DUR: Prospective Drug Utilization Review: Early Refill Alerts
Early refill or over-utilization interventions are intended to protect patients from adverse events associated with using a prescribed medication beyond the recommended dose. Serious consequences of over-utilization may include drug overdose, additive toxicity and increased side effects. In addition, over-utilization of certain drugs may serve as an indication of uncontrolled disease. For example, excessive use of a beta-agonist inhaler, such as albuterol, should prompt the pharmacist to suspect poorly controlled asthma. Most asthma attacks are preceded by periods in which the patient gradually increases the use of their beta agonist or “fast-acting” inhaler. Recognizing this need and alerting the patient or the patient’s physician may result in the avoidance of emergency room visits and hospitalizations for asthma exacerbations.
In the first six months of 2004, the Medi-Cal prospective alert system issued 9,156,644 alerts. Early refill or over-utilization accounted for nearly one-third of these alerts. Of the 2.7 million early refill alerts issued, less than 1 percent (0.08 percent) of the claims were cancelled; about 45 percent of claims with early refill alerts were dropped, meaning the pharmacist did not resubmit the claim with a DUR override; and 55 percent of alerts were overridden and the claims were filled as is.
Top-10 Early Refill Alerts for January 2004 through June 2004:
Rank |
Drug |
||
1 |
Olanzapine | ||
2 |
Gabapentin | ||
| 3 | Quetiapine Fumarate | ||
| 4 | Risperidone | ||
| 5 | Albuterol | ||
| 6 | Atorvastatin Calcium | ||
| 7 | Trazodone HCl | ||
| 8 | Paroxetine HCl | ||
| 9 | Amitriptyline HCl | ||
| 10 | Metformin HCl | ||
The over-utilization of these drugs can result in adverse effects and serious clinical consequences.
Medi-Cal is concerned with the high frequency of overrides on the early refill alerts, coupled with the types of drugs that are most frequently overridden. Medi-Cal reminds providers to carefully consider each early refill alert before they override it. Continued high volumes of such overrides may force Medi-Cal to examine the use of a “hard edit,” such as requiring a Treatment Authorization Request, instead of its current “soft edit” safety alert program, in terms of clinical and economic outcomes.