DRUG UTILIZATION

REVIEW (DUR)
Presented by :
NURULUMI BINTI AHMAD
LECTURE OUTLINE
1. Introduction : Definition and concept
2. 5 principles of DUR
3. Quality control
4. Advantages
5. 3 types of DUR – Retrospective, Concurrent and Prospective
6. DUR process – 10 steps
7. Educational program after DUR
8. Tips for successful DUR
LEARNING OUTCOMES
At the end of this lecture, students should be able to :
1. Describe DURs based on their types.
2. Explain the principles of DUR.
3. Develop strategies to implement DUR using its 10 steps approach.
 INTRODUCTION : CONCEPT
Base cost of
medications
Salaries of HC
professionals

Preventable
medication errors
To cope with these costs, health systems review the use and non-
of drugs within their populations to determine where preventable
adverse reactions
improvements in the process can be made to assure
high quality, cost-efficient care.

Rising cost
of medication use
 INTRODUCTION :
DEFINITIONS
 Medication use evaluation (MUE), drug use review (DUR), and MUE
medication use management (MUM) are synonyms for the drug use
evaluation (DUE) process.
 Role of DUE : a means of improving medication use within an
organization. DUR
 “Ongoing study of the frequency of use and cost of drugs, from which
patterns of prescribing, dispensing, and patient use can be determined”
(Brodie, 1972) MUM
 Five (5) principles of drug use review (Brodie, 1976)

DUE
 5 PRINCIPLES OF DRUG USE
REVIEW (DUR)

Understanding
Criteria against A mechanism for
the characteristics Availability of
Appropriate which drug usage assessing the
of the delivery existing profiles
authority (PTC) can be reviewed impact of changes
system and of drug usage
and judged implemented
population served

….remains the basic structural components of all DUR programs !

Source: Adapted from Brodie, DC and Smith WE. Hospitals 1976; 50: 143–150.
 QUALITY CONTROL
 From 1981 to 1985, the JCAHO (then the Joint Commission on Accreditation of Hospitals) applied
the DUE process to hospitalized patients receiving antibiotics.
 Antibiotic utilization review (AUR)
1. JCAHO required the medical staff to review the appropriateness, safety, and efficacy of antibiotics used
within an institution.
2. JCAHO also insisted that this review take place with the assistance of the department of pharmacy
through PTC.
 In 1986, the emphasis moved from strictly antibiotics to all drugs.
 In 1994, the JCAHO adopted the term medication use evaluation (MUE).
 To maintain accreditation, hospitals and health care systems are bound to conduct MUE/DUE
programs.
 JCAHO is now known as JCI (Joint Commission International)
QUALITY CONTROL
 Pharmacists are required to identify and resolve drug-related problems before they reached
patients
 New standards for utilization management :
1. Process must be an ongoing, criteria-based, systematic process designed to improve the use of drugs.
2. Responsibility for the safe and effective use of medications is shared among all practitioners involved
in the drug use process
 DUR programs are both qualitative and quantitative studies evaluating how a drug is used
compared with predetermined criteria.
5 PURPOSES OF
IMPLEMENTING DUR
1. Improve the use of the drug
2. Improved patient care
3. Benefit to the pharmacist and prescriber
4. Compare the quality of care delivered by practitioners
5. Encourage physician compliance to use formulary drugs, generic substitution, and clinical
practice guidelines
5 BENEFITS/ADVANTAGES OF
DUR
1. DUR programs play a key role in helping managed health care systems understand,
interpret, evaluate and improve the prescribing, administration and use of medications.
2. Employers and health plans find DUR programs valuable since the results are used to foster
more efficient use of scarce health care resources.
3. Pharmacists play a key role in this process because of their expertise in the area of medication
therapy management.
4. 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.
5. Pharmacists can then, in collaboration with prescribers and other members of the health
care team, initiate action to improve drug therapy for patients.
3 TYPES OF DUR Prospective

Concurrent

Retrospective
RETROSPECTIVE DURS
 The simplest to perform but are limited in impact.
 Patients have already received the drugs :
 One can simply review the charts of patients and determine whether the drug use met predetermined
criteria.
 Studies are not time dependent and require limited resources.
 Lack of impact they have on past drug use.
 Potential for incomplete data can lead to bias and invalid results.
 Retrospective reviews of drug use patterns can assist plans in developing strategies for more
comprehensive and relevant prospective DURs.
 Useful for identifying problems in therapeutic duplication, abuse of medications,
appropriate generic use, and inappropriate durations of therapy.
CONCURRENT DURS
 Conducted while patients are receiving medications.
 Allow corrective actions to be taken during the time the patients are receiving the
medications.
 Patients are identified as existing users of the drugs, and their profiles or charts are reviewed
to determine how well the drug use meets predetermined criteria.
 Opportunities to effect changes in the drug use —> improving the quality of care
 The difficulties in identifying patients and reviewing problems manually.
 Well suited for problems such as drug–drug interactions, incorrect dosage, and therapeutic
duplication.
PROSPECTIVE DURS
 occur before patients receive medications.
 Problems can be resolved before the patients receive the medications.
 Disadvantages :
1. they require well-defined and coordinated approaches to identifying drugs targeted for review.
2. Ready access to patient information and prescribers makes this difficult to implement.

 Problems useful for identifying and resolving before medication administration include
drug–allergy and drug–disease interactions, incorrect dosage, age or disease-state
contraindications, and therapeutic duplications.
 DUR PROCESS :
10 STEPS IN CONDUCTING A
DUR

These steps are based on the JCAHO 10-step process for conducting DUE/MUE programs.
STEP 1 :GAIN
ORGANIZATIONAL
AUTHORITY AND ASSIGN
RESPONSIBILITY
 To gain authority from the organization’s stakeholders and design an appropriate reporting
structure
 Authority : organization’s administration, medical staff, pharmacy staff, and nursing staff;
others
 Typical source of authority is the pharmacy and therapeutics committee (PTC)
 PTC may delegate the authority to one of its subcommittees or charge another committee
with the responsibility.
 The clear lines of authority should be maintained and reviewed periodically
 STEP 2 : DELINEATE SCOPE OF
DRUG USE
 To delineate the scope of drug use within the organization and outline what elements of the drug
use process should be reviewed.
 A review of peer-reviewed scientific literature, relevant clinical practice guidelines, and
accrediting organization requirements should be the underpinning for this step.

Key Processes Evaluated during a DUR

STEP 3 : IDENTIFY
IMPORTANT SPECIFIC DRUGS
TO BE MONITORED AND
EVALUATED
 To identify the specific drugs to be reviewed.
 Clinicians should be consulted to aid in determining which drugs should undergo the
evaluation process.
 Information from past due studies, clinical judgment, and current literature help the
organization decide the target drugs.
 Consider for evaluation :
1. drugs with high use within the organization
2. drugs that present a high risk to patients
3. drugs with a high cost
STEP 4 : IDENTIFY
INDICATORS
 to discuss and decide on the measures of quality pertinent to the drug being evaluated.
 Become the criteria for drug use
 developed by the clinicians using the medications based on evidence from the literature and
local experience.
 surrogate markers of disease or outcome, or both, must be used if more clinically relevant data
are not readily available (in computer or patient’s chart)
 DUR criteria should be developed in concert with the organization’s programmatic goals on
how medications should be used within the system.
 The criteria developed do not have to be comprehensive and include all five key processes for
a DUR —> can be based only on one or more of these key processes.
Abbreviated DUR Report for the Example Drug Peterpenem
5 KEY PROCESSES EVALUATED DURING A
DUR
 STEP 5 : ESTABLISH
THRESHOLDS
 To establish thresholds for optimal use
 Thresholds are the standards against which performance is measured.
 For example :
If the criteria for dosing a medication require that all patients receive a particular dose, without variation,
then the threshold will be set at 100% —> 100% of the patients must receive that dose.
 Not necessary to set absolute standards (e.g., 0% therapeutic duplication or 100% compliance with
dosage recommendations) —> individual variation
 For example :
A threshold includes the percentage of patients expected to achieve a certain outcome (e.G., Goal blood
pressure, 75%; adverse reaction, 12%).
 Clinical pharmacists and physician specialists should be involved in the development of thresholds
because of their clinical experience with the drug and should help set these reasonable thresholds.
Abbreviated DUR Report for the Example Drug Peterpenem
STEP 6 : COLLECT AND
ORGANIZE DATA
 To collect and organize the data
 Data collection can occur retrospectively, concurrently, or prospectively.
 A clear plan of collecting the data is essential —> misuse of information and “garbage in –
garbage out”
 Information specialists and clinicians must come together to determine the data to be collected
and the most efficient means of doing so.
STEP 7 : EVALUATE DRUG USE
 After data collection —> comparing and evaluating the results with predetermined thresholds
rests with the clinicians
 Initial results are reviewed by an experienced clinical pharmacist and then brought back to all
stakeholders for their review.
 All clinicians involved in the criteria and threshold development should jointly agree on
conclusions from the data.
 this process also sometimes uncovers new, appropriate trends in prescribing.
Abbreviated DUR Report for the Example Drug Peterpenem
STEP 8 : TAKE ACTIONS TO
IMPROVE DRUG USE
 To identify solutions to the problems identified in step 7.
 This step includes :
1. Formulating educational programs to improve the knowledge of the users of medications
2. Developing restrictions to drug use based on inappropriate use
3. Removing the drug from the formulary because of the potential dangers it might present

 Education is the most common means of corrective action and often becomes the cornerstone
of all interventions to improve drug use.
RECOMMENDATIONS FOR
THE PTC BASED ON AN
EXAMPLE DUR REPORT
STEPS 9 AND 10 : ASSESS EFFECTIVENESS OF
ACTIONS AND COMMUNICATE RELEVANT
INFORMATION
 involve :

1. Assessing the effectiveness of the actions taken in step 8

2. A continuous quality improvement (CQI) process
3. Communicating the findings, actions, and follow-up to the appropriate individuals involved
(patients, the provider, or the managed care organization).
 EDUCATIONAL PROGRAMS
AFTER DUR
 DUR program results should be shared with all the health care providers involved in the medication use
process.
 Strategies for communicating these results :
1. One-on-one education by pharmacists to providers (The best strategy!)
2. Workshops
3. Seminars
4. Newsletters

 Presenting DUE results directly to a health care professional more effectively changes how a provider uses
the medication —> academic detailing
 Early involvement of respected peers in the design and implementation of a DUR program aid in the
successful change of medication use.
 Offering clinicians short summaries of guidelines or recommendations for change, using one of the
respected peers, also improves medication use.
3 TIPS FOR A SUCCESSFUL
DUR PROGRAM
1. Assuring agreement among the stakeholders regarding the scope and authority of the program
—> by assuring medical staff concordance (most often through the PTC) and administrative
authority
2. Communicating results to all the individuals involved in the drug use
3. DUR results must be well documented so that when questions regarding the results arise, they
can be readily answered
LET’S TEST YOUR
UNDERSTANDING…
1. State THREE (3) types of DUR
2. List THREE (3) stakeholders that a DUR program needs to gain authority from.
3. State THREE (3) ways of sharing DUR program outcomes or results.
4. List FOUR (4) reasons of conducting a DUR in hospital.
 REFERENCES
Andrew M. Peterson; Managing Pharmacy Practice:
Principles, strategies and system; 2004.
THANK YOU