The effect of the introduction of a nationwide DUR system where local DUR systems are operating—The Korean experience

Highlights

• The main role of the nationwide DUR system is to detect contraindications among prescriptions.

• The number of drugs per prescription was not related to the nationwide DUR introduction.

• The introduction of duplicate guidelines is considered to be the main reason for no effect.

• The doctor’s behaviour likely played a role in nullifying the effectiveness of the nationwide DUR system.

Abstract

Objective

Outpatient clinics in Korea usually have local DUR (drug utilisation review) systems, which are integrated with EMRs or health insurance claims submission systems. Whenever, the government announces a list of drug contraindications, each local DUR system loads the list and applies it in practice. In December 2010, a nationwide DUR system was introduced. This study is to investigate the impact of the nationwide DUR system on prescribing practices where local DUR systems are already operating.

Methods

Between January 2009 and December 2012 the monthly number of drugs per prescription was retrieved from the health insurance claims data warehouse at the Health Insurance Review and Assessment (HIRA). The monthly proportions of 3 DDI (drug–drug interaction) pairs, 6 drug–age contraindications, and 3 drug–pregnancy contraindications from January 2007 to December 2012, at the outpatient clinic level, were also retrieved. An interrupted time series analysis was used for controlling government announcements of drug contraindications.

Results

There was no difference in the number of drugs per prescription before and after the introduction of the nationwide DUR system. Most proportions of the 3 DDI pairs, 6 drug–age contraindications, and 3 drug–pregnancy contraindications, were significantly reduced following the government announcement of drug contraindications in the short term and/or long term.

Conclusion

The number of drugs per prescription was not related to the nationwide DUR introduction in places where local DUR systems are operating. The introduction of duplicate guidelines, in locations where the guidelines were already well followed, is considered to be the main reason for this. Furthermore, the Doctor’s ignorance of alerts, and their continued substitution of regulated drugs, for non-regulated drugs, likely played a role in nullifying the effectiveness of the nationwide DUR system.

Introduction

The drug utilization review (DUR) system is a systematic review program, for patient safety, that determines whether patients receive, or are prescribed, appropriate medications. It is usually defined as “an authorized, structured, and on-going review of prescribing, dispensing, and use of medication” [1].

There have been two types of DUR systems in Korea, which are: (1) local DUR systems based on electronic medical records (EMRs) and electronic claims submission systems at healthcare institutions, and (2) a nationwide DUR system operated by the health insurance review and assessment (HIRA).

The Korean food and drug administration (KFDA), formerly the ministry of food and drug safety, announced a list of 10 drugs of drug–age contraindication, for the safe use of drugs, in 2004. The number of drugs on the list has increased to 103 for drug–age contraindication, 314 for drug–pregnancy contraindication, and 385 for drug–drug interaction as of 2011 [2]. Whenever the KFDA announced a list of drugs with contraindications, each healthcare institution loaded them onto their local DUR systems, which were designed to monitor unfavourable contraindications in any given prescription. Each healthcare institution’s local DUR programs are up to date because being identified as updated was regarded as an indicator of a good quality of services, and the HIRA has denied payment of medical claims that contain the drugs on the list.

The nationwide DUR in Korea started with two pilot programs in April 2008. In the first program, clinics and pharmacies were encouraged to monitor potential interactions in a given prescription. The second program [3] was started in May 2009. Newly prescribed drugs were compared with drugs previously prescribed for patients at the same, or different, healthcare institutions in order to monitor duplication of ingredients and potential interactions between drugs [4]. After the pilot studies, the drug-related patient safety information described above was loaded on the nationwide DUR system, which has been operating since December 2010. Its primary function is to improve the quality of care for patients and reduce pharmaceutical expenditure in the health care system. As of March 2011, 98.6% of 64,385 healthcare institutions were connected to the nationwide DUR system, and 90.1% of all prescriptions, as reported by health insurance claims, were checked by the system [5].

Clinics in Korea are responsible for primary healthcare. However, they are different from other countries, in that, they usually provide private and specialty services. Prices of services are strictly controlled by the fee schedule of the national health insurance program. Health insurance claims are submitted to the HIRA for review through the nationwide network of electronic data interchange (EDI) [6]. Ninety-nine percent of health insurance claims from clinics are submitted through EDI [7]. Half of them use EMR and the remainder use another kind of information system that supports EDI submission of health insurance claims. These are favourable electronic environments for the introduction of a nationwide DUR system.

Patients in Korea tend to visit several healthcare institutions for any reason, as the patients are allowed to access clinics, specialists, and hospitals without restriction [3]. Visiting multiple healthcare institutions is known to increase the possibility of exposing patients to potential risks from drug interactions [8], and poor communication between multiple providers is considered as a potential cause of drug–drug interactions (DDI) and adverse drug events (ADEs) [9], [10].

The average number of drugs in prescriptions is one of the indicators for the drug utilization research recommended by the WHO [11]. The number of drugs prescribed to patients is a strong risk factor for ADEs in various settings, such as hospitalized elderly patients [12], [13], ambulatory care settings [14], nursing homes [15], elderly in emergency [16], [17], and analgesic drug use emergency [18]. In addition, a strong relationship was found between the number of dispensed drugs and potential DDIs, especially for potentially serious DDIs [19], [20]. It implies that a reduction of potential ADEs and DDIs can be measured as a reduction of the number of drugs in prescriptions.

The average number of drugs per prescription in Korean clinics was 4.05 in 2009, which was a considerably higher number than most countries [21], [22]. By decreasing drug consumption, the DUR was expected to have the effect of, not only on reducing potential ADEs and DDIs, but also decreasing pharmaceutical expenditure [23], which accounted for almost 30% of total expenditure from the National Health Insurance in 2008 [24].

The purpose of this study was to investigate the impact of the nationwide DUR system on prescription changes in Korean out-patient clinics wherein local DUR systems were already operating.