Patient safety goes beyond drug-drug interaction

The practice of reviewing patient information during drug prescribing to identify and prevent potential adverse drug events has been as much a part of the clinical care model as prescription pads. Since physicians began prescribing in a professional and regulated environment, prescribers have generally conducted their own patient safety assessment, asking patients what types of medications they are on, considering factors such as age before prescribing a medication, and noting the results in the patient's record. The implementation of effective patient safety practices was simple when the clinical care team consisted generally of one physician prescribing and one pharmacist dispensing, and the drug-therapy options were relatively limited.

As time has passed, the traditional model of the clinical team has grown to include multiple physicians and multiple pharmacists, and the therapeutic options available to treat patients have grown exponentially. An analysis by Medco Health Solutions Inc. showed that one in four seniors -the most prominent healthcare consumer-was prescribed medications by four or more doctors, with one senior in seven filling prescriptions at five or more pharmacies in 2002. In short, the changing face of the clinical care model has ushered in an important expansion of traditional patient safety practices-an expansion that can also reduce healthcare costs.

Identifying Potential Problems

Generally, when a patient presents a prescription for dispensing at a pharmacy, the medication is compared with the patient's complete pharmacy record to identify potential problems between the drug prescribed and other drugs the patient may be taking. As the administrator on all prescription claims, the PBM may be the only source that holds a complete record of all the patient's medications, regardless of pharmacy or physician, and therefore serves as a safety net to catch any potential adverse drug events, including drug-drug interactions, excessive dosages, prescription duplication and over- or under-use.

Each year, millions of prescriptions are flagged by DUR systems, yielding untold savings to plan sponsors, while giving physicians the added insight into their patient's medication regimen that they may not have because of the advent of the multiple prescriber environment.

Retrospective Claims

While the prevention of drug interactions and adverse events may be the most prominent and fundamental function of patient safety systems, other patterns of costly medication mismanagement such as excessive utilization and fraud cannot be identified by such systems. In addition to real-time functions, drug utilization review is now being used in a retrospective fashion to identify additional medication mismanagement and high utilization cases and allow plan sponsors and payers to take action.

The "retro" DUR process involves calculating daily dosage utilization, especially in the cases involving controlled substances, and reviewing claims for questionable prescribing or dispensing. Once identified, communication can take place with the physician and pharmacists to verify course of therapy and, if necessary, take action. And the savings can add up. A 2003 analysis by Medco showed a 33% reduction in health plan costs following action taken in cases identified by its "retro" DUR process. But the impact on patient safety and error prevention provided by retrospective claims analysis may be immeasurable.

While traditional patient safety has remained contained within the pharmacy benefit, new safety systems are emerging that allow for integrated patient data analysis, with an eye on identifying those adverse drug events that can be most costly and often lead to hospitalizations. In 2000, hospitalizations caused by the use of prescription medications cost health plans more than $121 billion.

New integrated patient safety systems can provide a more in-depth analysis than traditional DUR because they take into consideration not only pharmacy data but also major medical and diagnostic patient data. As a result, these integrated systems can identify interactions between drugs and other diseases a patient may have, which would be missed in a traditional patient safety system. In a recent 12-month period, RationalMed-which consists of 5,000 patient safety rules that are not included in traditional DUR-helped avoid as many as 20,000 potential hospitalizations across its enrolled population, and generated alert packages for physicians to notify them of the situation. RationalMed is estimated to have saved more than $42 million in healthcare costs.