The P&T committee: Clinical Hospital Center, Zagreb, Yugoslavia

A P&T Committee was recently founded and organized by clinical pharmacologists at the Clinical Hospital Center in Zagreb, Yugoslavia. Although subtle differences are evident, the responsibilities of the Yugoslav P&T Committee parallel those of the P&T Committees in hospitals in this country. A hospital formulary has been established in Zagreb's Clinical Hospital Center, resulting in more rational prescribing of drugs. The criteria for formulary inclusion and protocol for submission are provided. Other responsibilities of the Yugoslav P&T Committee in Zagreb are discussed.     

The effect of an education program on cefazolin prescribing.

A study was conducted to identify cefazolin prescribing practices prior to a pharmacy based educational program and to assess the effect of the educational program on cefazolin prescribing and costs. The educational program consisted of the circulation of a drug information bulletin, a letter from the Chairman of the Pharmacy and Therapeutics Committee to all medical staff and pharmacists plus personal communications with physicians by pharmacists. The assessment involved a retrospective review of all cefazolin orders written during two 25-day periods, before and after the educational program. The results demonstrated a statistically significant reduction (p less than 0.05 by Z-test of proportions) in the number of cefazolin orders more frequent than every eight hours as well as the total number of doses given at more frequent regimens. This improvement in appropriate prescribing resulted in cost savings of $1,727.71 for the post education study period. This saving extrapolated to 12 months would lead to a $25,224.57 annual saving. This study suggests the effectiveness of a multifaceted educational program in optimizing prescribing.     

A multidisciplinary process to determine, communicate, and manage an antibiotic formulary

This article describes a collaborate process developed by the Pharmacy & Therapeutics Committee to define, determine, communicate, and manage an effective antibiotic formulary. Multiple professional disciplines represented by the antibiotic subcommittee evaluated each classification of antibiotics and recommended a preferred drug(s) for each classification. Decisions were based on relative safety, efficacy, and cost with minimal duplication of therapeutic equivalent antibiotics. A therapeutic interchange policy was unnecessary because extensive communication measures developed by the committee proved effective. The strategy used strengthened pharmacist/physician working relationships. This process permitted rationality and understanding by the medical staff, which resulted in unanimous formulary acceptance.     

Total formulary review--the easy way

In an effort to minimize drug costs, many hospital pharmacy services have limited their drug inventories through the development of a formulary. Evaluation of drug products for addition to the formulary is the responsibility of the Pharmacy and Therapeutics (P & T) Committee. The deletion of rarely used or outdated products is often overlooked. As a means to "clean up" the formulary, Hamot Medical Center (HMC) underwent a total formulary review. Drugs were separated into classes as defined by the American Hospital Formulary Service (AHFS). Approximately three drug classes were evaluated each month by the P & C Committee. Evaluation criteria was based on the following factors: current formulary status, usage statistics, negative comments appearing in six current publications, hospital acquisition cost, and number of formularies containing each product. A final compilation of all deletions and additions were distributed to all medical staff department and division chiefs. Following receipt of all their comments, a final draft of the formulary was made and prepared for publication. This system is a simple, uncomplicated means of either revising or beginning a formulary. It evaluates a drug based on efficacy, individual hospital usage, and cost of the drug while allowing for input of the medical staff. The end result is a formulary tailored to best fit each institution.     

The effect of pharmacy intervention on aminoglycoside costs.

Antibiotics constitute a large percentage of every hospital's drug budget. In an effort to control the escalating costs of antimicrobial therapy, we focused on the usage of aminoglycosides at our institution. The aminoglycosides, gentamicin and tobramycin, are similar in terms of antimicrobial spectra and toxicities. Since gentamicin is much less expensive, it was felt that significant cost savings would be realized if gentamicin were to be used preferentially over tobramycin. Specific criteria for the use of tobramycin were developed and approved by the Pharmacy and Therapeutics Committee. All patients prescribed parenteral tobramycin during the five week data collection period were entered into the study. We chose to use direct verbal intervention as our method for altering physician's prescribing patterns. An educational program of intervention was set up such that when a physician prescribed tobramycin, the patient's chart was immediately reviewed. If tobramycin was prescribed for a purpose other than those in the approved criteria for tobramycin use, the physician was contacted personally to discuss the cost-effectiveness of gentamicin use. Utilization figures from the previous six months showed that our interventions would save approximately $32,000 over a one year period. Our interventions on aminoglycoside prescribing represents a highly successful, cost-effective and educational method for altering physician's prescribing patterns.     

Characterization of errors detected during central order review

Characterization of prescribing errors detected by dispensary pharmacists in a tertiary-care teaching hospital is described. During the 25 week study period, 1330 prescribing errors were identified from a total of 237,798 medication orders processed by the pharmacy, representing a rate of 5.6 errors per 1000 orders. Resident physicians wrote more errant medication orders than any other physician class. Errors most often occurred on the general medicine teaching wards. The most common drug classes implicated were non-formulary medications and antibiotics. Approximately 11% of errors were defined as potentially fatal or severe (Type A) errors, 7% were potentially serious (Type B), 21% were potentially significant (Type C) and 61% were problem orders (Type D) based on a classification system of severity. The most common error types were inappropriate dosing of antibiotics and the prescribing of medications for patients who had a potential conflicting allergy history. The acceptance of pharmacists' suggestions was 67%. The study identified three major areas where future educational and corrective measures could be aimed: adherence to the formulary, antibiotic prescribing and allergy validation.     

An inside look at the UCLA P&T committee: how does it influence prescribing practices?

In the first of a series of exclusive P & T interviews in Hospital Formulary, Dr. Matthew Conolly describes the operation of the UCLA P & T Committee. He stresses that the role of their Committee is to educate the hospital staff--not to police prescribing habits. In maintaining the formulary, the Committee uses several effective methods of staff education regarding drug use and cost containment, including the formulary itself, other pharmacy service publications, lectures, noontime conferences, and grand rounds. The process by which P & T decisions become policy at the UCLA Medical Center is outlined. Areas of controversy and challenge in maintaining a formulary in this changing health care environment are highlighted.     

Experience with intrainstitutional clinical evaluations of newly marketed preparations as a basis for drug-product selection to hospital formularies

The decision to admit a new drug-product formulation (NDPF) to a hospital pharmacy formulary is a difficult task, particularly when minimal pharmacokinetic or clinical efficacy data are available. To provide objective information to the Pharmacy and Therapeutics (P&T) Committee, we implemented a procedure to evaluate these NDPFs at our institution. This procedure, termed clinical evaluation, was initiated at our institution in 1981. The clinical evaluations of two NDPFs were performed. The two NDPFs studied were a transdermal nitroglycerin preparation and a sustained-release procainamide preparation. The clinical assessment of the therapeutic and the pharmacokinetic performance of each preparation was made by clinical pharmacists. Following completion of the clinical evaluation, the data were presented at a regular meeting of the P&T committee. The presentation of clinical data derived from our patient population facilitated objective assessment by the P&T committee regarding formulary status. We conclude that the clinical evaluation represents a novel approach to acquire data necessary for objective decisions on NDPFs by the P&T committee.     

Micro/Macro Strategies for Improving Hospital Formulary Performance

Abstract

The majority of American hospitals utilize a drug formulary to guide the prescribing decisions of physicians who practice within this setting. In order to strengthen formulary performance, six administrative procedures - periodic evaluation, informal screening, explicit drug approval, educational campaigns, informal assessment, and periodic surveys of users—are recommended. Because of certain limitations inherent in these micro inputs, four macro strategies are proposed to support formulary implementation.

Presented at the 25th Annual Pharmacy Congress, St. John's University, Jamaica, NY, April 7, 1983.     

A targeted review of vancomycin use

In recent years vancomycin usage at the Ottawa Civic Hospital has been steadily increasing. In an effort to determine the reason for this resurgence, and whether or not it is justified, a prospective assessment of vancomycin utilization was performed. All new orders for vancomycin received in the pharmacy in a two-month period were evaluated against predetermined criteria for appropriate use, which were developed in conjunction with Infectious Diseases and Cardiac Surgery. Of the 55 orders evaluated during the study period, 32 (58.2%) were considered inappropriate, translating to a cost of approximately $5,500.00 for the seven-week period. Use of vancomycin in penicillin-allergic patients without a confirmed history of IgE-mediated reaction, was responsible for the majority of vancomycin prescribed unnecessarily (-66%). As a result of the review's findings, the following actions were taken by the Pharmacy and Therapeutics Committee: (1) vancomycin was restricted to specific indications; (2) vancomycin will be prospectively monitored by the Pharmacy Department; (3) physician education on approved indications and dosing of vancomycin; and (4) development of guidelines for assessment and prescribing in penicillin-allergic patients.     

Safety, efficacy, and lipid profile of doxazosin at a VA medical center

The Veterans Administration Lakeside Medical Center (VALMC) is a 500-bed hospital located in downtown Chicago providing a broad scope of inpatient and outpatient medical services for more than 12,000 veterans. The VALMC Pharmacy and Therapeutics Committee requested a study to evaluate doxazosin mesylate (Cardura) to determine if this agent would be an acceptable alternative to other formulary agents. It appears that doxazosin provides several therapeutic advantages, including once-daily dosing, when compared with other more costly antihypertensive agents.     

Cephalosporins: use review and cost analysis

The prescribing patterns for the cephalosporins and the cost-savings following restriction of cephalothin sodium and approval of cefazolin sodium were studied over a three-year period at a university hospital. The prescribing patterns for cefazolin relative to dose, frequency, duration of therapy and clinical indications were studied for 64 patients during a one-month period. Parenteral cephalosporin use for three years was analyzed to determine comparative use rates and costs. For the most part, cefazolin was used properly during the one-month study. The greatest misuse was as prophylactic therapy in postsurgical patients. The switch from cephalothin to cefazolin resulted in a projected annual savings of $5,500, equal to more than 10% of the hospital's expenditures for parenteral cephalosporins. The prescribed daily dose of cephalosporin dropped by one-third following the formulary change. The decision to use cefazolin as the major parenteral cephalosporin resulted in substantial cost savings.     

Strengthening the formulary system by implementing a drug usage guidelines program

The development and implementation of a Drug Usage Guidelines (DUG) program in a 1,200-bed, federal teaching hospital are described. The program was designed to promote effective formulary control through established procedures for the review and evaluation of drugs submitted to the Pharmacy and Therapeutics (P & T) Committee for addition to the formulary. The procedures required the submission of the DUG and an oral presentation to the Committee prior to any final vote on the request. Anticipated potential benefits of the DUG program are to: (1) stimulate rational drug therapy, (2) provide reliable drug information to the professional staff in a usable format, (3) promote a thorough evaluation of therapeutic agents before approving for formulary inclusion, and (4) provide physician-generated guidelines for use as criteria in drug utilization review audits.     

Reducing inappropriate prescribing of sublingual nifedipine.

OBJECTIVE: To report a program to reduce the practice of prescribing sublingual nifedipine. MONITORING AND EDUCATIONAL PROGRAM: Pharmacy records were used to identify orders for sublingual nifedipine at Georgetown University Medical Center. Initial review showed 30-40 orders/month, or approximately 11% of all nifedipine orders. A newsletter was published outlining Pharmacy and Therapeutics Committee guidelines for the use of nifedipine when rapid onset of action is desired. Further educational efforts involved correspondence with each attending physician responsible for the sublingual nifedipine orders. A reduction in orders for sublingual nifedipine to approximately 10 orders/month (3.9% of total nifedipine orders) was observed after using this educational approach. The reduction in orders has been maintained by frequent contact with the attending physicians. CONCLUSIONS: Repeated educational measures have resulted in a reduction in the inappropriate prescribing of sublingual nifedipine.