Transcript DUR & DUE - Academy of Managed Care Pharmacy

Drug Utilization Review & Drug
Utilization Evaluation:
An Overview
Presentation Developed for the
Academy of Managed Care Pharmacy
Updated: February 2013
Learning Objectives
• Differentiate between the terms drug utilization
review and drug utilization evaluation
• Explain the role of a pharmacist in a drug utilization
review program
• Provide an example for each of the three types of
drug utilization reviews: prospective, concurrent, and
retrospective
• Describe the key stakeholders vested in a successful
DUR/DUE program
Definition of DUR and DUE
• Drug Utilization Review (DUR): A systematic, ongoing
review of prescribing, dispensing, and member drug
fills to detect and manage preventable drug-related
issues related to cost, safety, and/or efficacy
• Drug Utilization Evaluation (DUE): A qualitative
evaluation of drug use, prescribing, and member fill
patterns to determine the appropriateness of drug
therapy
AMCP. Glossary of Managed Care Terms. http://www.amcp.org/amcp.ark?c=pr&sc=glossary
Goals of DUR and DUE
• Improve quality of care
• Encourage the practice of evidence-based, clinically
appropriate, cost-effective drug use
• Reduce drug misuse and abuse
• Reduce costs related to inappropriate drug use
Pharmacist Role in DUR & DUE
• Identifies opportunities for quality improvement
• Participates in efforts to improve:
– Patient outcomes
– Quality of programs
• Promotes appropriate drug use to reduce overall health
care costs and improve access to care
• Carries out ethical and professional responsibility
A Model DUR Program
• Access to member drug utilization data
• Qualified pharmacists with authority to review
• Knowledge of population served and delivery system
• Availability of established standards for comparison
• Measurement of utilization review outcomes
Prospective DUR
• A screening method by which a health care provider
reviews the necessity of drug therapy before it is
dispensed or administered
– Electronic DUE programs at retail pharmacies
– Prior authorization (PA) programs
AMCP. Glossary of Managed Care Terms. http://www.amcp.org/amcp.ark?c=pr&sc=glossary
Concurrent DUR
• A screening method by which a health care provider reviews
the necessity of drug therapy at the time of dispensing or
during treatment
– Case management
– Review of patient records
– Research projects that follow patients in randomized,
controlled trials
– Real-time system edits at the point of service
AMCP. Glossary of Managed Care Terms. http://www.amcp.org/amcp.ark?c=pr&sc=glossary
Retrospective DUR
• A screening method by which a health care provider
reviews the necessity of drug therapy after it has been
dispensed or treatment has started
– Review of medical charts, electronic medical records
and/or claims data to assess appropriate drug use
- Review provider prescribing patterns
AMCP. Glossary of Managed Care Terms. http://www.amcp.org/amcp.ark?c=pr&sc=glossary
The DUR Process
1.
2.
3.
4.
5.
6.
7.
Determine criteria
Collect data
Compare the data to established criteria
Perform intervention
Analyze results
Document DUR
Re-evaluate the program (on-going)
Who Benefits from DUE/DUR?
• Accrediting bodies/Government
• National Committee for Quality Assurance
• Joint Commission on Accreditation of Healthcare
Organizations
• Omnibus Budget Reconciliation Act 1990
•
•
•
•
Plan member
Health care provider
Pharmacist
Health care system
Conclusion
• A pharmacist performs DUR/DUE to improve overall
access and quality of care, and to reduce costs
• Each type of DUR represents an important step in
ensuring that the member receives the most
appropriate, cost-effective medication
• A successful DUR/DUE program benefits all health
care players, including the member
Thank you to AMCP member
Jennifer Wilbanks for updating
this presentation for 2013