THE COST-EFFECTIVENESS OF DRUG UTILIZATION REVIEW IN AN OUTPATIENT SETTING

Drug utilisation review (DUR) has been adopted as a mechanism for bala ncing cost containment and quality in prescription drug programmes. In this article we review published DUR reports in order to examine the cost effectiveness of DUR in an outpatient setting. DUR reports are de fined either as DUR studies, which examine patterns of drug use, or as DUR programmes, which examine patterns of drug use and subsequent eff orts to alter drug use. An adequate cost-effectiveness analysis (CEA) is defined as one that used multiple methods to measure and evaluate p atterns of drug use, and/or efforts to alter drug use, and that also p erformed an analysis of the costs of the review or intervention method s employed, with a focus on efficiency. DUR studies and programmes tha t satisfied all the criteria and thus fit the framework for conducting CEA were included; others that satisfied only some of the criteria we re examined for the insights that they could contribute to a study of costs relative to outcomes. We identified 14 reports that could be cat egorised as DUR studies. Only 3 of these examined more than 1 method o f measuring and evaluating drug use, thereby potentially fitting the C EA framework, but none included a cost analysis. Of the other DUR stud ies, only 1 contained estimates of costs for the DUR method employed, but since it examined only 1 DUR method it did not satisfy the criteri a for an adequate CEA. Although such studies provide information about different methods of identifying drug use patterns (a somewhat interm ediate outcome), they do not provide insight into the cost effectivene ss of methods designed to influence drug use. We identified 34 reports of DUR programmes. Only 5 of these reports fit the CEA framework; the y examined multiple efforts to change drug use patterns (after identif ying drug use patterns). None of them satisfied the criteria for an ad equate CEA; in 3 of the reports no costs were provided, and the other 2 provided only partial input costs or costs for only some of the inte rventions designed to change drug use. DUR programmes were grouped by drug or drug use issue in an attempt to gain insights by comparing rep orts on similar drugs. The drugs or drug classes and number of reports reviewed were: cephalosporins (3); chloramphenicol (3); antiulcer dru gs (2); dextropropoxyphene (2); tranquillisers (benzodiazepines) [3]; anti-infective agents (5); 'all drugs' (7); and other drugs/miscellane ous (9). The DUR programmes reported in the literature were conducted with the primary intention of changing clinician prescribing patterns. Economic perspectives and evaluations were secondary, if they were co nsidered at all. Thus, the literature does not fit the paradigms of ec onomic analysis. The DUR programmes analysed do suggest that various i nterventions can affect drug use patterns; however, without cost estim ates of the programmes we cannot conclude which intervention is the be st from an economic perspective. The existing literature on DUR studie s and DUR programmes reveals little about the cost effectiveness of DU R in an outpatient setting. Suggestions for investigators conducting f uture research include incorporating the criteria for an adequate CEA into the design of the research project, identifying a uniform outcome measure consistent with the goals and objectives of DUR, and giving c onsideration to the perspective from which the economic evaluation is conducted. The motivation for future research assessing the cost effec tiveness of DUR methods derives from the likelihood that no single met hod is the most cost effective for all drug classes. Thus, future rese arch should focus on applying economic evaluation techniques to define the optimum method of DUR for a particular drug class.