
The objective of the present study was to evaluate the effects of implementing a systematic Drug Utilization Review (DUR) system on contraindicated drug use and pharmaceutical expenditures in Korea.
A literature search was conducted using search engines such as PubMed, EMBASE, NDSL, and RISS for relevant systematic studies. The database search was performed and updated in April 2018. Two independent reviewers evaluated the abstracts to find potentially eligible articles.
In total, 1433 potentially eligible studies were selected, and 11 articles were eventually shortlisted for inclusion in the present review system. The outcome showed that contraindicated drug use decreased after implementation of the DUR system in Korea. The analysis also showed that the DUR system contributed to a reduction in pharmaceutical expenditures.
Our study showed that implementing the DUR system reduced both contraindicated drug use and pharmaceutical expenditures in Korea.
The drug utilization review (DUR) system is a systematic program to determine whether patients receive, or are prescribed, appropriate medication to improve patient health status.1) As defined “an authorized, structure, and on-going review of prescribing, dispensing, and use of medication”, DUR system adopted predetermined criteria for appropriate drug therapy compared to patient’s records. Effective implementing DUR system, as supported by various reports, promised to reduce or eliminate serious preventable drug-related adverse events such as contraindicated drug use.2,3) As contraindicated drug use is life-threatening for some patients, to ensure safety while prescribing drugs, avoiding contraindicated drug use is the most essential factor.4-6) Furthermore, contraindicated drug uses were attributed to increase expenditures by additional hospital admissions.2) Considering the risk for mortality increased by 40% with inappropriate exposure to contraindicated drugs for some vulnerable patients,6) ensuring effective implementation of DUR system is important for the clinical and economic aspects.
Nevertheless, some researchers reported current DUR system has yet to reach its full potential.7-9) These reports initially questioned about the important discrepancy between current practice and potential advantages from drug utilization review, which showed that critical drug interactions were not detected by DUR systems.7,8) Others described that current DUR systems fail to “promote appropriate use of medications without having to remove useful but clinically interacting agents from the market”9) with several studies suspected the efficiency of regulatory actions preventing prescription of contraindicated drugs.10,11) Besides, a systematic review and meta-analysis showed that computerized decision support systems linked to electronic health records such as DUR systems did not significantly reduce mortality and morbidity.12)
In Korea, also, the DUR system was implemented as a unique format to notify concurrent and real-time information to physicians and pharmacists. After the need for a DUR system was raised in 2003, the system was supplied nationwide in December 2010. The DUR system includes a list of medications predefined with DUR criteria including contraindications in pregnant women, drugs with drug-drug interactions, and drugs with age contraindications.3) It was managed with the Health Insurance Review and Assessment Service (HIRA) database includes nationwide information from hospitals and pharmacies on patient demographics, diagnosis, prescriptions, and healthcare providers, which is linked to the Korean National Health Insurance data that issues reimbursements.13) Despites of various research supports for the effectiveness of the DUR system in Korea, still, onethird of the users of the DUR system did not agree that the DUR alerts could identify rare adverse drug reactions. Indicated by Goedecke
The search was conducted in PubMed and EMBASE for previous relevant systematic studies. Also, for searching relevant articles in Korean, we performed database searches in National Digital Science Library (NDSL) and Research Information Sharing Service (RISS). Our database search was performed and updated in April 2018. Published articles searched for were limited that they investigated the effects of the DUR systems in Korea. The literature search was restricted to full-text articles that were written in English and Korean. In addition, we manually searched the references of the collected articles and systematic reviews for additional relevant studies. Supplementary Appendix 1 details the PubMed search strategy.
Two independent reviewers first evaluated the abstracts to find potentially eligible articles. All types of study designs were selected. We selected studies conducting analysis with HIRA data and evaluating the effects of the DUR system on contraindicated drug use and pharmaceutical expenditures in Korea. Data were classified into those of the following two periods: the “Pre-DUR” period data, collected from studies that provided data before implemented the nation-wide DUR system, and “Post-DUR” period data, collected after the implementation. In addition, we collected studies providing number of contraindicated drug uses and pharmaceutical expenditures as outcomes. No date or time restrictions were applied and all articles published before and after nation-wide DUR system implementation in Korea were analyzed. We excluded duplicates, abstracts, letters to editors, commentaries, and supplements. A contraindicated drug was defined in terms of the authors’ definition in each study that was included. The data extracted from the retrieved articles included the year of publication, study design, study setting, data source, types of database, observation period, main findings, and drug regimens prescribed. Any disagreements between two independent reviewers were solved through discussions.
Two investigators extracted data and assessed the validity with a qualitative evaluation system.15) For the assessment, we applied a checklist developed by Vander Stichele R.
We reported a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.17) Through our comprehensive search, 1341 potentially eligible articles were selected from PubMed and EMBASE. Additionally, 92 eligible articles were chosen from NDSL and RISS. After full-text review, 67 articles were selected. Fifty-six studies were excluded, and 11 articles were included in the present systematic review (Fig. 1). We did not include any article following the manual search.
Flow diagram for study selection.
The summary of characteristics of all the studies finally included was provided in Table 1. All included studies18-28) evaluated the effects of the DUR system implemented in Korea, and the majority of study data used in these studies were Health Insurance Review and Assessment Service (HIRA) data. SO Kim
Data provided by all included studies showed low risk of bias for data collection, and were retrieved from HIRA or NHIS database (Table 2). Three studies18,20,21) analyzing data from a local area in Korea showed high risk of extrapolation bias. Three studies20,22,28) provided specific data separated from between inpatient and outpatient settings. Also, there were possibilities for OTC sales of medicines prescribed in four studies.18,20-22) Risk of under-detection bias by OTC sales was determined to be a medium risk. Except for two studies,21,23) Anatomical Therapeutic Chemical Classification (ATC) or defined daily dose (DDD) assignments were not indicated, and thus others showed medium or high risk of bias.
Six included studies showed comparative outcomes between pre-DUR and post-DUR periods showing trends of contraindicated drug uses (Table 3). Except for the study by SO Lee
Three studies18,20,21) provided the changes of pharmaceutical expenditures after DUR system was implemented (Table 4). Two studies18,21) showed the reduction of expenditures through the implementation of DUR system in Korea. A pilot program18) conducted with the same system as nation-wide DUR system initiated from 2010 in Korea, which also showed a reduction of pharmaceutical expenditures. In this study, after implementing DUR system in Korea, absolute reduction of clinics showed $2126.74 and $246.14 for pharmacies. MH Yi
We conducted a systematic review to evaluate the effects of implementing the DUR system in Korea on prescribing trends for contraindicated drug use and pharmaceutical expenditure changes. We found that contraindicated drug reduced after the DUR system was initiated in 2010. In addition, the DUR system contributed toward decreasing the burden on pharmaceutical expenditures.
In the present study, the majority of included studies presented the reduction of contraindicated drug use after the DUR system was implemented. SO Lee’s
Moreover, our study showed that implementing the DUR system contributed to a decrease in pharmaceutical expenditures. MH Yi
Our study has several limitations as well. First, the findings of this present study should be applied with caution in the interpreting economic effects of DUR system to other entities such as pharmaceutical companies. Thus, future pharmacoeconomic evaluation should be conducted in future studies. Secondly, our study could not include clinical trials to conduct metaanalysis with included studies because of heterogeneity. We expected that more clinical studies evaluate the effects of DUR system for the patients’ safety and efficacy in Korea in the future. Next, the present study did not compare the magnitude of reduction between studies according to the risk of bias. According to the quality evaluation, several studies such as JY Shin
To our knowledge, this is the first systematic review to assess the effects of implementing DUR systems for contraindicated drug use and pharmaceutical expenditures in Korea. We conclude that the DUR system was successfully implemented to provide a reduction of prescribing contraindicated drugs. We also noted that the DUR system decreased pharmaceutical expenditures. Since the DUR system has been implemented in Korea in 2010, it has contributed to an improvement in patient safety and the economic status in Korea.
In conclusion, our study showed that implementing the DUR system both reduced contraindicated drug use and pharmaceutical expenditures. With regard to patient safety, the DUR system is a cost-effective regulatory action. However, there is a need to further evaluate the DUR system with various types of clinical outcomes or study designs in the future.
No funding sources for this study.
No conflicts of interest have been declared.
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