September 16,
2003
Prescription Drug Utilization Reviews
Are Less Than Useful
Mandated Programs Don't Reduce Prescription Errors
or Improve Patient Care
(Philadelphia, PA) - After examining
data from six state Medicaid programs, researchers from
the University of Pennsylvania School of Medicine
have concluded that drug utilization review programs
do not improve patient health or reduce the rate of
prescription errors. Their findings, presented in the
September 17 issue of JAMA, the journal of the American
Medical Association, represent the first published study
of the clinical effectiveness of such review programs.
Drug utilization review is required of all state Medicaid
programs and is also used by most private-sector prescription
programs. In theory, these reviews examine prescription
records in order to alert physicians to possible drug
interactions or the availability of alternative - perhaps
safer or cheaper - drugs. The Penn researchers, however,
have not been able to identify any positive effects
that these programs have, either in terms of clinical
outcomes or in preventing errors.
"We compared the rate of drug review alerts over a
four-year period and found that the existing system
has no detectable effect in changing the way drugs are
prescribed," said Sean Hennessy, PharmD, PhD, Assistant
Professor in Penn's Department of Biostatistics and
Epidemiology, and lead author of the report. "No matter
how many notice letters are sent out, the rate of prescribing
errors never changes. Given the lack of effectiveness
- and the potential for harm cited in previous research
- there is not much to recommend for keeping these costly
review programs."
Typically, a review program uses computers to screen
prescription information for potential drug interaction
conflicts, based on a pre-established set of guidelines.
When the software spots a violation of these rules,
it marks the record for review. The program staff then
sorts these marked records to determine whether or not
an alert notice, usually a letter, should be sent to
the prescribing physician.
"Anecdotal evidence suggests that most practicing physicians
simply ignore these alert letters and find them to be
useless," said Brian L. Strom, MPH, MD, Professor
and Chair of Penn's Department of Biostatistics and
Epidemiology, and co-author of the study.
According to Strom, the drug utilization review programs
do not account for the underlying reasons physicians
must consider when prescribing specific drugs for their
patients. "It is like one of those pesky "help" messages
that pop up on your computer's word processor - the
software wants to help you write a letter, while you
are trying to do something completely different," said
Strom. "Eventually, you learn to ignore the message."
Drug utilization review programs are supposed to work
through two mechanisms: "direct" effects and "spillover"
effects. Direct effects apply to patients who are identified
in alerts and benefit from a change in therapy. Since
most alert notices are sent months after a given drug
is prescribed, the spillover effect is thought to be
the driving rationale behind the review program. The
term spillover represents the possibility that physicians,
once alerted to a particular drug interaction or alternative
therapeutic, might apply the information to the care
of other patients.
The Penn study aimed to find the spillover effect on
the rate of prescribing errors identified by the drug
utilization review process. That is, if a particular
error notice triggers changes in the behavior of physicians,
it would be seen as a decline in similar errors.
The researchers reviewed data from six state Medicaid
programs and, using the same computer rules that the
states use, found no evidence to suggest that there
is a spillover effect at all. The researchers also cite
a previous study that suggests these reviews could be
harmful if they influence a prescribing physician to
use an alternative drug that does not violate the rules
but is nonetheless harmful, or if they abruptly discontinue
drugs that should be tapered slowly, which can often
have harmful effects.
"Despite their cost, and the enormous amount of energy
devoted by the well-intentioned professionals who run
these programs, the current model simply does not seem
to work. The current mandate should be withdrawn," said
Hennessy. "Following that, the model should be completely
re-designed and then tested before widespread implementation
of a new approach. We require evidence of safety and
effectiveness for our drugs, and should do the same
with our quality improvement programs."
For
a printer friendly version of this release, click
here.
To
see the Leonard Davis Institute issues brief on this
topic, click
here.
###
Editor's Note: This study was funded
through grants from the National Institute on Aging
and the Agency for Healthcare Research and Quality.
PENN Medicine is a $2.2
billion enterprise dedicated to the related missions
of medical education, biomedical research, and high-quality
patient care. PENN Medicine consists of the University
of Pennsylvania School of Medicine (founded in 1765
as the nation's first medical school) and the University
of Pennsylvania Health System (created in 1993 as the
nation's first integrated academic health system). Penn's
School of Medicine is ranked #2 in the nation for receipt
of NIH research funds; and ranked #4 in the nation in
U.S. News & World Report's most recent ranking of top
research-oriented medical schools. Supporting 1,400
fulltime faculty and 700 students, the School of Medicine
is recognized worldwide for its superior education and
training of the next generation of physician-scientists
and leaders of academic medicine.
Penn Health System consists of four
hospitals (including its flagship Hospital of the University
of Pennsylvania, consistently rated one of the nation's
"Honor Roll" hospitals by U.S. News & World Report),
a faculty practice plan, a primary-care provider network,
three multispecialty satellite facilities, and home
health care and hospice.
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