Developing a pharmaceutical purchasing strategy

The process commonly used by group purchasing organizations to contract for multisource pharmaceuticals and a strategic approach for the director of pharmacy in working with the purchasing group and the P & T Committee is described. The pharmacist should be knowledgeable concerning the group's contract commitment requirements, product specifications, terms and conditions and procedures for vendor selection, product award, contract implementation, and performance monitoring. To ensure results that meet the needs of the medical staff, it is important that the P & T Committee actively participate. The P & T Committee should understand the reasons for selecting a particular purchasing group, understand the necessary steps in obtaining the most favorable economic advantage, review products with potential brand interchange concerns, recommend product specifications, and reaffirm formulary procedures regarding the principle of current consent.

Drug use evaluation of acetaminophen-containing products at a community hospital

The Humana Hospital, a 356-bed facility, set up a drug use evaluation (DUE) program to monitor the administration of products containing acetaminophen (APAP), to observe the extent of overdosing of APAP products, and to educate and resolve the problems. The DUE originated in the OB/GYN unit and then was expanded to all hospital units. The study methods and the process used to resolve noncompliance with recommended dosing guidelines are presented below.

Therapeutic heparin monitoring service in a small community hospital

Upon the request of members of the medical staff, the Pharmacy and Therapeutics Committee at Tawas St. Joseph Hospital began monitoring patients receiving full-dose continuous intravenous heparin therapy. Problems were noted in the usage of activated partial thromboplastin times and the resultant changes in heparin therapy. The problems identified during this quality assurance activity were addressed by a heparin protocol developed by a clinical pharmacist. The protocol includes giving patients a heparin loading dose of 50-100 units/kg actual body weight, an initial infusion rate of 15-20 units/kg/hr, and drawing the first activated partial thromboplastin time 6 hours later. After the results of the activated partial thromboplastin times are known, the protocol provides for further patient management and changes in infusion rates, if needed. A review of the heparin protocol use at 6 months after initial implementation, and 6 months after minor changes in the protocol, showed that clinical pharmacists improved heparin therapy in the patients they treated. Pharmacists used larger initial continuous infusion rates, less activated partial thromboplastin times during treatment, and patients they managed reached therapeutic activated partial thromboplastin time ranges earlier than patients treated by physicians. When voluntarily prescribed by physicians, full-dose continuous intravenous heparin therapy initiated and monitored by clinical pharmacists improved the quality of patient's anticoagulation treatment during hospitalization.

Using the discharge process as one method to capture adverse drug reaction reports

Adverse drug reaction reporting programs must be constantly improved to remain successful. Using a combination of techniques that foster voluntary reporting from all disciplines--while providing routine feedback to the reporters--creates an environment that promotes better patient care through knowledge and education. The success of the ADR program at Mid-Maine Medical Center is based on this philosophy, and the program is really a system of programs. Capturing ADR reports through the discharge process, which is the cornerstone of the program, has proven very successful.

A successful community hospital program for monitoring adverse drug reactions

All health care professionals are responsible for reporting ADRs. The physician records these events in the patient's medical record. In the monitoring program at Meriter Hospital, pharmacy responsibilities include review and assessment of all reported ADRs. When appropriate, the ADR is reported to the FDA. The pharmacy department maintains ADR statistics, reports quarterly to the P&T committee, and disseminates information to appropriate hospital committees and departments. The P&T committee supports the ADR monitoring program and policy. This committee reviews all ADRs and recommends action plans. The ADR monitoring program has successfully increased the number of ADRs reported, and actions resulting from ADR reports have had a positive impact on patient care.

Criteria-based adverse drug reaction reporting and the use of a relational database

The criteria-based ADR reporting program at Shands Hospital has been successful. When the Joint Commission reviewed this program in January 1991, they were satisfied that it met their standards. Efforts are now focusing on improving the capture of ADRs, which will make the information available from the database even more valuable. Data from Shands Hospital will contribute to postmarketing surveillance, patient care, and staff education, and these data will influence drug usage evaluations and the formulary. Observations will be used to recommend alternate therapies to prevent ADRs as well as methods to manage reactions should they occur. The listing of criteria has facilitated the reporting of ADRs at Shands Hospital, and communication of the information has been greatly enhanced by the ADR database. Efficiency has been improved as a result.

Computerizing drug usage evaluation

Drug usage evaluation (DUE) has been computerized at the Department of Veterans Affairs Medical Center in Coatesville, PA. This article describes the implementation of a simple, cost-effective process and provides examples of facility-wide and provider-specific reports that can be used at the time of reappointment for privileges. As a result of computerization and the involvement of all pharmacists, the number of drug reviews have increased dramatically, and there is more consistency in the reviews.

Acceptance of a pharmacy-based, physician-edited hospital pharmacy and therapeutics committee newsletter

OBJECTIVE

To assess the level of physician acceptance and perceived usefulness of a pharmacy-prepared, physician-edited pharmacy and therapeutics (P&T) committee newsletter.

DESIGN

Two separate surveys conducted after 7 and 24 months of publication, respectively.

SETTING

500-bed, university-affiliated, tertiary-care hospital.

MAIN OUTCOME MEASURES

The initial survey was mailed to physicians after 7 months of publication and they were requested to rate various aspects of the newsletter, including timeliness of articles, usefulness of articles, quality of writing and design, and overall value of the publication on a scale of 1-4: (1 = excellent, 2 = good, 3 = fair, 4 = poor). Physicians were also asked to rank different categories of articles (articles on new drugs, drug-class reviews, topical reviews, formulary news, and articles providing P&T committee information) and were encouraged to provide comments. A separate follow-up survey conducted at 24 months asked physicians to indicate whether they (1) regularly received the newsletter, (2) regularly read the newsletter, (3) found the information in the newsletter to be useful, and (4) desired to continue receiving the newsletter.

RESULTS

Initial survey results yielded mean newsletter quality scores ranging from 1.54 to 1.66. Respondents preferred, in descending order, articles on new drugs, drug-class reviews, topical reviews, formulary news, and P&T committee information. The 24-month survey revealed that 96 percent of the physicians regularly receiving and reading the newsletter found the information useful and 97 percent felt that the newsletter should continue to be published. Favorable comments were also received from several prominent physicians.

CONCLUSIONS

The results indicate strong physician acceptance of a pharmacy-prepared, physician-edited newsletter and provide information about the types of articles preferred by physicians in a university hospital setting.

Hospital selection of home infusion therapy companies as preferred providers

The process by which a hospital selected home infusion therapy providers is described. Administrators at a 379-bed teaching hospital decided to attempt to reduce the high mean length of stay by expanding the use of home infusion therapy. Direct diversification into this field by the hospital was not feasible, so it was decided to establish contractual agreements with providers. A task force was appointed to evaluate and choose vendors in the area and to increase the number of patient referrals. The task force examined reports on past experience with providers, price lists, the range and level of services offered, and the amount of free care given and visited the companies' facilities. The group designated three providers as preferred and two as unacceptable. The number of patients referred increased from 21 during the 12 months before the task force was convened to 46 in the first 9 months afterward, for a saving of 2198 patients days. After one year the task force met again to consider company requests for evaluation or reevaluation, establish a plan for publicizing the benefits of home infusion therapy, and replace the site visits with a requirement for accreditation by the Joint Commission. After two years, the task force developed provider-evaluation criteria to streamline the process and reflect the experience gained. The responsibility for reviewing providers was transferred to the P&T committee. When a direct venture into home infusion therapy is not fiscally desirable, contracting for services can still offer the advantages of reduced length of stay and decreased drug expenses.

Compliance with medication orders among the elderly after hospital discharge

Patient compliance with medication prescriptions in the period immediately following hospital discharge should be of concern to all hospital personnel responsible for the appropriate use of medications, notably Pharmacy and Therapeutics and Quality Assurance Committees. We reviewed the medical records of patients over age 65 discharged from one acute-care hospital. Two days after discharge, we contacted subjects by phone and determined which medications they were taking and at what frequency. We compared discharge orders for medication use with actual use, as determined by self-reports. Of the 44 patients for whom we had complete data, 64% used at least one medication that was not ordered by the physician at discharge, and 73% failed to use at least one medication according to the way it was ordered. Of all drugs ordered at discharge, 32% were not taken at all. Hospital personnel should evaluate their discharge procedures and test techniques to improve compliance in discharged elderly patients.

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.

Determining the formulary status of quinolone antibiotics: one institution's approach

Streamlining antibiotic therapy--ie, simplifying regimens, route of administration, or both--is necessary in the modern treatment of hospitalized patients with infectious diseases. Due to their pharmacokinetic profiles and comparative efficacy and safety, the quinolone class of antibiotics is an ideal class for which to direct streamlining efforts. Including only one agent of this class on the formulary, however, is inadequate. Having several quinolones available, and thus expanding the local hospital market for them, enables more physicians to be contacted and educated by manufacturers' sales representatives as part of the hospital's antibiotic management program. By assisting in the education efforts, pharmaceutical representative help to conserve hospital resources, both in terms of cost and personnel. In addition, having more than one supplier of quinolones encourages competition, which favors price reductions.

P & T Committee response to evolving technologies: preparing for the launch of high-tech, high-cost products. Roundtable discussion

P & T Committees are entering an exciting era in which the introduction of biotechnology-derived pharmaceuticals is providing life-saving opportunities for conditions for which there was little or no hope for a cure. The P & T Committee at Thomas Jefferson University Hospital has anticipated the challenge that these novel therapeutics present, and has already positioned itself for the pending approval of the first therapeutic human monoclonal antibody. Nebacumab (HA-1A, formerly known as Centoxin; by Centocor) will be used for the treatment of gram-negative sepsis. Although this antiendotoxin has a good side effect profile, its use also carries a high price tag. This will raise several difficult ethical issues once the product is introduced. In this exclusive Hospital Formulary roundtable, members of Thomas Jefferson's P & T Committee and Technology Assessment Subcommittee provide their insights for responsibly managing a high-tech, high-cost product such as nebacumab.

Drug usage evaluation of warfarin sodium: the need for improved patient education

Due to documented problems encountered during therapy, the potential for drug-drug interactions, and possible readmissions due to therapy complications, the Ohio State University Department of Pharmacy decided to conduct a drug usage evaluation (DUE) of warfarin sodium. The results of their DUE are presented below.

Audits of radiopharmaceutical formulations

A procedure for auditing radiopharmaceutical formulations is described. To meet FDA guidelines regarding the quality of radiopharmaceuticals, institutional radioactive drug research committees perform audits when such drugs are formulated away from an institutional pharmacy. All principal investigators who formulate drugs outside institutional pharmacies must pass these audits before they can obtain a radiopharmaceutical investigation permit. The audit team meets with the individual who performs the formulation at the site of drug preparation to verify that drug formulations meet identity, strength, quality, and purity standards; are uniform and reproducible; and are sterile and pyrogen free. This team must contain an expert knowledgeable in the preparation of radioactive drugs; a radiopharmacist is the most qualified person for this role. Problems that have been identified by audits include lack of sterility and apyrogenicity testing, formulations that are open to the laboratory environment, failure to use pharmaceutical-grade chemicals, inadequate quality control methods or records, inadequate training of the person preparing the drug, and improper unit dose preparation. Investigational radiopharmaceutical formulations, including nonradiolabeled drugs, must be audited before they are administered to humans. A properly trained pharmacist should be a member of the audit team.

Impact of a pharmacist/physician cooperative target drug monitoring program on prophylactic antibiotic prescribing in obstetrics and gynecology

The pharmacist's role in promoting rational, cost-effective use of drugs has been described in the literature. In a target drug monitoring program (TDMP), a single agent or group of agents becomes targeted for review. Antibiotics have been the primary focus of TDMP because of their therapeutic impact and cost considerations. The objectives of this project were to assess the prophylactic antibiotic prescribing habits of OB/GYN physicians and to evaluate the impact of a pharmacist/physician cooperative TDMP on prophylactic antibiotic prescribing and cost. The study was conducted in three phases: 1) a retrospective chart review of 150 patients, 2) an in-service education session, and 3) a concurrent chart review of 107 patients. Patient selection, timing of preoperative dose, and use of single dose prophylaxis were according to criteria in greater than 90% of patients both before and after the in-service training. Compliance with recommended regimens increased from 45 to 73% after the in-service training. A cost savings was not realized because the physicians wished to use a regimen with anti-anaerobic coverage (i.e., cefotetan) rather than a less expensive agent. However, the cost of selection of resistant organisms must be considered when discouraging the use of multiple broad spectrum agents. Active involvement of the medical staff in a pharmacy-based TDMP produces a cooperative atmosphere in which to educate clinicians and promote rational prescribing habits.

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.