Drug usage guidelines, Part 3: assessment of acceptance of the program

The Drug Usage Guidelines (DUG) program, as perceived by the members of the P & T Committee and by physicians who had prepared and submitted DUGs, was demonstrated to be an effective method for evaluating drugs for formulary inclusion. The majority of P & T members felt that the DUG program had strengthened the drug review process without being too tedious or preventing the addition of valuable drugs to the formulary. Sixty-eight percent of physicians who had submitted a DUG expressed the opinion that it served as a vehicle for providing educational information on rational therapeutics. A majority of respondents stated that they would recommend the DUG program to other hospitals.     

Drug usage guidelines, Part 2: Analysis of program outcome

The effect of integrating a Drug Usage Guidelines (DUG) program with a hospital formulary system was analyzed. Significant changes were observed in both the number of requests submitted to the P & T Committee and the number of drugs added to the formulary after implementation of the DUG program. Failure to follow the DUG submission protocol, particularly with respect to the requirement for supportive clinical data from the primary literature, led to delayed consideration and eventual withdrawal of several highly promoted drug products. The initial involvement of physicians in the planning and implementation of the DUG program has been an important factor in the continued success of the program.     

Achieving an effective committee through reorganization: the Ohio State University Hospital's experience

The P & T Committee at Ohio State University (OSU) Hospitals, Columbus, is unique in that it accomplishes the bulk of its tasks through subcommittees. Four subcommittees are currently in place: a formulary subcommittee, a policy and surveillance subcommittee, an antibiotic subcommittee, and a therapeutic drug monitoring subcommittee. An advantage to this method of organization is that it allows for much more medical staff involvement in P & T Committee activities. Other unique aspects of this P & T Committee are that it is responsible for maintaining both an inpatient and outpatient formulary, and it provides decision-making services for a specialty cancer hospital. Expansion of their drug usage evaluation program, further development of their therapeutic monitoring program, and improved communication with the medical staff are future goals of this P & T Committee.     

Developing a unit-of-use drug distribution system for the hospital emergency room

The development of a unit-of-use drug distribution system for hospital emergency rooms (ERs) is described. Initially, each emergency room physician was requested to compile a list of medications for an emergency room formulary. These lists were edited into a single list and presented to the ER Committee for review. This committee was to recommend the least number of medications possible per therapeutic category. During this time, the support of the ER staff was gained, policies and procedures were established, and a unit dose cart system was chosen. The final step was to present the recommended emergency room drug formulary to the Pharmacy and Therapeutics Committee for their review and approval. The advantages of this system are: establishment of pharmacy drug control in the ER; reduction of ER inventory; greatly improved drug security; proper drug labeling; and automatic restocking of medications in the ER, resulting in time savings for ER personnel.     

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.     

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.     

Cost containment through P & T committee drug utilization review

Provoked by changes that are occurring in health care, hospitals are currently formulating and implementing strategies to identify and control costs while maintaining the highest quality of care. Because drug costs account for a significant proportion of the hospital supply budget (5 to 10%), there is an increased need for the P & T Committee to become involved in the cost containment effort. This article will demonstrate how an existing program of drug utilization review (DUR) has reduced drug expenses without sacrificing the quality of care or imposing unnecessary restrictions on formulary items. Furthermore, implementation of the DUR program has not resulted in conflict between pharmacy, medical, nursing or administrative staffs within the institution.     

Formulary evaluation of third-generation cephalosporins using decision analysis

A structured, objective approach to formulary review of third-generation cephalosporins using the decision-analysis model is described. The pharmacy and therapeutics (P&T) committee approved the evaluation criteria for this drug class and assigned priority weights (as percentages of 100) to those drug characteristics deemed most important. Clinical data (spectrum of activity, pharmacokinetics, adverse effects, and stability) and financial data (cost of acquisition and cost of therapy per day) were used to determine ranking scores for each drug. Total scores were determined by multiplying ranking scores by the assigned priority weights for the criteria. The two highest-scoring drugs were selected for inclusion in the formulary. By this decision-analysis process, the P&T committee recommended that all current third-generation cephalosporins (cefotaxime, cefoperazone, and moxalactam) be removed from the institutions's formulary and be replaced with ceftazidime and ceftriaxone. P&T committees at other institutions may structure their criteria differently, and different recommendations may result. Using decision analysis for formulary review may promote rational drug therapy and achieve cost savings.     

Concurrent ceftazidime DUE with clinical pharmacy intervention

Ceftazidime use at our institution, a 580-bed county teaching hospital, has steadily increased since its addition to the formulary in 1986. In response to this increased use and because the institutional antibiogram showed increased resistance by Pseudomonas aeruginosa (from 10 to 28% resistant), the P & T Committee requested that a drug use evaluation (DUE) of ceftazidime be conducted. Analysis of this retrospective pilot study showed that 87% of ceftazidime use was inappropriate. To further evaluate ceftazidime use, to identify problems not assessed during retrospective review, and to correct problems while patients were receiving the drug, a concurrent ceftazidime use evaluation was conducted. The methods and results of the concurrent review are presented below.     

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.     

Survey of formulary system policies and procedures.

A telephone survey was conducted to determine the policies and procedures of hospital formulary systems. Directors of pharmacy at a random sample of 150 community hospitals were interviewed, and letters were sent to each respondent requesting copies of the formulary and drug evaluation form. One hundred thirty hospitals completed the interview (gross response rate of 87%), and 35 evaluation forms and 49 printed formularies were received. Almost all hospitals had a formulary system and a printed formulary; the most frequently stated purposes were to decrease costs and to ensure appropriate therapy. Most formularies received were simple drug lists with no supporting information. The typical pharmacy and therapeutics committee consisted of 11 members, met every month, and reported to the executive committee. About 80% of the responding institutions had formal procedures for considering formulary additions. Less than half had standardized drug evaluation forms. Most hospitals have a formulary system and a printed version of the formulary; however, the formulary often serves primarily as a drug list, with no supporting information.     

Mission, role, and functions of the P & T Committee

This introductory article in a series on P & T Committees discusses the mission, role, and function of the committee in a hospital. With increasing complexity of drug therapy, the committee's mission has evolved into a multifaceted program related to promotion of rational and safe drug therapy within the institution. Components of the mission, the committee's responsibilities and functions, including formulary, policies and procedures, drug utilization review, drug administration, investigational drug studies, and education, are introduced and briefly discussed in terms of their role in the institution, accreditation standards, and published standards of practice. Future articles will provide fuller consideration of these topics.     

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.     

Financial impact of formulary revision of second-generation cephalosporins.

Hospitals are under increasing pressure to reduce the costs of treating patients. Due to their high cost and wide usage, antibiotics are frequently targeted for cost containment. In January of 1986, a drug formulary revision program was initiated wherein cefuroxime was automatically substituted for cefamandole unless the ordering physician specifically stated otherwise. Since these antibiotics are usually ordered in different standard doses, a table of comparable doses was prepared and approved by the hospital Pharmacy and Therapeutics Committee. Costs for both drugs were calculated from pharmacy drug acquisition records. A list was prepared of all patients who had received cefamandole from January 1, 1985 to June 30, 1985 and cefuroxime from January 1, 1986 to June, 1986. Forty patients who had received cefamandole and 31 patients who had received cefuroxime were identified. During the period of review in 1986, no orders requiring the substitution of cefamandole with cefuroxime were written. The cost avoidance by using cefuroxime was approximately $3,000 (41 percent) while the cost of instituting the program was negligible.     

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.     

Therapeutic decision-making: a model for formulary evaluation

A systematic approach of evaluating medications for a hospital formulary is discussed. The hospital formulary is a program of objective evaluation, selection, and use of medicinal agents in the hospital. In light of the ever-increasing numbers of new and/or improved therapeutic agents, formulary decisions must be made with an eye to the future. Therefore, it appears that the best means of choosing a medication for formulary addition, both clinically and economically, is to choose an agent based on its clinical indication(s). Examples of such indications are presented. Selecting formulary agents by indication rather than by simple drug cost or pharmacologic class should ensure the most effective utilization of therapeutic agents and hopefully a diminution of overall costs.     

Formulary decision making: identifying factors that influence P&T committee drug evaluations.

This study identifies outcomes related to hospital formulary decision making and estimates the importance of 16 specific types of data to five P & T Committees during the formulary decision making process. The two most important outcomes, according to the Committee members involved in this study, were the effects of the potential formulary addition on the quality of drug treatments available in the hospital followed by its impact on hospital costs. Information about the therapeutic advantage of the potential drug addition, the relative adverse effect profile, and cost information were viewed as especially important. On the other hand, promotional literature provided by pharmaceutical companies and letters of evaluation from respected physicians at hospitals other than their own, were not viewed as important. By understanding the factors involved in hospital formulary decision making, strategies encouraging optimal formulary decisions may be developed.