplication.

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