Correspondence

Computer-Based Drug-Utilization Review

N Engl J Med 1995; 333:1290-1291November 9, 1995

Article

To the Editor:

Much of the concern voiced about drug-utilization review by Drs. Soumerai and Lipton (June 15 issue)1 — about the lack of proof that this process is cost effective, the lack of attention paid to the underuse of effective medications, and the inadequacy of the criteria used in screening — is on target. This concern also suggests a substantial disconnectedness between the research community and those dealing with drug-utilization review in an operational environment. The rush to managed care and the passage of the Omnibus Budget Reconciliation Act of 1990 resulted in the widespread implementation of drug-utilization review before some important questions were answered. Nevertheless, the assessment of outpatient programs of drug-utilization review as implemented has revealed the problems noted by Soumerai and Lipton.

The authors rightly point to the risks to appropriate medical care resulting from denials of claims (through rejection of reimbursement for early refills or prior-authorization requirements) in various states. They say that the goal of drug-utilization review ought to be to improve therapy through education. Might it not be argued that what they point to is less a failure of the review process than a failure of administrators to understand the connection between their efforts to control costs through administrative mechanisms and the need to improve the appropriateness of therapy? Finally, although Soumerai and Lipton acknowledge that the scientific base for drug-utilization review is in its infancy, they discount the fact that the review process is a moving target. Retrospective drug-utilization review is moving away from identifying individual prescriptions that are inappropriate and toward a true analysis of patterns. Similarly, although little has been done to examine the direct effect of drug-utilization review on patients' outcomes, as the authors point out, it is probably also true that it has taken the implementation of the review process in its present form for the process to begin to move from a drug-based approach to a disease-based approach and for efforts to apply outcomes measures to begin.

In the final analysis, it seems premature to condemn computer-based drug-utilization review as a boondoggle. What is needed is a more constructive collaboration between the research community and those implementing review programs to solve the real problems associated with making this process work. Then we will know whether the work being done has been worth the effort.

Thomas R. Fulda
United States Pharmacopeial Convention, Rockville, MD 20852

1 References

1. 1

   Soumerai SB, Lipton HL. Computer-based drug-utilization review -- risk, benefit, or boondoggle? N Engl J Med 1995;332:1641-1645
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We agree with Mr. Fulda that problems with many existing programs of drug-utilization review reflect a “substantial disconnectedness” between researchers and program managers. However, the decisions of these managers can be constrained by a well-intentioned but possibly overoptimistic Congress that, in 1990, required that all states conduct specific types of unproved programs,1 such as prospective drug-utilization review in pharmacies. Clearly, we need more effective and timely mechanisms for communicating the results and implications of relevant research to both managers and policy makers.

We share Mr. Fulda's concern that state Medicaid programs are using certain features of drug-utilization review as devices that may inappropriately deny patients necessary medicines at the point of sale.2 We did not, however, wish to imply that all forms of drug-utilization review are potentially ineffective and hazardous to patients. A critical principle is that the patients' interests should not be compromised at the point of sale. For example, the occurrence of unnecessary warnings involving essential drugs should be minimized by the judicious selection of valid screening criteria. But the real value of such systems would seem to be in retrospectively reviewing practice patterns across patients and over time, coupled with targeted programs of educational outreach. We have documented that the use of educational methods, such as brief one-to-one educational visits and ongoing feedback on performance, can lead to substantial improvements in the quality and efficiency of care without untoward effects.3-5

Finally, we wish to recognize the contributions of Dr. Patricia Byrns to an unpublished synthesis the three of us made of data from public reports on regulations concerning early prescription refills; we inadvertently omitted to mention this in the text that appears in paragraphs 4 and 5 on page 1643. Additional sources of these data were the federal reports for fiscal year 1993 on programs of drug-utilization review in Maryland and Tennessee.

Stephen B. Soumerai, Sc.D.
Harvard Medical School, Boston, MA 02115

Helene L. Lipton, Ph.D.
University of California School of Pharmacy, San Francisco, CA 94143

5 References

1. 1

   Omnibus Budget Reconciliation Act of 1990, Section 4401Fed Regist 1992;57:49397-49412
   Medline

2. 2

   Soumerai SB, Lipton HL. Computer-based drug-utilization review -- risk, benefit, or boondoggle? N Engl J Med 1995;332:1641-1645
   Full Text | Web of Science | Medline

3. 3

   Soumerai SB, McLaughlin TJ, Avorn J. Improving drug prescribing in primary care: a critical analysis of the experimental literature. Milbank Q 1989;67:268-317
   CrossRef | Web of Science | Medline

4. 4

   Soumerai SB, Lipton HL. Evaluating and improving physician prescribing. In: Strom BL, ed. Pharmacoepidemiology. 2nd ed. Chichester, England: John Wiley, 1994:395-412.
   

5. 5

   Lipton HL, Byrns PJ, Soumerai SB, Chrischilles EA. Pharmacists as agents of change for rational drug therapy. Int J Technol Assess Health Care 1995;11:485-508
   CrossRef | Web of Science | Medline