DRUG UTILIZATION EVALUATION

(DUE)
❖ According to WHO, Drug Utilization evaluation is defined as the
marketing, distribution, prescription and use of drugs in society, with
special emphasis on the resulting medical, social and economic
consequences.
❖ Drug Utilization Evaluation (DUE) is an ongoing authorized and
systematic quality improvement process, designed to:
✓ Review drug use and or prescribing patterns.
✓ Provide feedback of result to clinician and other relevant groups.
✓ Develop criteria and standards.
✓ Promote appropriate drug use.

❖ Drug use/usage/utilisation evaluation (DUE) was originally known as drug

utilisation review (DUR) in the 1970s and early ’80s. The terms drug
utilisation review (DUR) and drug use evaluation (DUE) are
interchangeable.
Medication utilization evaluation (MUE): ) is another term that has been
used in place of DUE by some authors since 1994.
• It is similar to DUE but emphasizes on improving patients clinical
outcome and individual quality of life.
• It is highly dependent on multidisciplinary approach.
• It will assess clinical outcomes ( cured infection , decrease lipid levels)

❖ Objective of DUE:
1) To ensure that drug therapy meets current standard of care.
2) To control drug costs.
3) To prevent problem related to medication , ADRs.
4) To evaluate effectiveness of dug therapy.
5) To identify area of practice that require further education of
practitioners.
❖ Types of DUE :
1. Drug focused: Where the drug utilization evaluation of a single
drug (e.g. amikacin) or a class of drugs (e.g. Cephalosporin) is
tested.
2. Indication focused: Where the use of drug or drugs that is used for
specific indication is examined for their use.
(Example: Intravenous omeprazole for bleeding peptic ulcer.)
3. Quantitative: It includes collecting, organizing and estimation of
drug usage in figures in the pattern of drug prescribing, dispensing,
consumption and distribution.
4. Qualitative: These are multidisciplinary operation, which collect,
organize, analyze, and report information on actual drug use.

The main difference between qualitative and quantitative DUE

studies is that qualitative DUE includes the concept of criteria.

❖ DUE Committee:
• DUE Committee should be composed of physicians, pharmacists
and other relevant health-care professionals.
• The committee must include professionals with on interest in
improving drug therapy in the hospital and have ready access to
experts in the medicine, surgery and major hospital specialists.
• Pharmacists generally play a major role in the delivery of DUE and
it is usual for the committee to include pharmacy department
representation.

❖ Phases and steps involved in conducting a DUE

 • It is important to keep in mind that DUE operates in a repeating cycle.
• The DUE process is a continuous one and will be most valuable if the cycle
is completed rather than performing different steps in isolation. The DUE
cycle should include the following seven major activities or phases

Phase 1 :Planning
STAP 1 Identify drugs or areas of practice for
possible study
STAP 2 Design the study
STAP 3 Define criteria and standards
STAP 4 Design the data collection form
Phase II: Data collection
STAP 5 Collect data
Phase III : Evaluate
STAP 6 Collect data and evaluate result
Phase IV : Feedback of result
STAP 7 Feed result back to clinicians and other
hospital staff.
Phase V : Interventions
STAP 8 Develop and implements interventions.

Phase VI : Re-evaluation
STAP 9 Re-evaluate to determine if drug use has
improved.
STAP 10 Re-assess and revise DUE programme as
needed.
Phase VII : Feedback of result
STAP 11 Feed result back to clinicians and other
hospital staff
❖ Steps involved in conducting a DUE cycle
Step 1: Identify drugs or therapeutic areas of practice for possible
inclusion in the program.
• It is not possible and also unnecessary to examine and evaluate every
drug used in a hospital.
• Hence, the DUE committee must identify priority drugs or areas of
practice where improvement in use will result in the greatest clinical
impact.
• These areas can be identified through various sources of information
such as medication error reports, ADR reports, feedback from
prescribers or clinical pharmacists, local microbiological data and
medical and pharmaceutical literatures.
• ABC or VEN analysis is another important tool used to identify high
priority or target drugs.
• ABC analysis divides the drugs into three classes based on their
annual usage:
a)Class A drugs constitute 75-80% of the total values of
drugs consumed or purchased and are the highest cost or
highest volume items.
b)Class B items constitute 15-20% of expenditure.

c)Class C includes low cost or low volume items, which

form 5-10% of expenditures.

• In VEN analysis the drugs are generally classified as vital (V), essential
(E) and nonessential (N)

❖ Common targets for DUE include:

✓ Commonly prescribed drugs. (antibiotics , PPIS)
✓ Drugs associated with potentially significant drug interactions. (warfarin,
theophylline, digoxin and phenytoin )
✓ Expensive drugs. (low molecular weight heparins, broad spectrum
cephalosporins, anti-HIV medications )
✓ New drugs .
✓ Drugs with a narrow therapeutic index .(digoxin, phenytoin, cyclosporine,
theophylline and zidovudine)
✓ Drugs which upon withdrawal may cause problems (antidepressants,
benzodiazepines and anti-convulsants)
✓ Drugs that frequently cause serious/ significant adverse drug reactions.
(antibiotics, anti-convulsants, anti- coagulants, anaesthetic drugs, non
steroidal anti-inflammatory agents, ACE inhibitors and antimalarials)
✓ Drugs used in high-risk patients ( elderly, transplant patients, cancer
chemotherapy and intensive care patients, neonates or children.)
✓ Drugs used in the management of common conditions, such as chronic
pain, respiratory tract infections or urinary tract infections.
✓ Complex area of prescribing ( anticoagulation )

Step 2: Design of study

A variety of research methods have been used in DUE studies.
1) ) Observational research method: most commonly used.
Are more commonly used than experimental methods.

2) Experimental methods: E.g. Randomized controlled trials.

3) Cross-sectional studies: Drug use is examined at a single point in

time, are useful for problem identification.

❖ Based on design of study, DUE studies may also be categorized as

prospective, concurrent, retrospective depending on the timing of data
collection.
I. Prospective review:
✓ It involves evaluating a patient's planned drug therapy before
a medication is administered.
✓ Depending on the study design, interventions may be
provided if necessary before the patients receive the
prescribed drug.
✓ Identification of drug-drug interactions in one issue
commonly addressed by a perspective DUE.
✓ For example, another physician may prescribe a patient who
is on warfarin for atrial fibrillation on NSAID. This increases
the rise of gastrointestinal bleeding in the patient. Thus, a
DUE of concurrent use of warfarin and NSAIDs should be
designed in a way that allow the pharmacist to advise the
treating doctor of the risks with this drug combination.
 II. Concurrent review:
✓ It is performed during the course of treatment and involves
the ongoing monitoring of drug therapy.
✓ This may involve consideration of laboratory test results and
other monitoring data when appropriate and usually does not
offer immediate benefit to the patient.
✓ It differs from prospective review in that data collection does
not have to occur prior to the administration of a first dose.
✓ For example, in the setting of a DUE evaluating
aminoglycoside dosing, a patient with reduced renal function
may be prescribed a high dose of gentamicin, which may be
inappropriate for the patient based on the patient’s estimated
creatinine clearance. The clinical pharmacist identifies the
dose as inappropriate during their regular treatment chart
review and alerts the prescriber about the problem.

III. Retrospective review:

✓ It involves reviewing prescribed drugs after they are
dispensed to the patient.
✓ The patient’s medication sheets (including discharge
prescriptions), daily progress notes, nursing observations,
pathology/biochemistry results and therapeutic monitoring
results are screened to determine whether drug therapy met
pre- determined criteria
✓ For example, a hospital performs a DUE on gentamicin, with
criteria that states that use is contraindicated in renal failure.
Records for patients discharged during the previous month are
reviewed in the medical records department and the review
may show that a prescribing problem exists. The medical staff
decides to do a more intensive review of all aminoglycosides,
with similar results. An education program is conducted for
the entire medical staff on antibiotic use in renal failure.
 Step 3: Define criteria and standards
• After the DUE target has been selected, it is important to conduct a
comprehensive literature review.
• The step involved in literature review are:

o Perform an exhaustive literature search for the chosen drug or therapeutic

area using multiple search mechanisms (eg: Medline, Micromedex,
Drugdex, Cochrane library, Embase) and pharmacy based systems (eg:
Drug information service, international pharmaceutical abstracts).
o Assemble full copies (not just the abstracts) of all the relevant original
research papers.
o Critically evaluate the studies directly relevant to the chosen drug or
therapeutic area.
o Briefly summarize the literature review, identifying the “key” papers in the
chosen area and the drug use criteria that can be derived from the evidence
based literature.

Step 4: Design the data collection form.

• As it is impossible to monitor and evaluate all the drugs used in a hospital,
it is also impossible to address all aspects of use for each drug.
• It is important to limit data collection to only the most important and
relevant aspects of drug use and to factors which may influence these.
❖ Some aspects of drug use which are commonly surveyed during DUE
are:

✓ Patient demographics .
✓ Prescriber details.
✓ Disease severity.
✓ Co-morbidities.
✓ Indication for drug use.
✓ Drug-disease contraindications.
✓ Side or adverse effects.
✓ Dosing information.
✓ Duration of drug treatment.
✓ Drug or drug class duplication.
✓ Therapeutic duplication.
✓ Preparation and administration.
✓ Drug-drug and drug-food interactions.
 ✓ Monitoring of drug therapy P.
✓ Patient education or instructions.
✓ Cost of therapy.
✓ Over or under utilization of drug.

❖ Sources of data for DUEs in hospitals

I. Clinical data.
▪ Patient treatment charts.
▪ Patient admission (re-admission) records.
▪ Departmental audits. (surgical or discharge audits)
▪ Pathology records.
▪ Microbiological data.
▪ Medication charts.
▪ Medical notes.
▪ Observation charts.
▪ Patient interview.
▪ Nursing progress notes.

II. Demographic data

▪ Breakdown of patient population by age, disease, average length of stay,
etc.

III. Administrative data

▪ Drug purchasing and trends data.
▪ Drug utilization and trends data .
▪ Cost per adjusted hospital bed stay (if available)
➢ Data collection form for a DUE assessing the appropriateness of
ciprofloxacin use:

Step 5: Data collection

• Data collectors should be chosen carefully and should be familiar
with how information is arranged in the patients case notes.
• Knowledge of drug names, strength and the way orders are written
is also important.
• Depending on their availability, physicians, pharmacists and nurses
make ideal data collectors.
• Another concern is the timing of data collection.
• This should be done in a period that is likely to be representative of
the usual patterns of drug use.
• For example, a DUE examining the use of prophylactic antibiotics
prior to surgery should be done when the usual surgeons are in
attendance, taking care to avoid a period when key surgeons are on
leave.
Step 6: Evaluate results
• Data evaluation is one of the most critical steps in a DUE.
• The data obtained should be collated using available resources such
as spread sheeting, databasing and word processing.
• The next step is to summarize the major categories of results and to
identify where exactly the data shows deviation from the guidelines
and usage criteria that are previously identified.

• Reasons for deviation may include:

✓ Drug being used for new indications.
✓ Outdated procedures.
✓ Inadequate resources.
✓ Gaps in knowledge or misinformation or misunderstanding.

Step 7: Provide feedback of results

• The success of any DUE strategy depends on feedback of the results
to prescribers, other hospital staff involved in the study and to
administrative heads.
• The presentation of any report is also very important.
• The report should be well-presented and well-reasoned document
with no grammatical or typographical errors.
• It is important to prepare a scientific interpretation of the results
rather than a value judgement.
• The results can also be circulated to hospital staff through
newsletters. DUE meetings or the hospitals academic meetings.
Step 8: Develop and implement interventions
• If a drug use problem was identified, the next step is to consider how
the problem can be addressed.
• Interventions to improve drug use can be educational or operational.
1. Educational interventions:
✓ Educational interventions consist of educational
meetings, academic detailing circulation of protocols,
feedback of study results, letters to individual
physicians, newsletters and other informational
materials such as posters and guidelines.
2. Operational interventions:
✓ Operational interventions include the development/
modification of drug order forms, manual or
computerised reminders, prescribing restrictions,
formulary additions/deletions, automatic stop orders or
re-allocation of staff.

Step 9: Re-evaluate to determine if drug use has improved

• Drug use and prescribing patterns need to be monitored to determine
the success of interventions
• Typically, the re-evaluation is done 3–12 months after the introduction
of the intervention, and should involve collecting the same data as in
the original DUE evaluation.
• If a complete evaluation with several criteria uncovered only a few
problems, the focus may be narrowed to problematic criteria
 Step 10: Re-assess and revise the DUE programme
• At the conclusion of a DUE evaluation cycle, an evaluation of the DUE
programme is necessary. The questions addressed should include the
following:
➢ Did the programme address important aspects of care?
➢ Were the criteria developed appropriate?
➢ Were drug use problems identified?
➢ Were the interventions made appropriate?
➢ Did the interventions have any unexpected or adverse effects?
➢ Were drug use problems solved?
➢ Did the DUE have an impact on the incidence of adverse drug reactions,
drug–drug interactions, or medication errors?
➢ Did the DUE programme have a financial impact on the hospital?

• The DUE process involves cooperation and coordination between various

hospital staff.
• It is understandable that sometimes things may not happen as planned.
Hence, lessons learnt from the first DUE cycle should be used to improve
the quality, efficiency and effectiveness of future DUEs.

Step 11: Feedback results

• It is important to circulate the results of the DUE to clinicians and
other involved hospital staff.
• This is also a suitable time to obtain their opinions about the success
or otherwise of the interventions and how these can be improved.
❖ Possible role for pharmacists in DUE
• Pharmacists play a key role in the overall process of a DUE
programme because of their experience in the area of pharmaceutical
care.
• DUE affords pharmacists the opportunity to identify trends in
prescribing within groups of patients such as those with asthma,
diabetes or high blood pressure.
• Pharmacists can then, in collaboration with physicians and other
members of the healthcare team, initiate action to improve drug
therapy for both individual patients and patient populations.
o Planning, organizing and implementing a DUE programme.
o Programme, development, supervision and coordination.
o Education of hospital staff about DUE in conceptual an
practical terms. .
o Promotion of the goals and objectives of DUE.
o Development or review of audit criteria, guidelines, study
protocols and educational materials.
o Development of data collection instruments.
o Pilot testing , data collection , analysis and report writing.
o Documentation of programme outcome, effectiveness and
cost benefits.
o Participation in hospital committees concerned with quality
assurance in general and drug usage.
o Presentation of DUE results at meeting and conferences.
o Publication of results in peer-viewed journals.