Drug utilisation evaluation in clinical pharmacy

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Drug Utilisation Evaluation (DUE) in Clinical Pharmacy

Definition

Drug Utilisation Evaluation (DUE) - also called Drug Utilization Review (DUR) or Medication Use Evaluation (MUE) - is an authorized, structured, ongoing quality-improvement activity designed to ensure that medications are prescribed, dispensed, and used appropriately, safely, and effectively to optimize patient outcomes.

The ASHP MUE guidelines define it as a performance improvement method that focuses on evaluating and improving the entire medication-use process. The StatPearls DUR article notes it encompasses prospective, concurrent, and retrospective review.

Synonymous Terms:

Term	Organization
Drug Utilization Review (DUR)	CMS, AMCP, Medicaid
Drug Use Evaluation (DUE)	Traditional/older term
Medication Use Evaluation (MUE)	ASHP (current preferred term)
Pharmaceutical Utilisation Management	NCQA

Types of DUE

1. Prospective DUE

Evaluation of planned drug therapy before medication is dispensed
Allows identification and resolution of problems before the patient receives the drug
Routinely done by pharmacists during dispensing
Screens for: drug interactions, inappropriate dosage, therapeutic duplication, contraindications, allergy alerts

2. Concurrent DUE

Ongoing monitoring of drug therapy during the course of treatment
Real-time clinical intervention while the patient is receiving the medication
Focuses on: monitoring parameters, dose adjustments, changing therapy as condition evolves

3. Retrospective DUE

Review of completed drug therapy after dispensing/administration
Analyzes patterns of prescribing across a population or patient group
Example: reviewing all patients with asthma to see if step-up therapy was initiated appropriately
Useful for policy development, trend identification, and formulary decisions

Goals and Objectives

Ensure medications are used appropriately, safely, and effectively
Improve patient health outcomes and quality of life
Identify and resolve actual drug-related problems
Prevent potential drug-related problems
Provide prescriber feedback and corrective action
Reduce preventable adverse drug reactions
Minimize inappropriate pharmaceutical expenditure and reduce healthcare costs
Support formulary management and policy development

Common Problems Identified by DUE

Therapeutic duplication
Drug-drug interactions
Drug-disease contraindications
Drug-allergy interactions
Incorrect dosage or dosing frequency
Inappropriate duration of treatment
Overutilization or underutilization
Clinical misuse or abuse
Absence of required monitoring parameters
Non-adherence to clinical guidelines
Pregnancy-related prescribing alerts

The DUE Process - Step by Step

Step 1: Topic Selection

Prioritize high-risk, high-volume, or problem-prone medications
Consider drugs with narrow therapeutic indices, high cost, frequent ADRs, or recent guideline changes
The Pharmacy and Therapeutics (P&T) Committee typically authorizes and oversees the process

Step 2: Develop Criteria and Standards

Establish explicit, measurable criteria for appropriate use, based on:
- Evidence-based clinical guidelines
- Published literature
- Institutional protocols
- FDA-approved indications
Criteria usually cover: indication, dosage, route, frequency, duration, monitoring, therapeutic endpoints

Step 3: Data Collection

Identify patient population and sample size
Collect prescription/medication records, clinical notes, lab data
Use pharmacy information systems, EMR, or manual chart review

Step 4: Data Analysis

Compare actual drug use against pre-defined criteria
Identify deviations and classify as:
- Process problems (prescribing/dispensing/administration errors)
- Outcome problems (therapeutic failures, ADRs)
Quantify the rate of appropriate vs. inappropriate use

Step 5: Evaluation and Recommendations

Formulate conclusions based on analysis
Develop specific, actionable recommendations
Present findings to the P&T Committee and relevant stakeholders

Step 6: Implement Interventions

Possible interventions include:

Education - targeted sessions for prescribers/nurses/patients
Formulary changes - adding or removing a drug
Guideline updates - new institutional protocols
Restricted order entry - requiring prior authorization
Adjusting monitoring requirements

Step 7: Follow-up and Re-evaluation

Reassess outcomes at a defined timeframe (3, 6, or 12 months)
Repeat the cycle to confirm improvement (FOCUS-PDCA model per ASHP)
Document all actions taken

The FOCUS-PDCA model used in MUE:

Find a process to improve
Organize a team
Clarify current knowledge
Understand process variation
Select a strategy
Plan, Do, Check, Act

Role of the Clinical Pharmacist

The clinical pharmacist holds a central role in DUE:

Leads or co-leads the DUE team
Provides drug expertise for criteria development
Performs prospective DUR daily during dispensing (dose, drug interactions, duplication)
Participates in concurrent monitoring on clinical rounds
Designs and executes retrospective studies
Educates prescribers, nurses, and patients on findings
Collaborates with the P&T Committee to update formulary and policies
Uses computer-generated algorithmic alerts for contraindications, interactions, and duplications

Governance - The P&T Committee

The Pharmacy and Therapeutics Committee (or equivalent body) is the institutional authority overseeing DUE. Membership includes:

Pharmacists (often the lead)
Prescribers/physicians
Nurses
Administrators
Quality/safety officers

The P&T Committee receives DUE reports, approves recommendations, and authorizes formulary and policy changes.

Legal and Regulatory Framework

OBRA-90 (Omnibus Budget Reconciliation Act 1990): Mandates prospective DUR for Medicaid patients in community pharmacies in the USA - pharmacists must perform a prospective review before dispensing
Medicaid DUR Program (since 1993): Section 1927(g) requires each US state to develop a DUR program targeting clinical misuse/abuse of outpatient prescription drugs
CMS Medicare Part D: Requires DUR programs for beneficiaries
NCQA and Joint Commission: Mandate medication-use evaluation as part of hospital accreditation standards

Applications of DUE in Clinical Settings

Setting	Application
Hospital	Antibiotic stewardship, high-alert medication review, post-surgical opioid use
Community pharmacy	OBRA-90 prospective review, chronic disease monitoring
Managed care	Population-level trend analysis, formulary management
Long-term care	Polypharmacy review, potentially inappropriate medications (Beers criteria)
ICU	Sedation protocols, renal dose adjustment compliance

DUE vs. Pharmacovigilance

While both monitor drug safety, they differ:

DUE focuses on evaluating appropriateness of drug use in a defined population against pre-set criteria - it is primarily a quality improvement tool
Pharmacovigilance focuses on detecting, assessing, and preventing ADRs at a population/national level - it is primarily a safety surveillance tool

Summary

DUE is one of the most important functions of the clinical pharmacist. It systematically bridges the gap between evidence-based prescribing guidelines and real-world medication use. By running prospective, concurrent, and retrospective evaluations, clinical pharmacists ensure that patients receive the right drug, at the right dose, via the right route, for the right indication, with appropriate monitoring - and that practice improves continuously over time through the FOCUS-PDCA cycle.

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