DO PRACTICE GUIDELINES AUGMENT DRUG UTILIZATION REVIEW

Drug utilisation review (DUR) or drug use evaluation (DUE) studies or programmes are intended to detect and/or correct inappropriate drug us e. Appropriateness can be assessed at 3 levels: (i) whether any medica tion is warranted, or whether either no therapy or nondrug therapy is preferred (level 1); (ii) assuming drug therapy is indicated, which of several alternative drugs is the preferred choice? (level 2), and (ii i) appropriateness of the drug regimen, including dosage, duration, ty pe and frequency of monitoring, and drug interactions (level 3). The t raditional approach to DUR/DUE has been to begin the appropriateness e valuation after a drug is prescribed. However, changes in healthcare o rganisation provide the basis for a disease-management or health-maint enance approach to DUR/DUE, and practice guidelines afford a possible source for guiding such studies. We hypothesised that the latter appro ach to DUR/DUE would be more likely to result in evaluation of level 1 drug-therapy issues than the traditional DUR/DUE approach. We tested this hypothesis by reviewing 56 practice guidelines involving drug the rapy and also reviewed research studies published from 1992 to 1996, W e found that studies that used the traditional DUR/DUE approach were m ost likely to examine level 3 drug-therapy issues, never addressed lev el 1 issues, and typically evaluated adherence to provider-or study te am-developed guidelines rather than published guidelines. In contrast, the disease-or health-management approach nearly always examined leve l 1 issues, seldom addressed level 3 issues, and almost always evaluat ed adherence to a published practice guideline. Regardless of the DUR/ DUE approach, about 40% of studies evaluated level 2 issues. The guide lines themselves were much more likely to include recommendations abou t level 1 and level 2 issues than about level 3 issues; however, even when a guideline included level 2 or level 3 issues, studies of adhere nce to the guideline rarely assessed anything beyond level 1 issues. T his suggests that guideline recommendations about level 2 and level 3 issues may be too imprecise for use in evaluative studies. The drug-in formation compendia, on the other hand, provide detailed recommendatio ns about level 3 issues. Revision of drug compendia may be warranted t o include recommendations about all levels of drug-therapy issues. The results of intervention studies to improve drug-therapy compliance wi th guidelines suggest that information provided at the time of prescri bing, information presented by local health professionals and informat ion provided with a large amount of provider contact may be more likel y to demonstrate significant improvements in drug therapy. We conclude that practice guidelines are a useful resource for augmenting DUR/DUE but that challenges to optimising their use include whether they can be kept current, acceptable and accessible to providers.