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.

Change in prescribing patterns of intravenous histamine2-receptor antagonists results in significant cost savings without adversely affecting patient care

OBJECTIVE

The cooperative efforts and educational activities associated with a major histamine2-receptor antagonist (H2RA) formulary change and the clinical and financial results are described. EVALUATION PROCESS: An extensive financial and clinical evaluation was conducted. Sources included primary literature, reference texts, institution-specific financial data, and reports of other hospitals' experiences.

INTERVENTIONS

Through cooperative efforts with key members of the medical staff, several interventions were adopted: maintain only one parenteral H2RA on the formulary; develop guidelines for H2RA use and stress ulcer prophylaxis; investigate a target drug-reminder system to promote oral H2RA use.

RESULTS

Within a month after implementing the formulary change and educational process, prescribing of parenteral H2RAs changed from 80 percent ranitidine to 99 percent cimetidine. Monitoring of nonformulary ranitidine use revealed only three cases of possible or probable association of adverse central nervous system effects with cimetidine in an eight-month period. Elevations of theophylline, lidocaine, or phenytoin serum concentrations; or prothrombin time above the therapeutic range during warfarin therapy occurred in only 5 of 142 monitored patients who received concomitant therapy with an H2RA. No change in serum theophylline concentrations above the therapeutic range was noted to the hospital before and after the conversion. Savings have been estimated at $250,000 in the first year and $775,000 over four years, mostly from the conversion from intravenous ranitidine to intravenous cimetidine therapy.

CONCLUSIONS

Successful intervention can be accomplished by cooperation between the pharmacy and the medical staff to achieve cost savings without sacrificing the quality of care.

Perception of hospital pharmacists/dispensing personnel of the essential drugs concepts (EDC) in Zimbabwe

The perception of hospital pharmacists/dispensing personnel on the essential drugs concept in Zimbabwe was prospectively evaluated. To this end, 100 ad hoc questionnaires were mailed to the health professional cadre around the country in October 1989. 54 health centres responded and these consisted of 4 central hospitals, 3 provincial, 22 general and district, 14 rural hospitals, 7 private hospitals/clinics and 4 city polyclinics. These health centres serve an estimated population of 6 million people. Of the dispensing personnel, 22% had been trained in their respective health professions after 1983, i.e. after the introduction of the essential drug concept. 65% of the respondents had a working knowledge of the essential drugs concept. Pharmacists and pharmacy technicians made up 59% of the dispensing personnel, while nurses accounted for 32%. Significantly all respondents used the Essential Drug List for Zimbabwe hand book and they thought the concept is a good one.

Cost-control issues within the hospital environment in the United Kingdom

Health care in the United Kingdom is dominated by the National Health Service, which operates under a system in which care is delivered free at the point of need and is funded by taxation. Experimentation with a number of different models has occurred since 1980 and has culminated in recent National Health Service reforms characterized by the separation of purchaser and provider functions. An inescapable result of this is the formal definition of the relationship between need and service provision (contracts or performance arrangements), and the equally unavoidable costing of "patient episodes" or equivalent as a tool for estimating both supply and demand. This change has completely altered the way in which individual capital and revenue costs are viewed in the National Health Service. With regard to drugs, costs can now be seen as part of a patient's consumption of resources as opposed to a hospital budget heading. The new system acknowledges that higher drug costs can be incurred if the overall patient-episode cost is reduced as a result. Such a reduction in average patient costs might then lead to more contract work and a higher revenue for the hospital. Quality of care specifications by purchasers may also affect drug costs.

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.

Teicoplanin vs vancomycin: cost-effectiveness comparisons

The rising incidence of methicillin-resistant staphylococci and resistant enterococci in recent years has led to increased use of vancomycin as an active combatant in the treatment of gram-positive infections. Teicoplanin is an investigational glycopeptide that shares a similar spectrum of activity with vancomycin and appears to have similar efficacy. Teicoplanin offers several theoretical advantages compared with vancomycin including once-daily dosing, fewer side effects, and the option for intramuscular administration. While these may be perceived as substantial advances in the glycopeptide class of antibiotics, teicoplanin will probably not replace the now generically available vancomycin on hospital formularies. If competitively priced as a once-daily dosing regimen, teicoplanin will likely gain initial acceptance as an alternative in patients with an intolerance to vancomycin infusion-related side effects or in patients placed on combination aminoglycoside therapy for extended periods of treatment, as an intramuscular antibiotic in patients with poor venous access, and for routine antibiotic prophylaxis where protection from resistant gram-positive pathogens is important. The use of teicoplanin in the hospital may become more widespread as its side effect profile and economic advantages of less frequent dosing compared with vancomycin become better understood.

Reducing outpatient costs of nonsteroidal antiinflammatory drugs at a Department of Veterans Affairs teaching hospital

OBJECTIVE

To determine how formulary changes, based on the recommendations of a clinical pharmacy specialist, affected outpatient nonsteroidal antiinflammatory drug (NSAID) prescribing patterns and drug costs in a Department of Veterans Affairs (VA) teaching hospital.

DESIGN

Cost-benefit analysis.

SETTING

VA teaching hospital.

PATIENTS

Outpatient veterans.

INTERVENTIONS

Sulindac, piroxicam, and diflunisal were removed from the formulary and made available only on a case-by-case review process. Buffered aspirin and phenylbutazone also were removed from the formulary; these drugs were made unavailable altogether. Ibuprofen, indomethacin, salsalate, enteric-coated aspirin, and plain aspirin retained their formulary status and were available for routine prescribing.

MAIN OUTCOME MEASURES

Changes in the number of prescriptions dispensed and in prescription costs for each NSAID were measured 3 months before and 5 and 21 months after implementation of formulary changes.

RESULTS

No prescriptions were dispensed for diflunisal, buffered aspirin, and phenylbutazone 21 months after implementation of the formulary changes. During this same period, prescriptions for sulindac and piroxicam declined 95.7 and 97.1 percent, respectively. The average cost per outpatient NSAID prescription declined from $14.78 to $4.75 (67.9 percent) after 21 months. An extrapolated yearly savings of $137,704 was calculated.

CONCLUSIONS

Formulary changes based on recommendations of a clinical pharmacy specialist resulted in altered physician prescribing patterns and reduced outpatient drug costs for NSAIDs in a VA teaching hospital.

Current treatment of gram-positive infections: focus on efficacy, safety, and cost minimalization analysis of teicoplanin

The current health care environment has had a significant impact on hospital Pharmacy and Therapeutics Committee formulary decisions. In evaluating a new therapy for formulary inclusion, a cost savings along with equivalent or an improvement in patient care and safety is optimal. Teicoplanin is an investigational glycopeptide antimicrobial agent with a spectrum of activity similar to vancomycin. Unlike vancomycin, however, teicoplanin has a long elimination half-life permitting administration once daily, and is well tolerated when given intramuscularly. In addition, teicoplanin is associated with a favorable safety profile. Red man syndrome does not appear to be a significant clinical problem. Results of our cost minimalization analysis using the average acquisition costs of vancomycin revealed that teicoplanin (400 mg), at an average acquisition cost of less than $28.46 when administered intravenously and $30.93 when administered intramuscularly, offers a clinically efficacious, safe, and less expensive alternative to vancomycin 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.

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.

Pharmacy and Therapeutics committee. Cost-containment considerations

The Pharmacy and Therapeutics committee is a frequently used mechanism for health care organizations to meet mandated standards. The control that the committee has over the formulary is often seen as a potential way of controlling the expenditures for drugs. As the Pharmacy and Therapeutics committee is the means for the clinical staff to have an effect as to what agents are available to practitioners, it is incumbent on the committee members to have a clear idea of what their role should be in cost containment. An important concept that impacts on cost is that optimal health benefit is not necessarily the result of maximum expenditure. The welfare of the patient is paramount to all in the health care field; however, it is the task of clinicians to determine what constitutes optimal health benefit and to act as agents of the patient. Clinicians must maintain patient care as their top priority. Although health care expenditures are an extremely important issue, quality of patient care cannot be subrogated to a secondary concern.

Implementing an automatic fluoroquinolone therapeutic interchange program in a community hospital

A community hospital developed an automatic therapeutic interchange program for fluoroquinolone antibiotics. After considering efficacy, available formulations, and cost, this P&T Committee selected ciprofloxacin (Cipro) as the class representative for formulary use. The steps taken to implement this automatic therapeutic interchange policy are presented.

Association between formulary strategies and hospital drug expenditures

National survey data were analyzed to determine whether an association existed between formulary strategies and hospital drug expenditures. Data on community hospitals were obtained from (1) ASHP's 1987 national survey of pharmaceutical services, (2) the American Hospital Association, and (3) the Health Care Financing Administration. Along with size, case mix, and salary information, data were collected on whether the hospitals used a well-controlled formulary, whether they used therapeutic interchange, and how much money they spent on drugs. A logarithmic cost-function model was used to obtain a straight-line equation that expressed the relationships between drug cost per patient day and the other variables assessed. Summary statistics were calculated with data from 514 hospitals. The adjusted coefficient of multiple determination indicated that the model was able to explain 24.6% of the observed variation in drug cost per patient day. A significant association was found between decreased costs and a well-controlled formulary, therapeutic interchange, or both. Hospitals that used either strategy spent 10.7% less for drugs than those that used neither. Hospitals that used both strategies spent 13.4% less than those that used neither. Analysis of national survey data suggests that use of a well-controlled formulary, therapeutic interchange, or both are associated with lower pharmacy drug expenditures.

Surfactant replacement therapy: development of criteria for appropriate use. Ohio State University Hospitals

At The Ohio State University (OSU) Hospitals, DUE criteria were established when colfosceril palmitate, a synthetic surfactant, was added to the formulary in January 1991. The DUE criteria were designed to assure appropriate drug use, educate physicians, and establish an effective way to monitor drug use and patient outcome (ie, response rate and complications). The criteria include a mechanism for evaluation and modification of the guidelines, as necessary. In addition, a review process will be used to determine the therapy's cost effectiveness and to serve as a guideline for making recommendations on other surfactant formulations as they become available.