Although distinctions historically have been made among the terms drug-use evaluation, drug-use review, and medication use evaluation (MUE), they all refer to the systematic evaluation of medication use employing standard, observational quality-improvement methods. MUE is a quality-improvement activity, but it also can be considered a formulary system management technique. An MUE is a performance improvement method that focuses on evaluating and improving medication-use processes with the goal of optimal patient outcomes.
MUE encompasses the goals and objectives of drug use evaluation (DUE) in its broadest application, emphasizing improving patient outcomes. The use of MUE, rather than DUE, emphasizes the need for a more multifaceted approach to improving medication use. MUE has a common goal with the pharmaceutical care it supports: to improve an individual patient’s quality of life through the achievement of predefined, medication-related therapeutic outcomes. Through its focus on the system of medication use, the MUE process helps to identify actual and potential medication-related problems, resolve actual medication-related problems, and prevent potential medication-related problems that could interfere with achieving optimum outcomes from medication therapy.
Issues of Concern
In the institutional setting, MUE methods have traditionally involved establishing evidence-based criteria for medication use and applying those criteria retrospectively to determine the degree to which a particular medication was used in discordance with established criteria. Interventions then could be used to improve prescribing based on those data. As electronic medical records have become increasingly important and more widely available, MUE activities have matured from simple paper-based medical record reviews to sophisticated analyses drawing on multiple data sources regarding medication use. A more expansive approach to MUE has been described in which the use of individual medications and the entire process of care for disease states are examined. Quasi-experimental research methods may provide more meaningful information for quality improvement purposes (e.g., economic, clinical, and humanistic outcomes of greater relevance than arbitrarily set appropriateness criteria).
MUE can be simply informative, such as collecting data to guide decision-making or measuring the effect of interventions, such as the addition of a new agent to the formulary or the implementation of a new medication use policy. MUE activities can focus on any dimension of the medication-use process (from medication acquisition to patient monitoring), presenting an opportunity for improvement. While MUE often focuses on problem-prone, high risk, or high-cost medications, MUE can be used to examine any aspect of medication use that is problematic to the institution conducting the evaluation.
A systematic plan to monitor, evaluate, and improve medication use should be established within the organization. Such a plan is an accreditation requirement for many organizations, such as the Joint Commission. MUE should be a part of the organization’s overall quality-improvement program. MUE activities should be conducted to examine the effect of medication use policy decisions, particularly those made in the absence of convincing evidence from the biomedical literature, but they also can be conducted to inform decision-making, again, particularly when making policy decisions under conditions of uncertainty. Specific projects to evaluate medication use can involve assessing how an individual medication is used or evaluating medication management of a given disease state. All steps of the medication-use process should be evaluated over time. The P and T committee, or its equivalent, should be involved in the MUE process.
In the community pharmacy setting, DUR is mandated by Federal Law (OBRA-90) for those patients receiving drugs through Medicaid. A review for preventable problems (pro-DUR) is a mandated component of this process. There are Federal mandates for resources to be used in creating the criteria used. The State agency administering Medicaid is also mandated to perform the quality review discussed above and called retro-DUR in this setting. DUR programs play a key role in helping managed health care systems understand, interpret, and improve the prescribing, administration, and use of medications. Employers and health plans find DUR programs valuable because the results are used to foster more efficient use of scarce health care resources. Pharmacists play a key role in this process because of their expertise in the area of pharmaceutical care. DURs allow the managed care pharmacist to identify trends in prescribing within groups of patients such as those with asthma, diabetes, or high blood pressure. In collaboration with other health care team members, pharmacists can then initiate action to improve drug therapy for both individual patients and covered populations. DURs serve to improve the quality of patient care, enhance therapeutic outcomes, and reduce inappropriate pharmaceutical expenditures, thus reducing overall health care costs.
MUEs and DURs are classified into three categories: prospective, concurrent, and retrospective. In a prospective review, evaluating a patient's therapy is planned and takes place before the medication is dispensed. In a concurrent review, the review is ongoing, and drug therapy is monitored during treatment. In a retrospective MUE, the evaluation and review of the therapy occur after the patient has received the medication. Specific elements addressed in each medication use evaluation are:
- Define the purpose, focus, and priorities,
- Develop the usage criteria to be evaluated,
- Collect the usage data; review and evaluate the data collected,
- Develop and implement actions to improve medication usage,
- Assess the actions that were implemented,
- Document the results, and
- Report the results to other healthcare professionals.
The success of each medication usage evaluations should be reviewed within a specific timeframe, whether it be three months, six months, or a year.
Concurrent evaluation (collecting data during care delivery and sometimes as a component of the care process) is usually preferred over retrospective methods because it allows organizations to select relevant outcomes for collection rather than rely on outcomes routinely documented within patient medical records. For example, quality-of-life measures remain an infrequently documented measure in medical records. Only through concurrent evaluation can that outcome measure be reliably captured. Medications recently added to the formulary should be evaluated, especially if there is the potential for inappropriate use or adverse effects of concern. This review should occur 6 to 12 months after their addition to the formulary. High-cost, high-use, and problem-prone medications also are good candidates for evaluation.
Nursing, Allied Health, and Interprofessional Team Interventions
Applying MUE to patient care is an interprofessional team activity; it cannot occur within disciplinary "silos." For MUE to be effective, it requires communication and coordination among the various healthcare team members, where clinicians, specialists, pharmacists, and nurses all have input and open access to all data regarding medication use. Each team member must be empowered to contribute to the process, and the latest studies and data should apply in the decision making process. Clinicians need to be open to input from pharmacists and nursing staff so that optimal medication use and procurement can lead to optimal patient outcomes. [Level 5]