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.     

Taking the byte: more thoughts about microcomputers.

Appropriate use of computerized data bases can be useful to the P & T Committee. Although the use of computerized literature searches has been recognized, the microcomputer can be used for other important and time-saving applications. One software system in use at a VA Medical Center is presented here, and its function are described. Potential uses and future applications are discussed.     

Formulary issues at a pediatric hospital: experience at Children's National Medical Center

At Children's National Medical Center in Washington, DC, patients treated range from premature babies to 21-year-olds. Therefore, a broad base of drug therapy is practiced. University affiliated, the facility serves as the pediatric department for George Washington University School of Medicine. This hospital is seen as an innovator in specialized areas, such as neonatology, pediatric trauma, oncology, and organ and bone marrow transplantation. P & T Committee participation and communication are excellent, allowing members to focus sharply on therapeutic issues. One of their successful strategies has been the institution of a rather extensive subcommittee structure, which has facilitated intense but timely formulary review and strengthened drug policy. In this exclusive Hospital Formulary interview, Dr. George Cohen and Mr. Stephen Allen, Chairman and Secretary of the P & T Committee, respectively, share their experiences, providing insight for other P & T Committee members in hospitals serving both children and adults nationwide.     

Developing guidelines for biotechnology drug use: experience with antithrombin III

Development of institutional guidelines for use of high-cost biotechnology drugs, such as antithrombin III, is a valuable tool in formulary management. This article describes the process by which the University of California Davis Medical Center used an ad hoc committee to the P & T Committee to develop guidelines for antithrombin III use. Performing an objective analysis of available literature to address the appropriate role of a biotechnology agent is necessary to develop consensus guidelines. Approval of use guidelines by the P & T Committee provides the necessary structure for optimal use of biotechnology agents, such as antithrombin III.     

P & T Committee rises to challenges of the changing healthcare environment

The ever-increasing importance of the P & T Committee is well illustrated in this exclusive interview with members of a committee from a leading academic, private-practice, health-science center--Rush-Presbyterian-St. Luke's Medical Center. The participants detail the progress achieved in P & T Committee policy making, particularly in recent years. Unprecedented change in the healthcare environment has demanded a more aggressive P & T Committee, and theirs has responded appropriately. Because the medical staff at Rush constitute a unique blend of academicians and private practitioners, the mechanics of their decision making tends to be consensus-related, while the implementation of those decisions is education-oriented. Other P & T Committees can learn from their political and professional strategies in the management of drug therapy.     

Integration of formulary systems with centralized pharmaceutical procurement

The integration of formularies with pharmaceutical group purchasing and supply systems for multiple hospitals and ambulatory health centers in the Indian Health Service of the US Public Health Service is described. Two models by which these systems have been integrated are presented. The approach of one group of facilities for maintaining high-quality therapeutics in a cost-effective manner was to maintain separate P & T Committees and formularies for each facility, with one centralized drug procurement center. The other group developed a central P & T Committee and formulary to serve all area facilities, as well as continued to maintain a separate P & T Committee at each facility that could act between meetings of the central committee. These models of centralized procurement have provided both decreased drug costs and increased information on drug use within the multifacility systems. In both models, staff have reached consensus on drugs that will provide quality therapeutics in a cost-conscious environment.     

Initiation of a clinical pharmacology consult service as a formulary management tool

Establishment of a multidisciplinary clinical pharmacology consult service (CPCS) can be an important adjunct to a successful formulary management system. This article describes the model of a CPCS developed at the University of California Davis Medical Center. The CPCS provides patient-specific consultations, serves a leadership role in directing the medical staff toward hospital-wide drug usage guidelines for high cost pharmaceutical agents, and enforces the P & T Committee adopted criteria on selected high-cost or high risk agents. The mission of the CPCS is to provide the P & T Committee with a multidisciplinary mechanism to educate health care providers, improve patient care, establish drug usage criteria, and enforce those criteria.     

Managing high cost and biotech drugs: two institutions' perspectives

A proactive and multidisciplinary approach is used at The University of Texas MD Anderson Cancer Center to forecast the effect of new biotechnology and other high-cost agents prior to their commercial availability. Protocols, practice guidelines, and drug-use policies are developed to promote cost-effective use of these agents. To promote optimal utilization, two pharmacoeconomic strategies are used: cost reduction and drug performance. An economic impact analysis is performed on pending drug protocols, which includes hospital cost, patient billing, and estimates of insurance reimbursement denial risk. The management of biotechnology drug usage at the University of Pittsburgh Medical Center is through the drug advisory program (DAP). DAP is an organized, multidisciplinary program comprising numerous drug usage review functions including drug information, therapeutic evaluation and modification, drug morbidity and surveillance, and an investigational drug service. The objective of DAP is therapeutic efficiency, which has as its key elements efficacy, low toxicity, and low cost. The actual work of DAP takes place via multiple subcommittees and task forces whose recommendations are forwarded to the P & T Committee. These multidisciplinary groups ensure the involvement of the appropriate specialists in therapeutic decisions and, therefore, successful implementation of the recommendations.     

A survey of selective administration procedures in formulary maintenance

The survey attempts to examine various Pharmacy and Therapeutics (P & T) Committees' activities for indications of a rational and objective approach to drugs and the hospital formulary. The objectives were: 1) to gain insight as to how drug products attain formulary listing by examining select P & T Committee's reasons for adding and deleting drugs; 2) to determine whether P & T Committees are attempting to follow generally accepted guidelines for the operation of the formulary system; and 3) to determine how the hospital pharmacist is responding to the rational and/or irrational drug selection by the P & T Committee. The results showed that the hospitals studied appeared to be acting in agreement with the guidelines presented. Definitive statements concerning the activities of the pharmacist and the rational approach of the P & T Committee to the hospital formulary could not be made. The author recommends that P & T Committees begin documenting the methods they utilize to promote and maintain the formulary system in hospitals. This information should be used as an educational tool by the P & T Committee.     

P & T Committee formulary requests: criteria for admission

The criteria for P & T Committee members to consider when adding or deleting a product to the formulary are discussed. Although each institution will require and develop different standards that reflect the characteristics of the patient population they serve, two general sets of factors should be studied. The anticipated needs of the institution and the therapeutic application of the medication in consideration must be identified. Furthermore, the characteristics of the drug, including pharmacokinetics, biopharmaceutics, and cost must be clearly defined. The P & T Committee formulary decisions are critical in ensuring high-quality, cost-effective health care.     

How a longstanding P & T Committee identifies and meets current therapeutic challenges

The P & T Committee at the University of Michigan, Ann Arbor, has run smoothly for some time. Nevertheless, it is not immune to today's fiscal and drug therapy challenges. In this exclusive Hospital Formulary interview, Dr. Jeoffrey Stross, chairman; Dr. Richard deLeon, secretary; and Dr. Burgunda Volger, a key University Hospital P & T Committee member, candidly describe their committee's philosophy and the mechanics by which it functions. This committee uses restriction to modify inappropriate prescribing, but it also carries out educational activities. As newer, more expensive, therapies become available, the responsibility to ensure efficacious, safe, economical therapy becomes increasingly complex. The following discussion highlights some of their strategies for success.     

Multi-purpose evaluation of H2-antagonist usage

At Cabrini Medical Center, drug usage evaluation (DUE) and monthly purchasing data analysis were used to determine the indications for which H2 antagonists were being used, the appropriateness of parenteral therapy, the use of extended dosing intervals, and the cost effectiveness of cimetidine (Tagamet). The study was also used to review a decision of the P & T Committee to maintain cimetidine and remove ranitidine from the hospital formulary.     

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.     

Preparing the P & T committee agenda for new drug requests

Preparing an agenda is an important element in conducting an effective P & T Committee meeting. A key responsibility of P & T Committee members is reviewing the rationale for formulary requests. Therefore, it is generally an agenda item. This article describes a process for planning, preparing, and distributing agenda materials for a committee meeting. A specific format and sequence for reviewing new drugs for formulary admission and criteria for selecting new drugs are discussed.     

Strategic planning for the management of biotechnologic products: development of a biotech committee

Strategies and tactics for managing biotechnologic products are critical to cope with the increasing number and cost of such products. One strategy is to develop a biotech committee to formulate long-term goals for managing biotechnologic products and to evaluate controversial or extremely expensive new products and recommend their formulary status to the P & T Committee. Involvement of the P & T Committee is crucial to establish strict criteria and monitors to ensure the appropriate and cost-effective use of these products. Involvement of the pharmacy department is also essential to detect usage patterns and reimbursement profiles of approved biotechnologic products in the hospital, as well as their potential financial impact on the hospital's budget.     

The role of the microbiology laboratory in guiding formulary decisions.

Typically, P & T Committee antibiotic selection criteria have included such factors as cost, pharmacokinetics, side effects profile, spectrum of activity, and relative activity against specific pathogens. The microbiology laboratory can provide the P & T Committee with other useful information to help guide them in making even more appropriate and cost-effective formulary decisions. This information includes specific susceptibility data (including prevalence of pathogens, source of infection [community or nosocomial], anatomical site of isolates, specific unit or service where isolated, type of culture specimen, total number of pathogens in the hospital), resistance trends data, an evaluation of microbiologic data presented in published studies, further data regarding an antimicrobial's spectrum of activity and activity against specific pathogens, and the relevance and limitations of in vitro data. With this information in hand, P & T Committee should be in a much better position to optimize formulary decision-making.     

Concerns of a pediatric hospital's P & T Committee: quality care emphasized over cost considerations

One of the greatest challenges faced by the P & T Committee at Children's Hospital of Denver--a full-service, regional pediatric referral center--is the absence of pharmacologic and pharmacokinetic data for many drugs that are on the market for the treatment of adults but are unapproved for pediatric use. To acquire the needed information, Children's Hospital will rely on its P & T Committee to conduct numerous drug usage evaluations. In addition, the committee is undertaking a cooperative data-exchange venture with other children's hospitals across the U.S. and Canada. Although cost issues must be addressed at Children's Hospital, issues such as quality of care--and even how various formulations taste--are top priorities at this hospital.     

Operation, formulary decision-making activities of a P & T Committee in a managed care setting

Managing drug benefits in a Health Maintenance Organization (HMO) is perhaps best accomplished through a formulary, as demonstrated by Kaiser Permanente of Colorado. According to Dr. Jim Adams and Ms. Jackie Richardson, the Chairman and Secretary, respectively, of Kaiser Permanente's P & T Committee, since the advent of their formulary only a few years ago, the cost of drugs has been kept well under control, without jeopardizing the quality of care. Both physician and patient education are critical to the success of a formulary in a managed care system--both monumental tasks for Kaiser Permanente of Colorado considering that prescribers exceed 300 and the number of patients they treat approaches 250,000. What is clear in this exclusive Hospital Formulary interview is that HMOs--long recognized for their ability to control costs--can also provide quality health care for patients who use their facilities.     

P & T Committee interview: Establishing and maintaining a dynamic formulary.

In an exclusive interview with Hospital Formulary, Dr. Stephen Rostand and Mr. Herman Lazarus--the P & T Committee Chairman and Secretary of the University of Alabama Hospital--share their experiences in establishing an effective, functional formulary system. Discussed in this interview are the current activities of this Committee which include: reviewing adherence to an established Committee guideline on an effective antibiotic dosing regimen, creating a more effective adverse drug reaction reporting system, and establishing a computerized program to alert prescribers to the possibility of drug-drug interactions. By their willingness to cooperate, communicate, and remain flexible to medical staff requests, this 15-member Committee has been able to maintain a dynamic formulary.