Controlling the cost of branded drugs

Formularies are no longer used merely to cut costs. The new emphasis is on providing appropriate pharmaceuticals at the most cost-effective price.

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.

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.

Computer-assisted use of tracer antidote drugs to increase detection of adverse drug reactions: a retrospective and concurrent trial

The authors found that a concurrent review of use of antidote drugs commonly used for the treatment of adverse drug reactions is an effective method for identifying such reactions. Computer-assisted detection helped rule out false-positives and decrease the number charts to be screened, thereby reducing the time needed to find adverse drug reactions.

Pharmacist clinical intervention program

Our efforts have helped us demonstrate the positive impact of pharmaceutical care for patients. Our experience with the Clinical Notes section of our computer system leads us to recommend that such capabilities be sought in all pharmacy computer systems. A significant advantage to avoiding paper-based systems for documenting and collecting information relevant to clinical interventions, ADRs, DUE data, and patient outcomes has been proven in our institution. Various ways to categorize intervention data have been reported in the literature. We recommend clinical intervention categories be based on the eight categories of drug misadventuring so that data from different hospitals can be tabulated or compared. The success of our system is that it is one system rather than many systems. The importance of pharmacist documentation demands that it be simple, efficient, and painless, or it will be nonexistent.

Pharmacoeconomic series: Part 3. Applying pharmacoeconomic and quality-of-life measures to the formulary management process

P & T Committees were established as an institution's primary organizational tool for the development and maintenance of the formulary. Traditionally, P & T Committees have focused on the safety, efficacy, and acquisition cost of medications to be considered for formulary approval. Today, the impact of pharmaceuticals on patients' quality-of-life and total health care expenditures are increasingly important considerations to be weighed by P & T Committees. Pharmacoeconomic analyses and quality-of-life outcomes represent valuable contributions to the formulary decision-making and management process.

Decision analysis in formulary decision making

Although decision making about what drugs to include in an institutional formulary appears to lend itself readily to quantitative techniques such as decision analysis and cost-benefit analysis, a review of the literature reveals that very little has been published in this area. Several of the published decision analyses use non-standard techniques that are, at best, of unproved validity, and may seriously distort the underlying issues through covert under-counting or double-counting of various drug attributes. Well executed decision analyses have contributed to establishing that drug acquisition costs are not an adequate measure of the total economic impact of formulary decisions and that costs of labour and materials associated with drug administration must be calculated on an institution-specific basis to reflect unique staffing patterns, bulk purchasing practices, and the availability of surplus capacity within the institution which might be mobilised at little marginal cost. Clinical studies of newly introduced drugs frequently fail to answer the questions that weigh most heavily on the structuring of a formal assessment of a proposed formulary acquisition. Studies comparing a full spectrum of therapeutically equivalent drugs are rarely done, and individual studies of particular pairs of drugs can rarely be used together because of differences in methodology or patient populations studied. Gathering of institution-specific economic and clinical data is a daunting, labour-intensive task. In many institutions, incentive and reward structures discourage behaviour that takes the broad institutional perspective that is intrinsic to a good decision analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Bar-code technology applied to drug-use evaluation

Bar-code technology was used to determine: (1) patterns in histamine H2-receptor antagonist use and (2) the occurrence of adverse drug effects and drug interactions associated with the use of these agents in critically ill patients. Patients at Henry Ford Hospital (Detroit) receiving histamine H2-receptor antagonists over a two-month period were evaluated. Clinical information was collected in the intensive care units by using a bar-code system. The data-capture menu was based on drug-use-evaluation criteria for H2-receptor antagonists. Data collected in the scanning wands were uploaded into a computer database and were analyzed at the end of the study. Data were collected for 207 patients. Cimetidine was the predominant H2-receptor antagonist used, and the predominant indication was stress-ulcer prophylaxis. Dosing trends followed accepted guidelines for cimetidine dosage adjustment in renal and hepatic failure. Two drug interactions and six adverse drug reactions occurred. Pharmacists made 92 recommendations to the medical staff regarding modification in therapy, involving 32% of the patients. Data collection required an average of 10 minutes per day each for three pharmacists. H2-receptor antagonist use patterns were evaluated in intensive care units through the application of bar-code technology. The speed and efficiency of this automated tool facilitated collection of a large amount of data.

Fluconazole dosing in renal impairment: a drug usage evaluation

Fluconazole is an antifungal agent available for oral and parenteral use. Drug dosage is based on the type and severity of infection, identity of the causative organism, the patient's renal function as determined by creatinine clearance, and response to therapy. To determine whether or not IV fluconazole was being dosed appropriately based on the above parameters, the pharmacy department at St. Joseph Hospital in Flint, Michigan, decided to perform a 3-month drug usage evaluation. As had been speculated, many fluconazole-treated patients were receiving inappropriate dosages. Specifically, renal function was not being taken into consideration in 30% of the cases. Additionally, 33% of patients received higher than necessary doses based on site and severity of infection. With the help of the P & T Committee, an educational program was implemented to assist physicians in the appropriate dosing of fluconazole.

Formularies: the role of pharmacy-and-therapeutics (P&T) committees

Pharmacy-and-therapeutics (P&T) committees have been established by most hospitals and serve as the primary formal communications link between pharmacy and the medical staff. The P&T committee is responsible for all matters related to the use of medications in the institution, including the development and maintenance of the formulary (the continually revised compilation of drug products available to the medical staff). The basic objectives of a P&T committee are to specify drugs of choice and alternatives, based on safety and efficacy; to minimize therapeutic redundancies; and to maximize cost-effectiveness. Procedures necessary to strengthen the role of P&T committees and improve their decision-making processes are discussed. The increasing concern with controlling health care costs will support the continued expansion of P&T committees, formularies, and the formulary system.

Formulary control of antimicrobial usage. What price freedom?

Formulary controls are the most common and probably the most effective method for controlling abuse of antimicrobial agents in hospitalized patients. Such programs may include restriction of both the number of agents available and the way these agents may be used. These programs have been demonstrated to control pharmacy expenditures. Other potential advantages include reductions in the incidence of adverse drug reactions and the antimicrobial resistance among the hospital flora, and improvements in the overall quality of prescribing of antimicrobials. There are few data to document such benefits, however. Potential disadvantages are also poorly documented but include inconvenience for prescribing physicians, increased administrative costs, prescribing errors, and increased antimicrobial resistance. Antimicrobial control programs will likely remain common, but the availability of new information technologies should enable a transition to systems based on concurrent assessment of antimicrobial appropriateness with immediate feedback to the prescribing physician.

Adverse drug reaction surveillance and risk management

ADR programs are most successful when developed from a multidisciplinary approach. Physicians and other health care workers should be encouraged to report and evaluate ADRs to potentially decrease risks involved in an ADR case. Management of ADRs should include prompt feedback of individual patient and grouped data for educational and risk management purposes. Risk managers should play a significant role in all aspects of an ADR surveillance program.

Clinical appropriateness, therapeutic equivalence, and cost of conversion of H2 antagonist therapy

A 12-month drug monitoring program targeting the use of H2 antagonists was initiated at the Erie County Medical Center, a 650-bed academic teaching hospital in Buffalo, NY. Discussed in this article are the development of indicators used to determine appropriateness of therapy, implementation of a H2 antagonist monitoring and screening program, examination of the effect of the program on budgetary expenditures for H2 antagonist therapy, evaluation of adverse effects and potential drug interactions associated with drug use, and measurement of possible drug cost savings resulting from the implementation of the program.

Quality improvement in the use of medications through a drug use evaluation service

Continuous quality improvement methods have the potential to improve processes that cross several disciplines. The medication system is one in which coordination of activities between physicians, pharmacists, and nurses is essential for optimal therapy to occur. DUE services can play an important role in helping to ensure that patients receive high-quality pharmaceutical care. It is necessary for pharmacy managers to review the structure, goals, and outcomes of their DUE programs to ensure that they are consistent with a philosophy of continuous improvement in the quality of drug therapy.

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.

Evaluation of the use of i.v. ciprofloxacin

A drug usage evaluation was conducted at our institution, a 344-bed teaching hospital, in order to determine whether intravenous ciprofloxacin was being used appropriately based on preestablished hospital criteria.

Issues in formulary management: therapeutic interchange. The value, cost, and quality of therapeutic interchange

Therapeutic interchange is a process of substituting a prescribed medication with one that offers therapeutic and cost benefits. The practice not only provides short-term savings but also is associated with decreases in lengths of stay in hospitals and total hospital drug expenses. There may be medicolegal implications when FDA-approved indications differ for interchanged drugs. The potential for liability is decreased when a standard of care is met, but since standards can change, guidelines should be reviewed regularly. High-tech, high-cost drugs are sometimes appropriate for therapeutic interchange. Pharmacy and therapeutics committees should assure best value by considering indirect expenses, quality, and therapeutic outcome, as well as product cost. Therapeutic interchange programs enable pharmacy managers to neutralize or at least slow the rate of drug cost increases, ensuring appropriate utilization of resources and more favorable patient outcomes.