Strategies for deleting popular drugs from a hospital formulary

The approach used by a hospital pharmacy in planning, implementing, and evaluating a major formulary revision and the strategies used in deleting popular analgesics from the formulary are described. All phenacetin-containing products were deleted from the formulary of The Ohio State University Hospitals. The following steps of the process are described; identification of the problem, literature evaluation, soliciting medical staff support, presentation to the pharmacy and therapeutics committee, designing an implementation timetable, education, monitoring analgesic use, coordination of departmental activities, implementation and follow-up. The strategy used in this case resulted in the policy being implemented successfully.

Restricted cephalosporin use in teaching hospitals

The approaches of teaching hospitals toward limiting the number of cephalosporin drug products on formularies were studied in a mail survey. Pharmacy department directors of 128 teaching hospitals with 200 beds or more responded to teh survey. Forty-two of 128 (33%) hospitals had established formal restriction policies (FRPs) for cephalosporins (CS). Cephalexin and cephradine were the predominant formulary oral CS. Few hospitals had established "therapeutic equivalents" policies, yet the majority of hospitals had a single oral CS on the formulary. Cefazolin was the predominant injectable CS on all formularies; cefamandole and cefoxitin were the predominant restricted CS. In hospitals without restriction policies, these newer CS were on the formulary in 55% of the cases; in FRP hospitals, the figure was 15%. The occurrence of a single, formulary, unrestricted CS was much more likely in FRP hospitals (38%) than in hospitals with no restriction policy (NRP) (8%). FRP hospitals tended to have fewer unrestricted formulary CS. Eighty-three percent of FRP hospitals and 41% of NRP hospitals monitored CS use.

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.

Effectiveness of a cephalosporin education program--a pharmacy education program

In October, 1977, a cephalosporin drug-use review and an educational program were initiated to maximize savings in the pharmacy budget at UCSF and to revise the formulatory to include only one parenteral cephalosporin. The results of the drug-use review were presented to the Pharmacy and Therapeutics Committee where our proposal for an education campaign to encourage appropriate dosing of cefazolin was approved. An explanatory document comparing cephalosporin costs and equivalency was developed for hospital-wide distribution. Pharmacy staffs were informed of program objectives to coordinate education efforts. Physician education was undertaken via document and personal contact with pharmacy personnel. A drug-use review one month after institution of the cephalosporin education program showed marked changes in physician prescribing habits, with greater impact on services where pharmacists were members of the medical rounding team. A change to appropriate dosage prescribing of cefazolin resulted in significant cost savings to the pharmacy budget. These findings resulted in formulary revision to cefazolin as the single cephalosporin available at UCSF. Because cefazolin is available from more than one manufacturer, we were able to obtain a lower bid price the following year, thus realizing an additional cost savings.

A survey of the use and educational value of the hospital formularly manual

The medical and nursing staffs of two affiliated hospitals were surveyed on their frequency and purpose of use of their hospital's formulary manual. A numerical rating of the perceived educational value of the manuals was also requested. Twenty-two per cent (141/650) of those surveyed completed their questionnaires. Ninety-six per cent of the respondents indicated use of the formulary manuals at least once a month; 62% used the manuals at least once a week. The frequency and character of use of various sections of the formulary manuals are presented. The perceived educational value of the manuals was rated 3 or greater on a scale of 1 (no value) to 5 (greatest value) by 80% of the respondents. The hospitals' formulary manuals are frequently referred to for various types of drug information. The professional staffs perceive the formulary manuals to be educationally valuable sources of drug information. Reasons for the low rate of response to the survey are presented. A plan of how to increase the response rate in a planned future survey is also presented.

Savings achieved through use of a less concentrated amino acid solution

The administrative process of adding a 5.5% crystalline amino acid solution to the formulary of two affiliated hospitals and the results of the addition are discussed. A formulary change was sought after it was found that many patients on parenteral nutrient therapy were receiving more amino acids than they needed. Nearly all patients on parenteral nutrient therapy were receiving 8.5% crystalline amino acid solution. The approach to achieving the pharmacy and therapeutics committee's approval of the formulary change included documenting amino acid needs from the literature, securing a multidisciplinary base of support and providing economic impact information. A standard TPN order form for physicians, education through the pharmacy newsletter, and presentations at surgery and medical conferences and grand rounds were implemented to assure that the change was effective. During the 12 months following approval of the formulary addition, 66% of the more than 20,000 total parenteral nutrient solutions were prepared using 5.5% amino acid solutions. This resulted in an annual savings of $41,028

Savings achieved through cephalosporin surveillance

The process by which a 427-bed, acute-care teaching hospital reduced the cost of cephalosporin therapy is described. During a nine-month surveillance period, cefazolin prescribing patterns were monitored. Of the 674 patients who received cefazolin, 640 (92%) received dosages greater than those recommended in the literature. Attempts were made to alter inappropriate prescribing through pharmacist-physician consultation and through contact with the medical service representative of the company which supplied cefazolin. Because these efforts failed, the pharmacy and therapeutics committee decided to delete cefazolin from the formulary. Cephalothin and cephapirin were found to be clinically similar; therefore, the committee recommended that the less expensive cephapirin be dispensed whenever a parenteral cephalosporin was ordered. Prior to the switch to cephapirin, cefazolin accounted for 49% of all parenteral cephalosporin use and 62% of the cephalosporin cost. Cephalothin and cefazolin were 30% and 88%, respectively, more expensive than cephapirin. In the first year after the switch, the hospital saved $33,196 (28.8% of the previous year's total expenditures for cephalosporins).

Bid purchasing of pharmaceuticals

The effects of bid purchasing of drug products by hospitals and the factors to consider in bid purchasing of pharmaceuticals are reviewed; further, the prices available with bid purchasing to a specific hospital in 1974 and 1977 are presented. Factors important for a successful bid purchasing system of pharmaceuticals are: (1) use of a formulary policy, (2) an effective procedure for handling bid purchasing and (3) criteria for evaluation of drug products. Significant differences were found between prices available with and without bid purchasing for 50 nonproprietary drug products in 1974 and for 19 products in 1977. Although monetary savings to hospitals do exist with bid purchasing of pharmaceuticals, the degree of savings is dependent upon the drug usage for that hospital.