Current status of prospective drug utilization review.

BACKGROUND: The Omnibus Budget Reconciliation Act of 1990 offered the promise that prospective drug utilization review (pDUR) systems would improve the quality of drug prescribing and patient drug use. There is little evidence that this promise has been fulfilled. To the contrary, there is growing evidence that suboptimal use of drugs (in terms of preventable drug-related morbidity) is at least as costly as the prescription drugs themselves. Online computerized pDUR has been the subject of numerous critical examinations in the pharmacy and medical literature. Recent publications have sought to illustrate perceived shortcomings in the DUR systems currently in use. OBJECTIVE: We focus on the state of the art with regard to pDUR, what is known about its effectiveness, and how emerging technologies may change pDUR and consider the work that may be needed to establish its effectiveness. SUMMARY: A growing body of literature documents numerous problems and concerns with respect to the quality of DUR criteria, DUR alerts, and the response of health care professionals to these alerts. Problems with the current pDUR "system" can be grouped into those involving technical aspects (e.g., duplicate messaging from in-store and online systems, or message text limitations) and into those involving human aspects, specifically how pharmacists and other health care providers interpret and respond to potential drug therapy problem alerts generated by the electronic systems. CONCLUSION: DUR is a quality assurance system that holds promise as a tool that, if implemented effectively, could enhance appropriate drug use. We believe a more systematic approach to DUR is needed. Evaluation and management of public and private pDUR systems must link documentation of processes of care, such as pharmacists. cognitive services, patient interventions, etc. To address technical aspects, we strongly recommend (a) a national effort to validate DUR screen criteria relying upon evidence-based studies and (b) adoption of a minimal set of.critical. pDUR screen criteria by pharmacy service providers and third-party intermediaries, including pharmacy benefit managers. To address the human component of pDUR systems, we advocate (a) adoption of performance standards for pharmacists and (b) explicit remuneration for time spent identifying and responding to drug therapy problems.

Medicaid drug utilization review annual reports for federal fiscal year 1999: looking back to move forward.

OBJECTIVE: To review states' Medicaid drug utilization (DUR) annual reports for federal fiscal year (FFY) 1999 to assess the usefulness of the information provided in assisting states in improving their DUR programs. DATA SOURCES: Medicaid DUR annual reports from 43 states and the District of Columbia. DATA EXTRACTION: Five DUR experts conducted in-depth reviews of the annual reports to determine whether states provided the information required by the Health Care Financing Administration (HCFA; now the Centers for Medicare & Medicaid Services) annual report instructions, to assess the usefulness of information provided by states to other states seeking to improve their programs, and to consider what changes in report content are needed to increase the value of the reports. DATA SYNTHESIS: States provided the information requested by HCFA, but such information was not particularly useful in helping other states improve their programs, nor was it easily available to other states. These reports need to be reoriented. Rather than instruments useful for compliance monitoring, the reports should be remade as tools useful for educating DUR program staff. To do this, changes in report content are needed, and individual states should have access to reports from all states. Specific recommendations made based on these findings would be important first steps in improving the effectiveness of DUR programs. CONCLUSION: Much room for improvement remains in the content and distribution of Medicaid DUR annual reports. Finding ways to improve the effectiveness of DUR is especially important as the nation moves to implement a Medicare prescription drug benefit.

The role of pharmacy computer systems in preventing medication errors.

OBJECTIVE: To describe the controversies and review the evidence about computer-aided prospective drug utilization review (PDUR) systems. DATA SOURCES: MEDLINE search of the literature. STUDY SELECTION: Published studies of the effectiveness of computer-aided prescription screening. DATA SYNTHESIS: One randomized, controlled trial and four nonrandomized studies constitute the evidence base. The five studies are inconclusive with respect to whether computer-aided prescription screening causes health care providers to take action, either because of a no difference finding or because there was no comparison group. In the one randomized, controlled trial, a substantial number of actions were taken by the control group whose members did not receive alerts. No study evaluated the total effect of screening by in-store and payer (online) systems. Specific research recommendations are made to increase the evidence base. CONCLUSION: Limited and inconclusive evidence about whether these systems are effective and what system features are optimal may explain the wide variation among systems in terms of what problems are screened and may also explain clinicians' uncertainty about their value. A comprehensive national research agenda for reducing medical errors should include research on the effectiveness of computer-aided PDUR.