Despite the rising costs of pharmacological agents in the VHA, evaluation of trends in specific medications are based as a percentage of 30 day fills with the medication of interest as the numerator and all 30-day prescriptions as the denominator. There is no adjustment for disease prevalence. Drug utilization reviews are not standardized. The inability to assess "utilization" in a context of "appropriateness" hampers managerial decision-making and policy-making.
We propose that use of a medication order template (in the computerized patient record system) for designated medications will simultaneously accomplish three objectives: (1) clinicians will be required to review the essential health factors for ordering the specific medication; (2) the health factors will be stored in VISTA, enabling them to be subsequently retrieved electronically and downloaded into relational data bases for drug utilization reviews; (3) and a medication order progress note will be generated that can be accessed to review the appropriateness of an individual prescription order or to perform retrospective drug utilization reviews.
Specific aim 1: To determine the agreement between structured CPRS chart review by physician and pharmacy experts of the appropriateness of medication requests ("reference standard") and their review of a summary progress note of information based upon the requesting physician completion of a structured medication ordering -drug utilization evaluation template in CPRS.
Specific Aim 2: To evaluate whether the implementation of a medication order template increases the appropriateness score of medication dispensed.
For specific aim 1, we will evaluate the inter-rater agreement between implicit reviews of chart compared with the summary progress notes using intraclass correlation coefficient for interval ratings using repeated measures.
For specific aim 2, in order to evaluate changes in appropriateness score at the facility level, we will randomly sample medication order template progress notes and compare changes in the summary appropriateness scores and individual sub-domains.
The first template has finally been implemented VISN wide in FY 04. Preliminary datal, based upon a staggered implementation approach, suggests that the use of the template reduced utilization. Initial chart abstraction and comparison against the VISTA data is underway at New Jersey.
Validation of the review of a medication order progress note with auditable health factors against review of the CPRS medical record may prove to be an innovation in health care delivery if it reduces the need for chart abstractions for drug utilization review
External Links for this Project
None at this time.