3.4 Patient Counseling, Prospective DUR & OBRA '90 Mandates

Prospective DUR and Patient Counseling

Mississippi Article VIII makes prospective drug utilization review and patient counseling core pharmacist responsibilities. OBRA ’90 established Medicaid counseling and DUR expectations, while Mississippi’s regulation supplies the practice rule applied in the pharmacy. Do not confuse the offer with the counseling itself or shorten DUR to an inaccurate six-item list.

Prospective DUR

Before dispensing, the pharmacist reviews the patient profile and available information for:

• overutilization and underutilization;
• therapeutic duplication;
• drug-disease contraindications;
• drug-drug interactions;
• incorrect dosage or duration of treatment;
• drug-allergy interactions; and
• clinical abuse or misuse.

Overutilization and underutilization are separate concepts even though they appear together in the rule. Counting the list as only six categories omits a required screening dimension. The review is prospective: discovering a contraindication after release does not satisfy the duty.

A computer alert supports but does not replace pharmacist judgment. The pharmacist evaluates clinical significance using dose, timing, diagnosis, organ function, prior use, prescriber intent, and patient factors. A resolved alert may be documented with the basis for dispensing. An unresolved serious problem requires prescriber or patient communication, modification, delay, or refusal as appropriate.

Offer and provider

When counseling is required, the pharmacy must make a meaningful offer. A pharmacist’s agent may ask whether the patient wants to speak with the pharmacist, but the agent may not provide the professional counseling. Counseling is performed by the pharmacist; a registered intern may participate within authorized supervision.

A sign on the counter, a prechecked refusal box, or “call if you have questions” may be inadequate if the process does not genuinely give the patient access to the pharmacist. At the same time, the law does not force a competent patient to listen. The patient or caregiver may decline.

Article VIII should not be embellished with a universal command that every refusal must be entered into a particular electronic field or written log. Documentation is often excellent risk-management policy, and a pharmacy may require it, but an exam answer should distinguish that policy from the current regulatory text.

Counseling substance

Counseling is individualized to significant information. Depending on the prescription, cover the drug name and description; dosage form, dose, route, and duration; intended use and expected action; special directions; precautions and contraindications; significant interactions; common or serious adverse effects and response; self-monitoring; proper storage; refill information; and missed-dose instructions. The pharmacist may supplement oral counseling with written material but should not merely hand over a leaflet when discussion is needed.

Use professional judgment for refills and familiar maintenance therapy, but a changed strength, new interaction, adherence problem, high-risk drug, or patient question can make counseling significant even if the prescription is labeled a refill.

Delivery and remote pickup

When a prescription is delivered rather than handed to the patient at the pharmacy, Mississippi requires printed information that tells the patient how to contact the pharmacy and addresses the counseling information required by the rule. The regulation should not be converted into an invented “toll-free number” requirement for every delivery if it requires the pharmacy’s name, address, and telephone contact.

If counseling occurs by telephone or video, protect privacy and ensure the person can ask questions. A technician may facilitate connection but cannot answer clinical questions.

Exam sequence

Apply four gates: Was prospective DUR complete? Was a meaningful offer made? Did an authorized professional provide any counseling? Was content adequate for the patient and drug? A patient’s refusal ends the counseling conversation but does not erase DUR, labeling, verification, or the pharmacist’s duty to intervene in a dangerous prescription.

DUR and counseling example

A new trimethoprim-sulfamethoxazole prescription reaches a profile containing warfarin and a documented sulfonamide allergy. DUR identifies both a drug-drug interaction and an allergy problem before dispensing. The pharmacist gathers reaction history, indication, INR plan, and prescriber rationale, then resolves or refuses the order and records the outcome. A patient’s later refusal to hear counseling does not authorize ignoring either DUR issue.

For home delivery, include written pharmacy contact and significant counseling information and make pharmacist access workable. If the patient calls about bleeding or rash, a technician transfers the call rather than interpreting the symptoms. A leaflet can reinforce dosing and warnings, but it cannot substitute for pharmacist intervention when the profile reveals an unresolved hazard.