Utilization management and review (DUR) are programs utilized by many payers to promote patient safety and manage costs by an increased review and awareness of outpatient prescribed drugs. The theory behind utilization review is that more careful scrutiny of drug prescribing and dispensing patterns should help avoid unfavorable drug-drug interactions, drug-disease interactions, therapeutic duplication and over-prescribing by providers. DUR programs may be administered either prospectively or retrospectively. As a result of OBRA 1990, States were encouraged by enhanced federal funding to design and install point-of-sale electronic claims management systems that interface with their information systems operations to facilitate review of pharmaceutical utilization in real-time.
Several studies have shown that PRODUR programs have had a positive effect on patient safety, provider prescribing habits and dollars saved. For example, a GAO report examined the PRODUR systems of five States (Maryland, Missouri, New Mexico, Oregon, Pennsylvania) to evaluate their effect on patient safety and cost savings. During a 12-month period, the systems alerted pharmacists to over 6 million prescriptions that had the potential causing unfavorable medical events due to drug-drug interactions, overutilization, and pregnancy. Approximately 10% of these alerts resulted in canceling prescriptions due to possible risks to patients. These cancellations resulted in savings of over $5 million to these five States.18