A qualitative approach to the use of economic data in the selection of medicines for hospital formularies: a French survey

Managing conflicts of interest in pharmacy and therapeutics committees: A proposal for multicentre formulary development

WHAT IS KNOWN AND OBJECTIVE

While many countries have central agencies responsible for formulary development, within the United States, each hospital, health care system, or insurance provider has their own pharmacy and therapeutic committee, leading to both inefficiencies and inequalities across formularies. The number and variety of processes within pharmacy and therapeutic committees also increases the likelihood that conflicts of interest will influence the development of formularies. We sought to determine how such influences could be reduced by reviewing international evidence related to the presence and harms of conflicts of interest in formulary development.

METHODS

Several approaches have been taken to reduce the influence of conflicts of interest in pharmacy and therapeutics committee processes, including include disclosure, recusal, exclusion, universal consideration and dual committees. The feasibility of each of these approaches is considered in the context of the United States.

RESULTS AND DISCUSSION

A proposal is drawn from the discussion of various approaches to conflicts of interest in pharmacy and therapeutics committees: multicenter formulary development.

WHAT IS NEW AND CONCLUSION

Multicentre formulary development, where resources are pooled across institutions, may lead to a reduction in the influence of conflicts of interest in pharmacy and therapeutics committee processes in the United States, increasing the chances of including the most safe, efficacious and cost-effective drugs on formularies.

Applying an Implementation Framework to the Use of Evidence from Economic Evaluations in Making Healthcare Decisions

BACKGROUND AND OBJECTIVE

There is a need for the application of theory in understanding the use of evidence from economic evaluations in healthcare decision making. The purpose of this study is to review the published literature on the use of evidence from economic evaluations for healthcare decision making and to map the findings to the Consolidated Framework for Implementation Research (CFIR).

METHODS

A systematic search strategy was used to identify studies investigating the factors that determine the use of evidence from economic evaluation in healthcare decision making. Barriers and facilitators identified in the included studies were mapped across the five CFIR domains, with the "intervention" referring to the use of economic evaluations in decision making. Gaps, inconsistencies and emergent relations were identified through the mapping process.

RESULTS

Fifty-three studies met eligibility criteria and were included in the review. The CFIR constructs associated with the Intervention Characteristics and those associated with the knowledge and beliefs of users of economic evaluations were widely cited in the identified barriers and facilitators. Other constructs from the CFIR had not been reported in the literature, such as 'organisational networks' and 'individual stage of change'. Most of the stages in the implementation process as described by the CFIR were reflected in the identified barriers and facilitators.

DISCUSSION

By categorising barriers and facilitators into domains, the CFIR provides a systematic approach to assess how these factors interact. Literature gaps in the literature regarding the use of economic evaluation in healthcare decision making were identified, specifically issues regarding organisational networks and the role of feedback.

CONCLUSIONS

Through mapping findings from studies of the use of evidence from economic evaluations in healthcare decision making, we present an implementation framework based on the CFIR for understanding the use of economic evaluations into practice.

Management of Hospital Formularies in Ontario: Challenges within a Local Health Integration Network

BACKGROUND

Expenditures on drugs dispensed and administered to patients in Canadian hospitals have been estimated at $2.4 billion per year. Pharmacy and therapeutics (P&T) committees play a key role in the evaluation and management of drug therapies in this setting. Hospitals differ with respect to the composition of these committees, their members' expertise, and the processes used for making formulary decisions.

OBJECTIVES

To examine the current processes for formulary drug review from the perspective of P&T committees and their individual members, and to examine the needs and preferences of these stakeholders related to evidence review and potential collaborative drug review processes within a large Local Health Integration Network (LHIN) in Ontario.

METHODS

Twenty-three sites within 10 hospital corporations in LHIN 4 (Hamilton Niagara Haldimand Brant) were recruited. A 2-part questionnaire was developed and pretested for clarity and comprehensiveness. The institution profile section of the questionnaire was to be completed by pharmacy directors and the P&T section by committee members.

RESULTS

Ten pharmacy directors and 28 committee members representing 10 P&T committees responded. A mean of 6.4 new drug requests were reviewed annually by each P&T committee. Across the LHIN, the workload associated with reviewing submissions for new drugs to be added to the formulary represented 0.84 full-time equivalent. The quality of clinical evidence in the drug submissions was rated more favourably than the quality of economic evidence; furthermore, the use of economic evidence was limited by a lack of health economics expertise within the committees. A centralized review process for the LHIN was perceived as beneficial to improve efficiency, the quality of review, and standardization, and also to reduce costs.

CONCLUSIONS

Across the Hamilton Niagara Haldimand Brant LHIN, considerable time and resources are spent on the review of potential new drugs for addition to the hospitals' formularies. A standardized formulary review process, with greater use of provincial and national drug reviews, would likely benefit all LHINs.

The role of evidence in the decision-making process of selecting essential medicines in developing countries: the case of Tanzania

BACKGROUND

Insufficient access to essential medicines is a major health challenge in developing countries. Despite the importance of Standard Treatment Guidelines and National Essential Medicine Lists in facilitating access to medicines, little is known about how they are updated. This study aims to describe the process of updating the Standard Treatment Guidelines and National Essential Medicine List in Tanzania and further examines the criteria and the underlying evidence used in decision-making.

METHODS

This is a qualitative study in which data were collected by in-depth interviews and document reviews. Interviews were conducted with 18 key informants who were involved in updating the Standard Treatment Guidelines and National Essential Medicine List. We used a thematic content approach to analyse the data.

FINDINGS

The Standard Treatment Guidelines and National Essential Medicine List was updated by committees of experts who were recruited mostly from referral hospitals and the Ministry of Health and Social Welfare. Efficacy, safety, availability and affordability were the most frequently utilised criteria in decision-making, although these were largely based on experience rather than evidence. In addition, recommendations from international guidelines and medicine promotions also influenced decision-making. Cost-effectiveness, despite being an important criterion for formulary decisions, was not utilised.

CONCLUSIONS

Recent decisions about the selection of essential medicines in Tanzania were made by committees of experts who largely used experience and discretionary judgement, leaving evidence with only a limited role in decision-making process. There may be several reasons for the current limited use of evidence in decision-making, but one hypothesis that remains to be explored is whether training experts in evidence-based decision-making would lead to a better and more explicit use of evidence.

Pharmaceutical priority setting and the use of health economic evaluations: a systematic literature review

OBJECTIVES

To investigate which factors and criteria are used in priority setting of pharmaceuticals, in what contexts health economic evaluations are used, and barriers to the use of health economic evaluations at micro, meso, and macro health-care levels.

METHODS

The search for empirical articles was based on the MeSH index (Medical Substance Heading), including the search terms "economic evaluation," "cost-effectiveness analysis," "cost-utility analysis," "cost-benefit analysis," "pharmacoeconomic," AND "drug cost(s)," AND "eligibility determination," AND "decision-making," AND "rationing," AND formulary. The following databases were searched: PubMed, EconLit, Cochrane, Web of Science, CINAHL, and PsycINFO. More than 3100 studies were identified, 31 of which were included in this review.

RESULTS

The use of health economic evaluations at all three health-care levels was investigated in three countries (United States [US], United Kingdom [UK], and Sweden). Postal and telephone survey methods dominated (n = 17) followed by interviews (n = 13), document analysis (n = 10), and observations of group deliberations (n = 9). The cost-effectiveness criterion was most important at the macro level. A number of contextual uses of health economic evaluations were identified, including importantly the legitimizing of decisions, structuring the priority-setting process, and requesting additional budgets to finance expensive pharmaceuticals.

CONCLUSION

Factors that seem to support the increased use of health economic evaluations are well-developed frameworks for evaluations, the presence of health economic skills, and an explicit priority-setting process. Differences in how economic evaluations are used at macro, meso, and micro levels are attributed to differences in the preconditions at each level.

Literature review on the structure and operation of Pharmacy and Therapeutics Committees

AIM OF THE REVIEW

To review the literature on the structure and operation of hospital Pharmacy and Therapeutics Committees from an international point of view and examine the factors that influence decision-making of these committees.

METHOD

We performed a literature search in the Medline and Embase databases from 1997 to January 2009 with the search terms: formulary system decision making, pharmacy and therapeutics committee, formularies hospital, drug formulary, survey, drug selection and outcome assessment health care. Inclusion criteria were the following: studies analyzing Pharmacy and Therapeutics Committees published in English or Spanish from 1997 to January 2009. Exclusion criteria were: publications which were editorials or opinion pieces, studies relating to one hospital, and studies where full text could not be attained. The analysis was divided into structural/organizational data and data on factors affecting the decision-making process.

RESULTS

Seventeen studies met the inclusion criteria. Pharmacy and Therapeutics Committees and formularies were present in more than 90% of the hospitals in four of the five countries examined. Therapeutic interchange programs existed only in two of these countries. The mean number of committee members ranged between six and eight. More than 89% of the committees included a pharmacist. Standard operating procedures were implemented by 89% of the committees. The most influential factors in the decision-making were clinical trial results or drug costs rather than pharmacoeconomic studies. Other local organization-dependent factors were also important.

CONCLUSIONS

The structure and operating procedures of Hospital Pharmacy and Therapeutics Committees are similar in select Western countries. Information from clinical trials is the most influential factor in the decision-making process.

The role of pharmacoeconomics in formulary decision making in different hospitals in Riyadh, Saudi Arabia

OBJECTIVE

To assess the trend of using pharmacoeconomic information by Pharmacy and Therapeutics (P&T) committees when making formulary decisions.

DESIGN

A cross-sectional study conducted in 2007, using structured survey questionnaires which were distributed to members of the P&T committees in 11 different hospitals in Riyadh, Saudi Arabia.

RESULTS

A total of 100 survey questionnaires were sent to head of pharmacy departments of 11 different hospitals in Riyadh, Saudi Arabia. Out of these, 48 questionnaires were completed and returned. Of the total respondents participated in the study, 64.58% were medical doctors and 16.66% were pharmacists and 75% of the respondents said they have applied pharmacoeconomic evaluations in their decision making process. More than 80% of the respondents perceived that they had a fair knowledge of pharmacoeconomics. Approximately 80% of respondents expressed some degree of agreement that pharmacoeconomics should be applied as a decision making tool. The majority of decision-makers (95%) expressed the interest in attending workshops on pharmacoeconomics.

CONCLUSION

The study showed that pharmacoeconomics can play an important role in the P&T committee formulary decisions. However, more education to health care professionals and to hospital administrators should be conducted to facilitate the use of such a tool. Also, hospitals should recruit health care professionals with pharmacoeconomic expertise to manage limited health resources in the best way available.

The role of education in improving physicians' professional use of economic evaluations of health interventions: some evidence from a cross-sectional survey in Italy

A cross-sectional survey was carried out on a random sample of Italian physicians through a self-administered questionnaire to describe knowledge, attitudes, and professional behavior toward economic evaluations of health interventions. A response rate of 74.1% was achieved (760 questionnaires). Although many physicians show a positive attitude toward cost-minimization and, to a lesser extent, to cost-effectiveness analysis, they rated their methodological knowledge as unsatisfactory, and the professional use of the economic evaluations of the health interventions in clinical practice is quite low. Multiple logistic regression analysis showed that adequate knowledge and positive attitudes are associated with increased physicians' use of health economic evaluations, as well as time dedicated to continuing medical education and previous training experience about health economics and management. Education and specific training may play an important role in promoting a more cost-conscious behavior of physicians.

The role of economic evaluation in the decision-making process of family physicians: design and methods of a qualitative embedded multiple-case study

Background

A considerable amount of resource allocation decisions take place daily at the point of the clinical encounter; especially in primary care, where 80 percent of health problems are managed. Ignoring economic evaluation evidence in individual clinical decision-making may have a broad impact on the efficiency of health services. To date, almost all studies on the use of economic evaluation in decision-making used a quantitative approach, and few investigated decision-making at the clinical level. An important question is whether economic evaluations affect clinical practice. The project is an intervention research study designed to understand the role of economic evaluation in the decision-making process of family physicians (FPs). The contributions of the project will be from the perspective of Pierre Bourdieu's sociological theory.

Methods/design

A qualitative research strategy is proposed. We will conduct an embedded multiple-case study design. Ten case studies will be performed. The FPs will be the unit of analysis. The sampling strategies will be directed towards theoretical generalization. The 10 selected cases will be intended to reflect a diversity of FPs. There will be two embedded units of analysis: FPs (micro-level of analysis) and field of family medicine (macro-level of analysis). The division of the determinants of practice/behaviour into two groups, corresponding to the macro-structural level and the micro-individual level, is the basis for Bourdieu's mode of analysis. The sources of data collection for the micro-level analysis will be 10 life history interviews with FPs, documents and observational evidence. The sources of data collection for the macro-level analysis will be documents and 9 open-ended, focused interviews with key informants from medical associations and academic institutions. The analytic induction approach to data analysis will be used. A list of codes will be generated based on both the original framework and new themes introduced by the participants. We will conduct within-case and cross-case analyses of the data.

Discussion

The question of the role of economic evaluation in FPs' decision-making is of great interest to scientists, health care practitioners, managers and policy-makers, as well as to consultants, industry, and society. It is believed that the proposed research approach will make an original contribution to the development of knowledge, both empirical and theoretical.

Self-reported healthcare decision-makers' attitudes towards economic evaluations of medical technologies

BACKGROUND

Increasing costs have generated concern among governments and healthcare providers who have realized the need for cost containment measures and more efficient resource utilization. Health economics is one potential source of information that can make healthcare more efficient.

SCOPE

This review article summarizes the published literature on self-reported attitudes of healthcare decision-makers towards economic evaluations of medical technologies and examines the extent to which economic evaluations are used in health policy decisions.

METHODS

A systematic literature review of published English language studies was conducted using MEDLINE, EMBASE, and HEED from January 1995 to December 2007.

FINDINGS

Fifty-five articles investigated the use of economic evaluations on three levels of decision-making: central, local, and physician level. Results indicate the use of economic evaluation information increased from limited/minor to moderate use. The influence of economic evaluations increased with the level of centralization of healthcare system. Barriers to use health economics research varied across levels and included health economics research-related barriers such as timely availability, lack of credibility, insufficient methodological quality and decision-context-related barriers including limited decision makers' knowledge, inflexibility in healthcare budgets and variability among healthcare organizations.

CONCLUSIONS

For consistent policy-making it is important that similar recommendations for cost-effective interventions and programs are developed at all levels and that implementation is promoted by incorporating the appropriate incentives in healthcare provision.

Drug formulary decision-making in two regional health authorities in British Columbia, Canada

OBJECTIVES

Growing pharmaceutical demands challenge healthcare organizations to set drug funding priorities (i.e. establish a formulary list). This responsibility typically rests with pharmacy and therapeutics (P&T) committees, yet how the process transpires within regional health authorities is unclear. The purpose of this study was to construct an explanatory model of drug formulary priority-setting as it occurs within regional health authorities.

METHODS

A grounded theory approach was employed to study the practices of two regional health authority P&T committees in British Columbia, Canada. Data sources spanned committee documents, meeting observations (n=4), and semi-structured interviews with committee members (n=15). Data analysis involved coding using the constant comparative technique and writing analytic memos.

RESULTS

Regional P&T committees engaged in two activities related to drug formulary priority-setting: developing auto-substitution policies and reviewing drug addition requests. Four processes were central to decision-making: (i) negotiating margins of therapeutic advantage; (ii) seeking value for the resources allocated; (iii) interfacing between community and institutional settings; (iv) situating decisions within an organizational context.

CONCLUSIONS

Findings highlight opportunities for institutions to improve the fairness of agenda-setting practices, and for additional collaboration between policy-makers who prioritize drugs for publicly funded formularies applicable to institutional versus community settings.

Sources of information for new drugs among physicians in Thailand

OBJECTIVE

To determine the sources and the types of information about new drugs that Thai doctors at a teaching hospital perceived as important before prescribing and to assess their views on their preferred sources of drug information.

METHOD

There were two phases of this study, the quantitative and the qualitative components. For the quantitative study, a descriptive survey using a self-reported questionnaire was mailed. The qualitative component consisted of face-to-face interviews using a semi-structured questionnaire.

MAIN OUTCOMES MEASURE

The initial sources of information about new drugs; the reliability scores for each source of information; the types of information that doctors required before prescribing new drugs; and the prescribers' views on their preferred sources.

RESULTS

The general findings regarding the doctors' information sources on new drugs were consistent in both the quantitative and qualitative analyses. Conferences, medical journals, and meetings with medical representatives were the initial sources of information for new drugs. Safety and efficacy profiles of new drugs were the most common types of information considered before prescribing new medicines. Although the medical representatives were viewed as very efficient in providing information about new drugs, the interviewees perceived that the information obtained from the persons employed by the pharmaceutical companies was likely to be biased. Consequently, the physicians preferred to have an unbiased resource person who could proactively provide two-sided information for both existing and new drugs at the hospital.

CONCLUSION

The information sources on new drugs most frequently used by the physicians include scientific conferences, journals and medical representatives and they yearn for unbiased information regarding safety and efficacy of the promoted drugs before prescribing the new medicines. Thus, there is a window of opportunity for hospital pharmacists to serve the unmet needs of the physicians.

Cost-effectiveness analysis and formulary decision making in England: findings from research

In a context of rapid technological advances in health care and increasing demand for expensive treatments, local formulary committees are key players in the management of scarce resources. However, little is known about the information and processes used when making decisions on the inclusion of new treatments. This paper reports research on the use of economic evaluations in technology coverage decisions in England, although the findings have a relevance to other health care systems with devolved responsibility for resource allocation. It reports a study of four local formulary committees in which both qualitative and quantitative data were collected. Our main research finding is that it is an exception for cost-effectiveness analysis to inform technology coverage decisions. Barriers to use include access and expertise levels, concerns relating to the independence of analyses and problems with implementation of study recommendations. Further barriers derive from the constraints on decision makers, a lack of clarity over functions and aims of local committees, and the challenge of disinvestment in medical technologies. The relative weakness of the research-practice dynamics in this context suggests the need for a rethinking of the role of both analysts and decision makers. Our research supports the view that in order to be useful, analysis needs to better reflect the constraints of the local decision-making environment. We also recommend that local decision-making committees and bodies in the National Health Service more clearly identify the 'problems' which they are charged with solving and how their outputs contribute to broader finance and commissioning functions. This would help to establish the ways in which the routine use of cost-effectiveness analysis might become a reality.

Use of centrally developed pharmacoeconomic assessments for local formulary decisions

PURPOSE

The distribution, content, timeliness, use, and influence of pharmacoeconomic assessments (PEAs) of drugs in New Zealand public hospitals were examined.

METHODS

In April 2005, a questionnaire-based, cross-sectional survey was sent to chief pharmacists at all 29 New Zealand hospitals employing a pharmacist. The questionnaire asked pharmacists about the use and influence of PEAs in their hospitals' formulary decision-making process. Answers were given using a scale of 1 to 6, with 1 being the most positive response.

RESULTS

Of the 29 surveys mailed, 24 (83%) were completed. Data on 12 PEAs were analyzed. Assessments were seen and summaries read in most hospitals (median, 77% and 65%, respectively). Full documents were read in fewer hospitals (35%). In general, the PEAs were considered moderately easy to understand, provided a concise summary, and contained adequate detail of the methodology. Of the 24 respondent hospitals, 21 had assessment processes for new medicines; hence, a total of 252 hospital evaluations of Pharmaceutical Management Agency (PHARMAC)-assessed drugs were possible. A total of 132 possible evaluations (52%) were undertaken. More evaluations (106 [42%]) took place before PHARMAC's PEAs were distributed and fewer (26 [10%]) after distribution. Where used, the PEAs appeared to have a modest effect on hospital decisions.

CONCLUSION

The provision of 12 PEAS by PHARMAC to hospitals in New Zealand had only a modest influence on their formulary decision-making process, mostly due to the lack of timeliness of the PEAs. The timely delivery of centrally developed PEAs may be essential to generating a greater effect on the formulary decisions at a wider level.

Economic evaluation in health care: the point of view of informed physicians

OBJECTIVES

We investigated health professionals with a solid background in health-care management and economics to get their opinion and attitude on the use of economic evaluation at the policy, organizational, and professional levels of decision-making.

METHODS

A 12-item questionnaire was sent to 374 Italian health-care professionals who received training in economic evaluation of health-care programs in the last 10 years at the Bocconi School of Management, Milan, Italy.

RESULTS

The response rate was 46.8% (175 questionnaires). All respondents stated that the basics of economic evaluation analysis must be part of the overall knowledge of health-care professionals. The usefulness of economic evaluation for professional activities was rated 3.83 (scale 1-5). Respondents stated that economic evaluation is used more for managerial decisions than for clinical ones (mean 2.89 vs. 2.74, P = 0.09). "Decisions are taken according to a short-term perspective" was the most frequently reported barrier for the actual use of economic evaluation studies, particularly by managers (76.7%). "More training in health economics" was indicated as the incentive to expand its use by the majority of both clinicians and managers (64.6%). Significantly more managers than clinicians (74.4% vs. 54.1%, P = 0.005) considered that the maximum benefits of economic evaluation are reaped at organizational level.

CONCLUSIONS

Informed Italian health professionals have a positive attitude toward the principles and the techniques of economic evaluation. They show appreciation of their potential role and report making some use of them in actual decision making.

Scope of international hospital pharmacy practice

OBJECTIVE

To review the published English literature regarding international hospital pharmacy practice.

DATA SOURCES

A computer search of all English-language articles in MEDLINE (1966-June 2004) and other Internet sources and International Pharmaceutical Abstracts (1971-June 2004).

STUDY SELECTION AND DATA EXTRACTION

All studies that discussed hospital pharmacy or clinical hospital pharmacy activities outside of the US were considered for inclusion.

DATA SYNTHESIS

The scope of international hospital pharmacy practice is quite varied, both inter- and intra-country, and varying degrees of specialization exist. Although clinical pharmacy is well developed in some countries, it is still in infancy stages in others. In addition, there is disparity in the actual definition of clinical pharmacy throughout the world.

CONCLUSIONS

Since very few data have been published regarding hospital pharmacy practice on an international scale, we suggest a survey be conducted to objectively capture this information and increase awareness of clinical pharmacy in this setting.