• Tierney, William M. (PI)

Project: Research project

Project Details


Drug utilization review (DUR) has rapidly become a major focus of quality
of care within the medical community and has become a major financial
interest within the federal government. With the enactment of OBRA 1990
individual states are mandated to implement DUR programs by January 1993.
DUR is a process for improving pharmaceutical therapy by comparing actual
drug use to established predetermined criteria and providing the results
of this comparison to prescribing physicians. DUR has two basic
approaches: retrospective and prospective. Each of these have inherent
limitations, but optimism exists that prospective DUR offers efficacious
advantages. Controlled trials are currently lacking to support this
optimism. Previous research into physician decision making at Indiana
University and the Regenstrief Institute suggests that patient specific
reminders delivered to the health care provider at the time a decision
is being made may improve compliance with treatment recommendations.
These reminders utilize patient data from the Regenstrief Medical Record
System (RMRS) a longitudinal, combined, in-patient and out-patient
electronic medical record. Improvement in compliance has been
demonstrated for preventive care reminders and laboratory test ordering.
The proposed study will examine in a randomized controlled trial the
effect of reminders generated by a rule-based, expert system which will
be fed back to the prescribing physician at the time of prescription
writing or to pharmacists at the time of prescription dispensing. The
expert system will combine condition and patient specific treatment
recommendations with previously recorded patient data which is stored in
the RMRS to create highly patient specific reminders. Treatment criteria
will be developed based ont he scientific literature and compendia as
well as a local expert consensus panel. In addition, condition specific
predictive models will be developed and probabilities of patient outcomes
such as hospitalization provided to the physician as part of the
feedback. Three target conditions (congestive heart failure, reactive
airways disease, and coronary artery disease) were selected for DUR study
because they represent common, disabling, and morbid diseases. The 160
physicians in an academic, inner city, general medicine practice will be
randomized to (1) usual care (limited to the hospital's ongoing
retrospective DUR); (2) physician targeted prospective DUR; (3)
pharmacist targeted prospective DUR; or (4) combined physician and
pharmacist targeted prospective DUR. Five hundred patients with each
condition will be identified and followed at 6 month intervals for two
years. Primary outcome measures will include functional status (SF-36
scores), condition specific questions, patient satisfaction with health
care (PSQ scores), and subsequent medicine compliance and
hospitalization. Secondary outcome measures will be physician and
pharmacist compliance with guidelines, patient mortality, and direct
health care costs. This project will have considerable power to detect
differences in the primary outcomes. If shown to positively affect
patients' functional status, satisfaction with health care, or health
care utilization, a computer-based DUR will offer a cost-effective tool
for improving health care delivery.
Effective start/end date7/1/9312/31/97


  • National Institutes of Health
  • National Institutes of Health
  • National Institutes of Health
  • National Institutes of Health


  • Medicine(all)


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