DUR Board DUR Board Meeting Meeting

March 12, 2008March 12, 2008

West VirginiaWest Virginia

Department of Health and Human Department of Health and Human ResourcesResources

Bureau for Medical ServicesBureau for Medical Services

Drug Utilization Review BoardDrug Utilization Review Board

DUR Board DUR Board Meeting Meeting

March 12, 2008March 12, 2008

DUR Interventions DUR Interventions

– Review of monthly DUR cycles, profile review by Review of monthly DUR cycles, profile review by DUR Review Committee, includes review of Lock-In DUR Review Committee, includes review of Lock-In casescases

– Methadone – general warning intervention letterMethadone – general warning intervention letter– Pain Management – long term use of short acting Pain Management – long term use of short acting

narcoticsnarcotics– Polypharmacy – 20 or more different drugsPolypharmacy – 20 or more different drugs– Atypical antipsychotic utilization – review of criteria Atypical antipsychotic utilization – review of criteria

for duplicate therapy, impact on diabetes, for duplicate therapy, impact on diabetes, unlabeled usesunlabeled uses

DUR Board DUR Board Meeting Meeting March 12, 2008March 12, 2008

Monthly DUR Review CommitteeMonthly DUR Review Committee

– Committee meets the last Monday of the Committee meets the last Monday of the monthmonth

– 200 DUR cases – high risk score patients, 200 DUR cases – high risk score patients, includes those with multiple providers and includes those with multiple providers and criteria exceptionscriteria exceptions

– 50 Lock-In cases50 Lock-In cases– Lock-In re-review and annual review casesLock-In re-review and annual review cases

DUR Board DUR Board Meeting Meeting March 12, 2008March 12, 2008

DUR Review Committee September to December DUR Review Committee September to December

20072007 1,472 DUR Cases generated1,472 DUR Cases generated 2,073 prescriber letters generated2,073 prescriber letters generated 1,858 mailed1,858 mailed 215 letters not mailed due to bad prescriber 215 letters not mailed due to bad prescriber

address or hospital DEA number.address or hospital DEA number. 404 responses - 22% Response rate404 responses - 22% Response rate Pharmacy response rate is 27% Pharmacy response rate is 27%

DUR Board DUR Board Meeting Meeting March 12, 2008March 12, 2008

DUR Review CommitteeDUR Review Committee Case evaluation responseCase evaluation response 312 responses to the evaluation question312 responses to the evaluation question

””I have reviewed the enclosed I have reviewed the enclosed information and information and found it to be……”found it to be……”

87 Extremely useful87 Extremely useful 131 Useful131 Useful 17 Somewhat useful17 Somewhat useful 50 Neutral50 Neutral 27 Not Useful27 Not Useful

DUR Board DUR Board Meeting Meeting March 12, 2008March 12, 2008

Methadone UtilizationMethadone Utilization

– All patients taking Methadone during All patients taking Methadone during October 2007October 2007

– 297 patients and letters mailed 11/29/07297 patients and letters mailed 11/29/07– Letter had general warning about Letter had general warning about

Methadone toxicitiesMethadone toxicities– 12 letters could not be mailed or returned 12 letters could not be mailed or returned

due to bad addressdue to bad address– 114 responses – 39% response rate114 responses – 39% response rate

DUR Board DUR Board Meeting Meeting March 12, 2008March 12, 2008

Methadone UtilizationMethadone Utilization

– 114 responses – 39% response rate114 responses – 39% response rate 89 patient continuing without a problem89 patient continuing without a problem 7 no longer my patient7 no longer my patient 5 will reassess and modify therapy5 will reassess and modify therapy 4 has appointment to discuss therapy4 has appointment to discuss therapy 2 tried to modify therapy, symptoms returned2 tried to modify therapy, symptoms returned 3 ER or on call prescriber3 ER or on call prescriber 1 tried to modify patient non-cooperative1 tried to modify patient non-cooperative 1 not seen patient recently1 not seen patient recently 1 response did not discuss therapy1 response did not discuss therapy

DUR Board DUR Board Meeting Meeting March 12, 2008March 12, 2008

Pain Management – long term use of Pain Management – long term use of short acting narcoticsshort acting narcotics

Patients taking 4 or more doses per day of Patients taking 4 or more doses per day of short acting agent for 90 days and no long short acting agent for 90 days and no long acting agentacting agent

389 prescriber letters generated 389 prescriber letters generated 54 deleted, hospital DEA or bad address54 deleted, hospital DEA or bad address 335 letters mailed 12/26/07335 letters mailed 12/26/07 79 responses (22% response rate)79 responses (22% response rate)

DUR Board DUR Board Meeting Meeting March 12, 2008March 12, 2008

Pain Management – long term use of short Pain Management – long term use of short acting narcoticsacting narcotics

34 patient continuing without a problem34 patient continuing without a problem 13 has appointment to discuss therapy13 has appointment to discuss therapy 11 no longer my patient11 no longer my patient 5 will reassess and modify therapy5 will reassess and modify therapy 5 tried to modify patient non-cooperative5 tried to modify patient non-cooperative 4 tried to modify therapy, symptoms returned4 tried to modify therapy, symptoms returned 3 ER or on call prescriber3 ER or on call prescriber 1 not seen patient recently1 not seen patient recently 1 response did not discuss therapy1 response did not discuss therapy 1 unaware what others ere precribing1 unaware what others ere precribing 1 patient deseased1 patient deseased

DUR Board DUR Board Meeting Meeting March 12, 2008March 12, 2008

PolypharmacyPolypharmacy– patients with more than 20 different drugs during patients with more than 20 different drugs during

each month of a three month periodeach month of a three month period– Different drug label name, could be same drug Different drug label name, could be same drug

different dosedifferent dose– 44thth quarter 2007, 584 recipients, 1,598 prescribers quarter 2007, 584 recipients, 1,598 prescribers– Prescribers will receive a letter with a list of Prescribers will receive a letter with a list of

patients names and ID numbers and an patients names and ID numbers and an abbreviated 3 month drug history profile for each abbreviated 3 month drug history profile for each patient on the listpatient on the list

– Otherwise many prescribers would have received Otherwise many prescribers would have received many letters many letters

– General response form will not be patient specificGeneral response form will not be patient specific

DUR Board DUR Board Meeting Meeting March 12, 2008March 12, 2008

Criteria for atypical antipsychotic agents Criteria for atypical antipsychotic agents Therapeutic duplication of atypical agents – criteria Therapeutic duplication of atypical agents – criteria

alerts at GCN level which is drug/dose combination alerts at GCN level which is drug/dose combination 1,381 criteria exceptions - many could be same drug 1,381 criteria exceptions - many could be same drug

different dose different dose Atypical agents and worsening diabetes – any Atypical agents and worsening diabetes – any

atypical agent and a drug for the treatment of atypical agent and a drug for the treatment of diabetes or diabetes diagnosis will trigger alertdiabetes or diabetes diagnosis will trigger alert

1,197 criteria exceptions1,197 criteria exceptions Atypical agents not FDA approved for dementia in Atypical agents not FDA approved for dementia in

elderlyelderly 11 criteria exceptions11 criteria exceptions

Several high dose, dose optimization and drug–drug, drug–Several high dose, dose optimization and drug–drug, drug–disease interaction criteriadisease interaction criteria

DUR Board DUR Board Meeting Meeting March 12, 2008March 12, 2008

Criteria for atypical antipsychotic Criteria for atypical antipsychotic agentsagents criteria not active for WV but will be next criteria not active for WV but will be next

monthmonth Low dose quetiapine (<200mg) for Low dose quetiapine (<200mg) for

sedative use sedative use Multiple atypical agents, 3 or more Multiple atypical agents, 3 or more

atypical agents within 30 daysatypical agents within 30 days Multiple antipsychotic agents - 3 or more Multiple antipsychotic agents - 3 or more

of any antipsychotic agent within 30 daysof any antipsychotic agent within 30 days

DUR Board DUR Board Meeting Meeting March 12, 2008March 12, 2008

Atypical Antipsychotic Agents Maximum Quantity Limits Abilify® 5 mg; 15 mg - 1 tablet per day Geodon® 20 mg; 40 mg - 2 capsules per day Invega® 3 mg, 6 mg; 9 mg - 1 tablet per day Risperdal 0.25 mg; 0.5 mg; 1 mg; 2 mg - 2

tablets per day Seroquel® 25 mg - 4 tablets per day Zyprexa® 2.5 mg; 5 mg; 7.5 mg - 1 tablet per

day Zyprexa® Zydis® 5 mg - 1 tablet per day