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 The deletion of rarely used or outdated products is often overlooked.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.     

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.     

Structure and activities of pharmacy and therapeutics committees among public hospitals in South Africa; findings and implications

Introduction: The WHO identified Pharmacy and Therapeutics Committees (PTCs) as a pivotal model to promote rational medicine use in hospitals. This matches a key South African (SA) government objective to establish PTCs in all hospitals to ensure rational, efficient and cost-effective use of medicines. However, documentation on the functionality of PTCs in public hospitals in SA is limited. Areas covered: This study aimed to address this. A 3-phased mixed methods approach involving questionnaires, observations of PTC meetings and semi-structured interviews was used. The findings were converged during the interpretation phase. Expert commentary: Most professionals were represented in the PTCs, with variations across hospitals. Membership of PTCs included a pharmacist, who in the majority of cases was the secretary. PTC activities included dissemination of decisions (100%) and formulary management (89.5%). However, reporting of adverse drug reactions (ADRs) and medication errors was typically poor at all hospital levels. Lack of expertise of pharmacoeconomic analysis and evidence-based decision-making in formulary management was identified as a key challenge in formulary management. In conclusion, future programmes should strengthen PTCs in specialised aspects of formulary management. Further training in the principles of pharmacovigilance is needed to enhance ADR reporting, as well as to ensure compliance with both WHO and provincial guidelines.     

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.     

The formulary decision-making process in a US academic medical centre

This article reviews and describes the formulary decision-making process in an academic medical centre. The pharmacy and therapeutics (P & T) committee is the organisational nucleus of the drug use control process in the institutional environment. Thomas Jefferson University Hospital (TJUH), a 720-bed academic medical centre in an urban locality in the US, is used as a model representative of how most of these committees function. Survey responses collected from 29 peer academic medical centres are presented to compare and contrast the structure and function of the P & T committee at TJUH with corresponding procedures in other university hospitals in the US. TJUH is typical of the institutions which comprise the University Hospital Consortium (UHC). The P & T committee of TJUH is composed of 29 members, meets once per month for 10 months of the year, and has a network of 13 subcommittees. TJUH has an intermediately controlled (mixed) formulary, and uses both restricted drugs and treatment guidelines. Of the 29 UHC member institutions responding to the survey, the average P & T membership is 18, the average meeting frequency is 11 times per year, and 83% of these committees have a network of subcommittees. None describe their formulary system as open, 86% have a closed formulary and 14% have a mixed formulary system. There is a restricted drug programme in 76% of the institutions, 79% utilise treatment guidelines, 76% practice therapeutic interchange and all employ generic substitution. Specific areas addressed in this review include the history of the formulary system, the structure and function of the P & T committee, types of formularies, cost containment and the formulary decision-making process, the impact of organisational culture on physician decision making, the role of the pharmacy department, the role of pharmaceutical sales representatives and their impact on prescribing habits, the impact of the Joint Commission on Accreditation of Healthcare Organisations (JCAHO) Agenda for Change on the formulary process, and future challenges.     

Drug and therapeutics committees in Nigeria: evaluation of scope and functionality

ABSTRACT

Introduction: Inappropriate use of medicines remains a problem, with consequences including increasing adverse drug reactions (ADRs) and prolonged hospitalizations. The Essential Medicines List and Drug and Therapeutics Committees (DTCs) are accepted initiatives to promote the rational use of medicines. However, little is known about DTC activities in Nigeria, the most populous African country.

Areas covered: A cross-sectional questionnaire-based study was conducted among senior pharmacists, consultant physicians, and clinical pharmacologists in 12 leading tertiary health-care facilities across Nigeria.

Expert commentary: Six (50%, 6/12) health-care facilities had existing DTCs with three (50%) having a subcommittee on antimicrobials. Seventy-five percent had infection control committees, with presence even in centers without DTCs. Chairpersons and secretaries of the DTCs were predominantly physicians (83.3%) and pharmacists (100%), respectively. Hospital formularies were available in five facilities with DTCs, while one facility without a DTC had an Essential Medicines Committee responsible for developing and updating the hospital formulary. The evaluation of ADRs was undertaken by pharmacovigilance units in nine facilities. Overall, DTCs were present in only half of the surveyed facilities and most were performing their statutory functions sub-optimally. The functioning of DTCs can be improved through government directives and mechanisms for continuous evaluation of activities.     

Organization and operation of P & T Committees in the state of Florida: a survey

To determine the structure and function of P & T Committees in Florida, a survey was initiated. Questionnaires were mailed to all 289 hospitals in the state. Topics addressed included hospital demographics (type of service provided, institution ownership, hospital size), P & T Committee structure (size of the committee, membership breakdown by specialty, chairman specialty, number of meetings per year), formulary additions (personnel authorized to request drug additions, process for adding drugs to the formulary, monitoring new drug use), and formulary systems (prevalence of therapeutic interchange programs, methods of communicating formulary changes). Overall survey response rate was 71.5%. In general, P & T Committees in Florida appear to be functioning at a relatively high level. Since there is little current information about the composition and operation of P & T Committees in hospitals around the country, it is hoped that this survey will be useful to P & T Committees that wish to upgrade or expand their activities.     

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 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.     

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.     

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.     

Drug and Therapeutics (D & T) committees in Dutch hospitals: a nation-wide survey of structure, activities, and drug selection procedures

AIMS: To determine structure, activities and drug selection processes used by Dutch hospital drug and therapeutics (D & T) committees. METHODS: A pretested structured survey questionnaire based on the Australian process and impact indicators, previous research, and consultation of professionals was developed. Subsequently, D & T committees that met predefined selection criteria were asked to participate. RESULTS: The overall response rate was 70% (38/54). D & T committees varied considerably in size and representation of clinical expertise. Although responsibilities were theoretically alike, actual responsibilities were frequently passed on to other authorities, such as pharmacy staff. Few committees used detailed guidelines or decision supportive matrices to establish transparency in drug selection. With respect to drug selection, the value scores on the information resources used, the factors involved, and the selection criteria used varied. Hospital pharmacists were likely to be most involved and to have the greatest impact. A consensus was most difficult to achieve for drugs used in cardiology, oncology, and psychiatry. Interference of industrial marketing strategies on drug selection was recognized and identified. CONCLUSIONS: Our results indicate that Dutch hospital D & T committees differ with respect to their clinical expertise and their activities, a situation comparable with that observed in other countries. Furthermore, the lack of transparency in drug selection was considerable. These findings clarify the differences previously found between Dutch hospital drug formularies.     

Evaluating a restrictive formulary system by assessing nonformulary-drug requests

Nonformulary-drug requests were used to evaluate a restrictive formulary system in a large university hospital, and a telephone survey of eight similar hospitals was conducted to assess the restrictiveness of their formulary systems. Nonformulary-drug requests were evaluated by two drug information pharmacists over a 12-month period (January-December 1984) to assess the frequency with which nonformulary items were ordered, the costs associated with the procurement of nonformulary drug products, and the rationales given by physicians when ordering nonformulary products. Of all nonformulary requests, 65% were for drugs previously evaluated by the pharmacy and therapeutics committee and denied admission to the formulary. A cost savings of $1887 would have resulted if formulary alternates had been used instead of nonformulary products. Excluding 22% of nonformulary items that were requested for the continuation of preadmission drug therapy, only 13% of the rationales for the remaining requests were appropriate. Although the eight other hospitals surveyed said they had restrictive formularies, all had frequent requests and procedures for procuring nonformulary items and some formularies included most available drugs. The formulary system at the study hospital was considered restrictive, but procedures for nonformulary-drug requests limited the effectiveness of the system. If any benefit is to result from formulary systems, hospitals must strengthen their enforcement of formulary restrictions.     

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.     

The role of pharmacoeconomics in formulary decision making in different hospitals in Riyadh,Saudi Arabia

Objective

To assess the trend of using pharmacoeconomic information by Pharmacy and Therapeutics (P&T) committees when making formulary decisions.

Design

A cross-sectional study conducted in 2007, using structured survey questionnaires which were distributed to members of the P&T committees in 11 different hospitals in Riyadh, Saudi Arabia.

Results

A total of 100 survey questionnaires were sent to head of pharmacy departments of 11 different hospitals in Riyadh, Saudi Arabia. Out of these, 48 questionnaires were completed and returned. Of the total respondents participated in the study, 64.58% were medical doctors and 16.66% were pharmacists and 75% of the respondents said they have applied pharmacoeconomic evaluations in their decision making process. More than 80% of the respondents perceived that they had a fair knowledge of pharmacoeconomics. Approximately 80% of respondents expressed some degree of agreement that pharmacoeconomics should be applied as a decision making tool. The majority of decision-makers (95%) expressed the interest in attending workshops on pharmacoeconomics.

Conclusion

The study showed that pharmacoeconomics can play an important role in the P&T committee formulary decisions. However, more education to health care professionals and to hospital administrators should be conducted to facilitate the use of such a tool. Also, hospitals should recruit health care professionals with pharmacoeconomic expertise to manage limited health resources in the best way available.