Effects of Restricting Levothyroxine Dosage Strength Availability

We conducted a prospective, randomized, controlled trial to assess whether hospital formulary restrictions involving limiting dosage strengths of levothyroxine affect physicians' ability to manage patients effectively and provide pharmacy cost savings in a tertiary care federal government research hospital. Thirty-three endocrinologists were randomly assigned to prescribe levothyroxine from a restrictive (dosage strengths of 25, 50, 100, 125, and 150 μg) or a nonrestrictive (dosage strengths of 25, 50, 75, 100, 112, 125, 150, 175, 200, and 300 μg) formulary through a central computer system. Their 241 respective outpatients' laboratory results and drug compliance were outcome measures. Achievement of treatment objectives was measured by thyroid function tests (free and total thyroxine, total triiodothyronine, thyrotropin), number of clinic visits, and compliance (survey method). Additional measures were drug distribution patterns, drug costs, and pharmacy inventory costs. Restriction of levothyroxine's dosage strength did not significantly alter therapeutic outcomes. However, the restricted formulary was associated with more complex dosing regimens, and resulted in no significant cost savings. It is not known whether such restriction would adversely affect the care of patients of nohspecialists. Prospective studies are required to verify presumed cost-containment measures before such measures are adopted for widespread application.     

Antibiograms

In most hospitals, the results of countless cultures and sensitivities are summarized and reported in the form of antibiograms. The advantages and limitations of antibiograms must be considered when contemplating empiric therapeutic recommendations. Methods to optimally utilize this resource are described. Antibiograms may also be used to guide formulary decisions, although practically they are more useful in monitoring recent additions or deletions. Antibiograms that incorporate formulary, drug of choice, dosage, cost, and hospital-specific restrictions will facilitate patient-specific decisions.     

Potentially inappropriate prescribing in Canada relative to the US

OBJECTIVE: To explore the prescribing of potentially inappropriate drug therapy in Ontario, Canada where there is a restrictive drug formulary relative to the US where there is no single drug formulary. METHODS: A retrospective, cohort study using an administrative database (Ontario, Canada) compared with published survey results (US). All 1,088,680 community-dwelling adults >or=66 years of age in Ontario, Canada compared with published survey results from 2455 community-dwelling older adults in the US in 1996.Patterns of potentially inappropriate drug prescribing were compared between countries using a list of 33 potentially inappropriate drug therapies. These therapies were classified by an expert panel into three categories: (i) those to always avoid; (ii) those which are rarely appropriate; and (iii) those with only some indications to prescribe. RESULTS: Among the 33 potentially inappropriate drug therapies, 15 (45%) prescribed in the US were not available through Ontario's drug formulary. Potentially inappropriate drug therapies available through the Ontario Drug Benefit Plan (ODB) and also in the US were frequently prescribed in both Ontario and the US. Differences in prescribing patterns of individual drug therapies were noted between the two countries. Specifically, in the rarely appropriate category, diazepam, a long half-life benzodiazepine, was much more frequently dispensed in Ontario than in the US (3.18% vs 1.37%). In contrast, dextropropoxyphene, an opioid with a poor adverse event profile was more frequently prescribed in the US than in Ontario (6.21% vs 0.74%). CONCLUSION: Almost half of the potentially inappropriate drug therapies that are available in the US are unavailable from Ontario's drug formulary. Potentially inappropriate drug therapies that were available through the ODB were frequently prescribed in both countries. Alternative approaches that make information immediately accessible to physicians at the time they make prescribing decisions should be considered to improve prescribing practices.     

Decision analysis applied to selection of histamine H2-receptor antagonists for the formulary

The use of decision analysis in selecting a histamine H2-receptor antagonist for the formulary at a hospital in Spain is described. Cimetidine, ranitidine, and famotidine were identified as the possible alternatives. The evaluation criteria established were therapeutic efficacy, adverse effects, drug interactions, years of clinical use, dosage interval, cost, and dosage forms. The relative importance of the criteria was determined by assigning utility values to each. Probability values were assigned to estimate how well each drug met each criterion. By multiplying the utility and probability values for each criterion and summing the scores, a total score was calculated for each drug. The alternative with the highest total score was ranitidine. A sensitivity analysis showed that the results were stable over a plausible range of probability and utility values. Accordingly, ranitidine was selected for inclusion on the formulary. Decision analysis provided an effective method for selecting which histamine H2-receptor antagonist to include on the hospital's formulary.     

Effect of patient notification of formulary change on formulary adherence

OBJECTIVE: To evaluate the impact of patient notification of impending formulary changes on formulary adherence. METHODS: This pilot program in a large, Midwest-based health insurer utilized a randomized controlled trial research design. A list of 30 chronic-use medications that were to change formulary status were selected for the pilot. A review of adjudicated pharmacy claims records was performed to identify patients receiving one or more of the formulary change medications on the list. Members of 112 individual health plans of this large health insurer, all of whom were subject to the same drug formulary, were randomized to either the intervention (letter) or control arm. Patients in the intervention arm were sent a targeted communication that described the patient.s formulary change medication(s) and provided therapeutic option(s) for the formulary change medication(s). Pharmacy claims for patients in both arms were examined at 110 days after the date of the mailing to determine if there was a switch to a formulary alternative. Multivariate regression modeling was performed to adjust for baseline differences between the arms. RESULTS: A total of 7,247 unique formulary change medication regimens were identified (3,817 in the control arm and 3,430 in the letter arm) for 6,518 subjects (3,387 in the control arm and 3,131 in the letter arm). A higher proportion of formulary change medication regimens in the intervention arm were switched to a formulary alternative compared with the control arm (19.2% vs. 12.0%, P<0.001). After adjustment for baseline differences, regression modeling indicated that subjects in the intervention arm were 1.33 times more likely to switch to a formulary alternative (P<0.001). CONCLUSION: A letter-based, formulary change notification program is a pragmatic and effective strategy to increase drug formulary adherence. Such a program does not restrict access to medications but, rather, provides education and personalized information that may allow patients to participate more actively in their pharmacotherapy decision making.     

江苏省基本药物目录中儿童用药可获得性的比较研究

目的:为江苏省完善省级基本药物增补目录,提高儿童用药可及性、安全性提供参考。方法:对江苏省基本药物目录中儿童用药的可获得性进行调查分析,通过描述性分析方法对目前江苏省基本药物目录、处方集中儿童用药的分类、数量与剂型等进行统计、分析,并以世界卫生组织(WHO)儿童基本药物示范目录(2010版)、WHO儿童基本药物示范目录处方集为参照标准,对相关数据进行比较研究。结果与结论:目前,江苏省基本药物目录中儿童可用药物数量繁多,但分布不均衡,适合儿童品种剂型偏少,尚不能满足儿童用药需求,且处方集中包含项目和用法用量规定存在诸多不完善之处,建议该省尽快出台保障儿童用药政策规划,尝试制订省级基本药物儿童用药增补目录并配套规范处方集。     

A survey of the use and educational value of the hospital formularly manual

The medical and nursing staffs of two affiliated hospitals were surveyed on their frequency and purpose of use of their hospital's formulary manual. A numerical rating of the perceived educational value of the manuals was also requested. Twenty-two per cent (141/650) of those surveyed completed their questionnaires. Ninety-six per cent of the respondents indicated use of the formulary manuals at least once a month; 62% used the manuals at least once a week. The frequency and character of use of various sections of the formulary manuals are presented. The perceived educational value of the manuals was rated 3 or greater on a scale of 1 (no value) to 5 (greatest value) by 80% of the respondents. The hospitals' formulary manuals are frequently referred to for various types of drug information. The professional staffs perceive the formulary manuals to be educationally valuable sources of drug information. Reasons for the low rate of response to the survey are presented. A plan of how to increase the response rate in a planned future survey is also presented.     

A review of limited lists and formularies: are they cost-effective?

The 'limited list' or 'formulary' concept has been used to promote rational use of drugs and to set standards for drug use. Recently the concept has been aimed more toward containment of drug costs. Effective hospital formulary systems assist in purchasing and inventory management. Application of the formulary concept has resulted in savings within specific classes of drugs and in total hospital drug costs. Key features which promote effectiveness are development of policies by prescriber consensus and continued education along with feedback on drug usage. The formulary concept also provides a foundation for appropriate use of drugs in hospitals. In the community setting, limited lists can achieve cost savings and can assist in the rational use of drugs. National limited lists have been less successful in controlling overall drug costs, probably because they have focused on economic effects, rather than education, feedback or user participation. Properly organised drug rationalisation policies embracing the limited list concept can improve health outcomes by promoting rational drug use. They can also contain or reduce drug costs.     

Institutional formularies: the relevance of pharmacoeconomic analysis to formulary decisions

Formularies, in one form or another, have been in existence for nearly 100 years. Beginning simply as a list of available agents, the formulary has evolved into a complex system which acts as a guide to prescribing practices. As the importance of the formulary has increased, so has the need for formulary managers to make an appropriate decision about each drug's formulary status. Several systematic approaches to drug evaluations have been developed to aid in the decision process. However, while some reviews of drug utilisation contain fairly rigorous analyses of their clinical efficacy, very few include an economic evaluation that goes beyond the cost of drug acquisition, preparation, distribution and administration. This is surprising, since formulary managers rank economic data second only to clinical data when making formulary decisions. In the past this apparent oversight has been due, in part, to the absence of a sophisticated model which can both approximate a drug's true economic impact and express cost and quality in similar terms. The explosion of new and very expensive biotechnology drugs into the market has the potential to improve patient care significantly. Such drugs also have the potential to increase institutional pharmacy budgets significantly; with some analysts predicting a spending of $US60 million yearly for these drugs by the year 2000, critical evaluation will be mandatory. Fortunately, advances in the relatively new science of pharmacoeconomics have made it possible to conduct appropriate estimates of the true economic impact of new drug therapies. Pharmacoeconomic studies can be very useful in evaluating drugs for formulary inclusion and in assessing the effects of formulary changes on institutional budgets. Cost-effectiveness and cost-benefit analyses, utilising decision analysis models and/or data gathered from clinical studies, are used most frequently. Relatively simple models can be used to evaluate drugs within the same class if sufficient published data on their clinical efficacy and safety are available. More complex analyses are necessary when comparing dissimilar agents or when comparing agents with non-drug therapy. Pharmacoeconomic studies have frequently been used to demonstrate that very substantial direct costs of drug therapy are often offset by equal or greater reductions in other institutional direct and indirect patient care costs. Pharmacoeconomic studies have also been used to calculate the relative cost-effectiveness of drug therapies for different disease states, although such evaluations are more useful to governmental and regulatory agencies than to individual institutions.(ABSTRACT TRUNCATED AT 400 WORDS)     

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.     

Impact of an antimicrobial formulary and restriction policy in the largest hospital in Italy

We have analysed the expenditure on antimicrobial drugs in the largest hospital in Italy; over this period, a committee prepared an antibiotic policy document. This formulary lists all antimicrobial drugs available in the hospital. Some drugs were removed from the list and others are only available on special request for a named patient. In the hope of optimising drug utilisation, we included all the reasons for the choice of agent in the document. The introduction of this formulary resulted in an immediate saving and perhaps in the future we shall also observe an improvement in bacterial resistance patterns.     

Impact of a pharmacist education program on nonformulary drug use

The effect of an educational program for pharmacists that included instructions for handling nonformulary drug requests and determining suitable formulary alternatives for frequently prescribed nonformulary drug requests was measured. Results indicate a significant increase in the number of appropriate nonformulary drug dispensings when the postintervention phase was compared with the preintervention phase. Other values, including the financial impact per nonformulary drug request, did not differ significantly between the two phases. Since all nonformulary drug requests require pharmacist time, a more cost-effective nonformulary drug policy might focus the pharmacist's efforts on nonformulary drug products that are more costly than their formulary alternatives.     

国外处方集发展现状

处方集的制定是药事管理中的一项重要工作，也是贯彻实施我国医疗改革政策方针、促进医院合理用药和提高药事管理水平的重要措施。本文主要综述了国外处方集的基本概念和发展现状，旨在为进一步加快我国处方集的制定、实施和应用提供一定的参考。     

Documentation of pharmacists' interventions in an emergency department and associated cost avoidance.

PURPOSE: An analysis was conducted of pharmacist interventions and resuscitation experiences, including pharmacist participation in a hospital emergency department (ED), and the potential cost avoidance associated with the interventions made by the pharmacists. METHODS: All pharmacists working in the ED prospectively documented the pharmacist interventions that were accepted by physicians and nursing staff and entered into a spreadsheet on a weekly basis, between September 1, 2003, and December 31, 2003. Intervention categories included the provision of drug information; recommendations for dosage adjustment, formulary interchange, initiation of medications, alternative drug therapy, discontinuation of drug therapy, changes in medication therapy due to allergy notification, drug therapy duplication prevention, or changes in the route of drug administration; questions from nursing staff; order clarifications; drug compatibility issues; patient information; toxicology; and drug interaction identification. Intervention data were analyzed and the likelihood of harm was scored; interventions were classified and analyzed by calculating average cost, probability of harm, and potential cost avoidance. RESULTS: During the study, 2150 pharmacist interventions were documented. Pharmacists participated in the care of 1042 patients triaged to the resuscitation area of the ED. Cost avoidance during the study was determined to be 1,029,776 dollars. CONCLUSION: The most commonly documented interventions made by pharmacists involved in the care of patients visiting the ED included provision of drug information, dosage adjustment recommendations, responses to questions from nursing staff, formulary interchanges, and suggestions regarding initiation of drug therapy. The potential cost avoidance attributable to the pharmacist interventions during the study period was over 1 million dollars.