Drug utilisation review (DUR) has been adopted as a mechanism for balancing 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 defined either as DUR studies, which examine patterns of drug use, or as DUR programmes, which examine patterns of drug use and subsequent efforts to alter drug use. An adequate cost-effectiveness analysis (CEA) is defined as one that used multiple methods to measure and evaluate patterns of drug use, and/or efforts to alter drug use, and that also performed an analysis of the costs of the review or intervention methods employed, with a focus on efficiency. DUR studies and programmes that satisfied all the criteria and thus fit the framework for conducting CEA were included; others that satisfied only some of the criteria were examined for the insights that they could contribute to a study of costs relative to outcomes.
We identified 14 reports that could be categorised as DUR studies. Only 3 of these examined more than 1 method of measuring and evaluating drug use, thereby potentially fitting the CEA framework, but none included a cost analysis. Of the other DUR studies, only 1 contained estimates of costs for the DUR method employed, but since it examined only 1 DUR method it did not satisfy the criteria for an adequate CEA. Although such studies provide information about different methods of identifying drug use patterns (a somewhat intermediate outcome), they do not provide insight into the cost effectiveness of methods designed to influence drug use.
We identified 34 reports of DUR programmes. Only 5 of these reports fit the CEA framework; they examined multiple efforts to change drug use patterns (after identifying drug use patterns). None of them satisfied the criteria for an adequate 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 interventions designed to change drug use.
DUR programmes were grouped by drug or drug use issue in an attempt to gain insights by comparing reports on similar drugs. The drugs or drug classes and number of reports reviewed were: cephalosporins (3); chloramphenicol (3); antiulcer drugs (2); dextropropoxyphene (2); tranquillisers (benzodiazepines) ; anti-infective agents (5); ‘all drugs’ (7); and other drugs/miscellaneous (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 considered at all. Thus, the literature does not fit the paradigms of economic analysis. The DUR programmes analysed do suggest that various interventions can affect drug use patterns; however, without cost estimates of the programmes we cannot conclude which intervention is the best from an economic perspective.
The existing literature on DUR studies and DUR programmes reveals little about the cost effectiveness of DUR in an outpatient setting. Suggestions for investigators conducting future 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 consideration to the perspective from which the economic evaluation is conducted. The motivation for future research assessing the cost effectiveness of DUR methods derives from the likelihood that no single method is the most cost effective for all drug classes. Thus, future research should focus on applying economic evaluation techniques to define the optimum method of DUR for a particular drug class.