Quality control of hospital formularies

Dutch hospital drug formularies: pharmacotherapeutic variation and conservatism, but concurrence with national pharmacotherapeutic guidelines

AIMS

This research examines current hospital drug formularies (HDFs) of all Dutch general hospitals. It assesses the extent to which they recommend the same drugs, the breadth of their coverage in terms of therapeutic areas, drug groups incorporated and individuals drugs included, and their extent of conservatism by considering the year of introduction of the drugs included within groups. Furthermore, it considers the extent to which their recommendations concur and comply with those of national pharmacotherapeutic guidelines and the WHO Essential Drugs List (EDL).

METHODS

Seventy-eight (81%) out of all 96 current Dutch HDFs were received of which 62 were suitable for study. Differences between HDFs and eventual associations with hospital characteristics were researched by statistical testing and case-control studies. To evaluate HDFs' concurrence with national guidelines and compliance with the WHO EDL, nine drug groups were studied in detail: benzodiazepines, calcium channel blockers, beta-adrenoceptor blocking agents, ACE-inhibitors, angiotensin-II inhibitors, NSAIDs, H2-receptor antagonists, 5HT3-antagonists, and H+-pump inhibitors. Concurrence and compliance with national guidelines and the WHO EDL was defined as inclusion of recommended drugs. Non-concurrence was defined as inclusion of nonrecommended drugs.

RESULTS

The total number of indications addressed and drug groups incorporated within HDFs varied from 28 to 72 (median 56) and from 30 to 123 (median 97), respectively. The total number of individual drug entities (pharmacological substances) included ranged from 239 to 658 (median 430) and the total number of drug products, including all different dosage forms, from 412 to 1121 (median 655). Within drug groups, drug entities first marketed were most frequently included. Teaching hospitals were most likely to include recently marketed drugs. Depending on the drug group, HDFs' concurrence and compliance with national guidelines and the WHO EDL ranged from 35% to 100%.

CONCLUSIONS

Findings indicate that Dutch HDFs are rather uniform in the indications addressed and the drug groups incorporated. However, the number of individual drug entities and drug products included within groups varies considerably. Furthermore, Dutch HDFs are considered rather conservative, as older drugs are favoured over more recent drugs. Generally, with some drug exceptions, Dutch HDFs concur and comply with recommendations in national pharmacotherapeutic guidelines and with the WHO EDL over 90%.

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.

The quality of Dutch hospital drug formularies: evaluation of technical features and organisational information

INTRODUCTION

Hospital drug formularies (HDFs) are widely used tools to help influence clinicians' prescribing behaviour. Besides the therapeutic quality of HDFs, the available information and the way in which this is presented are key factors in HDFs' success or failure to influence prescribing behaviour and enhance prescribing quality. This research evaluates the technical features and organisational information of Dutch HDFs.

METHODS

Seventy-two (75%) of all Dutch HDFs were evaluated based on criteria retrieved from international literature and additional criteria drafted by occupational groups working with HDFs. Aspects that were studied were physical appearance and layout, practicability with respect to the available information and how easily this could be retrieved from the HDFs, information regarding drug choice policies such as seamless care, and the available type of therapeutic and pharmaceutical information.

RESULTS

Thirty-three (46%) of the HDFs were less than 3 years old. Physical appearance of all HDFs was very well looked after. Two (3%) HDFs were disease-oriented rather than drug-oriented. Changes from pre-admission therapy were addressed in 30 (42%) of the HDFs, but other seamless care policies were addressed in less than 20% of the HDFs. Finally, less than 50% provided therapeutic information that clinicians indicated as important.

DISCUSSION

Although Dutch HDFs are technically practicable with respect to user-convenience, practice-oriented features are capable of improvements. Furthermore, Dutch HDFs lack important clinical information for daily practice. To enhance seamless care across healthcare, generic prescribing and prescribing on admission from and discharge to any other sectors should be addressed more specifically.

[Structure and activities of drug committees in Germany. Results of a survey of 143 hospitals. Pharmaco-economic Study Group and Rational Drug Therapy of the German Society of Clinical Pharmacology and Therapy]

BACKGROUND

To obtain information on the structure, present activities and decision making process of hospital drug committees in Germany in 1995 a questionnaire with 36 items was designed and sent to 450 hospitals in Germany with more than 400 beds. 143 returned questionnaires could be evaluated.

RESULTS

According to hospital size the median value of the annual drug budget 1993 ranged between DM 2.4 Mio for hospitals with less than 500 beds and DM 30.0 Mio for university hospitals with more than 1,000 beds (including blood and blood derived products). In 53% of drug committees a pharmacist held the position of the chairman, followed by medical specialists (32%), (clinical) pharmacologists held this position only in 8% of the hospitals, but in almost 50% of the university hospitals. In most cases all clinical specialties are represented in the drug committee, the number of members ranging between 5 and 40 (median 12). The number of drugs included in the internal drug list ranging between 400 in hospitals with < 500 beds and about 700 in university hospitals was strongly correlated with the number of beds and, interestingly, with the number of drug committee members. Treatment guidelines were implemented mainly for antiinfectives (87%), infusion solutions (30%), antiemetic drugs (5-HT3-receptor antagonists, 27%) and blood and blood-derived products such as intravenous immunoglobulins (23%). However, effective control of these guidelines was only performed in about 50% of the hospitals. A drug information service was provided in most hospitals, where 95% of queries were answered by pharmacists.

CONCLUSION

The results of our survey showed, that German hospital drug committees vary considerably with regard to their function and control mechanisms on drug use. Most of the responders would appreciate a more intensive exchange of current problems and treatment guidelines.

Considerations in Deciding Which Drugs Should Be in a Formulary

The formulary is a compendium of pharmaceuticals, along with important drug information, that reflects the current clinical judgment of the medical and pharmacy staffs of an organization. Sound formularies have been shown to have a positive effect on prescribing. Poor formularies, those with too many marginal, obsolete, or redundant drugs, may contribute to less than ideal therapy in some patients, and probably at more expense. At the core of a sound formulary is having sound criteria and procedures for adding drugs. Such criteria should be general and specific. Should there be separate criteria for adding new drugs? For antibiotics? For biotechnology drugs? Criteria for maintaining and deleting drugs should also be in place. This keeps the formulary up-to-date and viable. Even with sound criteria, the process of adding, maintaining, and deleting drugs can be flawed by pressures, outside and inside organizations. However, such barriers can be overcome. The process of evaluating drugs for formulary status has been changing. New techniques are being developed to make the process more objective, more scientific, and more patient-outcome-driven.