How can hospitals ration drugs? Drug rationing in a teaching hospital: a method to assign priorities. Drug Committee of the Royal Adelaide Hospital

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How can hospitals ration drugs? First consider the overall process of care

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How can hospitals ration drugs? Fairness is at issue

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How can hospitals ration drugs? Formulate, don't formularise

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Formulary management of antiulcer drugs: economic considerations

Peptic ulcer disease (PUD) is a common medical problem costing billions of dollars annually around the world. Since the availability of the first histamine H2-receptor antagonist, cimetidine, many economic analyses have been conducted to compare the impact of this drug class on resource consumption. H2-Antagonists have been shown to reduce mortality, hospitalisations, ambulatory care visits and endoscopy use caused by PUD. Because of changing risk factors and variations in diagnosis, it remains controversial whether these drugs have had a long term impact on PUD incidence and prevalence. Three studies conducted after the introduction of cimetidine showed it to reduce total direct medical healthcare expenditures, despite increases in drug costs. Studies investigating the short term treatment of PUD show mixed results because of diverse study designs and different comparator drugs. No specific therapy appears consistently superior economically because of variations in population studies, ulcer relapse rates and drug acquisition costs. However, maintenance therapy for PUD has been shown to be cost-effective. When compared with surgery--an extremely efficacious option--maintenance therapy (both daily and intermittent) is cost-effective over at least a 10-year period. Within the maintenance therapy options, daily ranitidine has been shown to be more cost-effective than intermittent therapy for up to 2 years. Omeprazole is the least costly and most efficacious treatment for gastroesophageal reflux disease (GORD or GERD) compared with ranitidine and/or lifestyle modification alone. It has also been shown that the costs for empirical treatment of GORD are offset by the costs of additional investigation of those who do not have the disease. Thus the decision of whether to treat empirically should be based on physician and patient preferences, and not on costs. The use of misoprostol for ulcers caused by nonsteroidal anti-inflammatory drugs is somewhat controversial. Three studies examining the short term (3-month) costs of misoprostol generally show it to be cost saving or cost neutral. Misoprostol is consistently more cost beneficial in elderly or other high risk patients. Results are highly sensitive, however, to several parameters, such as patient type, ulcer severity and rate, drug costs and patient compliance. One study examining prophylaxis using misoprostol over 1 year showed it to be a generally expensive therapy for primary prevention, but was more cost effective for those with a proven GI bleed in the previous year.(ABSTRACT TRUNCATED AT 400 WORDS)

Enhancing the role of physicians in the cost-effective use of pharmaceuticals

The appropriate use of pharmaceuticals, like much else in medicine, is receiving increased public scrutiny. Health care practitioners are looking for ways to reduce costs without negatively influencing quality of care. This article reviews methods for physicians and pharmacists to work together to implement cost-effective prescribing practices and assess clinical outcomes. These methods include educational initiatives, administrative programs to restrict ordering practices, use of formularies and prescribing guidelines, financial incentives, and programs that support physician and pharmacist collaboration.

Hospital drug therapy cost containment through a preferred medicines list and drug utilisation review system

AIM

To measure the economic impact of the introduction of a preferred medicines list and drug utilisation review process on drug therapy costs at the six Christchurch hospitals in the Canterbury Area Health Board.

METHODS

The preferred medicines list, a consensus derived recommended drug list, was introduced along with a drug utilisation review process in December 1990. Detailed drug therapy costs were collected from the pharmacy computer for the 1990/1 and 1991/2 hospital financial years. Data was analysed under the 15 British National Formulary drug groups and also 14 other categories. National hospital drug costs based on sales to hospitals and local drug cost trends prior to the preferred medicine list system introduction were used as baseline measures. Hospital patient discharge numbers and patient days were also recorded.

RESULTS

Prior to the preferred medicines list introduction local drug therapy costs had been rising on average 30% per year. Between 1990/1 and 1991/2 total drug costs fell by 2% from $12.16M to $11.86M while nationally, drug sales to hospitals increased by 15%. Included in the local expenditure were drugs external to the preferred medicine list/drug utilisation review system whose costs are reimbursed to the area health board. When these costs were deducted, inpatient drug costs fell by 11% from $8.76M to $7.7M. In the 29 categories reviewed, 17 had decreases, while the remaining areas increased. Total patient numbers during the period increased by 3% while total patient days decreased by 10%.

CONCLUSION

The preferred medicines list and the associated drug utilisation review process played a major role in the reduction of inpatient drug therapy costs at the Christchurch hospitals. Other factors such as cost shifting or changes in community drug use may have also been responsible for some of the savings.

Physicians' behavior and their interactions with drug companies. A controlled study of physicians who requested additions to a hospital drug formulary

OBJECTIVE

It is controversial whether physicians' interactions with drug companies affect their behavior. To test the null hypothesis, that such interactions are not associated with physician behavior, we studied one behavior: requesting that a drug be added to a hospital formulary.

DESIGN

Nested case-control study.

SETTING

University hospital.

PARTICIPANTS

Full-time attending physicians. Case physicians were all 40 physicians who requested a formulary addition from January 1989 through October 1990. Control physicians were 80 randomly selected physicians who had not made requests.

MAIN EXPOSURE MEASURE

Physician interactions with drug companies, as determined by survey of physicians (response rate, 88% [105/120]).

RESULTS

Physicians who had requested that drugs be added to the formulary interacted with drug companies more often than other physicians; for example, they were more likely to have accepted money from companies to attend or speak at educational symposia or to perform research (odds ratio [OR], 5.1; 95% confidence interval [CI], 2.0 to 13.2). Furthermore, physicians were more likely than other physicians to have requested that drugs manufactured by specific companies be added to the formulary if they had met with pharmaceutical representatives from those companies (OR, 13.2; 95% CI, 4.8 to 36.3) or had accepted money from those companies (OR, 19.2; 95% CI, 2.3 to 156.9). These associations were consistent in multivariable analyses controlling for potentially confounding factors. Moreover, physicians were more likely to have requested formulary additions made by the companies whose pharmaceutical representatives they had met (OR, 4.9; 95% CI, 3.2 to 7.4) or from whom they had accepted money (OR, 1.7; 95% CI, 1.0 to 2.7) than they were to have requested drugs made by other companies.

CONCLUSION

Requests by physicians that drugs be added to a hospital formulary were strongly and specifically associated with the physicians' interactions with the companies manufacturing the drugs.

Medication noncompliance: an issue to consider in the drug selection process

Patient medication noncompliance is a major public health problem that represents a significant cost to our health care system. Health care professionals--through counseling programs, and the pharmaceutical industry--through various improvements in drug products, have helped to improve medication noncompliance. Yet, additional research needs to be conducted on noncompliant behavior and into methods to improve it. All health care professionals, particularly those involved in selecting and guiding drug therapy decisions, need to be made aware of the costs to the health care system that result from noncompliance.

Oral antibiotic usage in hospitalized patients

With the introduction of the fluoroquinolones, oral antibiotic usage is becoming an increasingly important issue. The medical record of 119 patients receiving oral antibiotics at a university hospital were reviewed to examine demographics and patterns of usage. The population was predominantly female and below 50 years of age. Urinary tract infections were most common followed by infections of the respiratory tract and skin and skin structure. The majority of usage was empiric in nature. The most commonly prescribed antibiotics were trimethoprim/sulfamethoxazole, cephalexin, and ampicillin/amoxicillin. Monotherapy with an oral agent was observed in 82% of the cases. Intravenous antibiotics were administered prior to oral therapy in 61% of the patients studied. The authors observed a trend from combination intravenous therapy to single-agent oral therapy. Of the patients discharged on an oral antibiotic, 84% received a prescription for the agent originally prescribed for them in the hospital. Tracking of oral antibiotic inpatient use is effective at assessing major trends in usage.

Use and misuse of pharmacoeconomic terms: a definitions primer

Given the current cost-conscious health care environment, pharmacists must now be able to assess the effects of an agent from safety, efficacy, and value considerations. This article describes the various methodologies that may be used in performing pharmacoeconomic analyses and highlights the use and misuse of pharmacoeconomic terminology. Case studies relating the use of these methods to the pharmacy practice setting are presented. The technical nuances of the various methods are explained to promote a better understanding of the appropriate use of these techniques and the terminology used to describe them.

Relationship between practice guidelines, formulary management, and pharmacoeconomic studies

Pharmacy and therapeutics committees can use pharmacoeconomic and outcome studies as tools to evaluate and implement clinical guidelines for patient care. Results of studies help optimize the clinical effects and control the costs of drug therapy. Such data also assist in positioning products in competitive environments. A four-part classification of research studies is offered as an aid to strategic research planning.

Drug formularies--good or evil? A view from the EEC

The use of standard treatment schemes is believed to provide easier, safer, and more rational prescribing of drugs. Provision of neutral information on relative costs and merits of individual therapies may induce physicians to prescribe more rationally and cost effectively. A drug formulary must be developed by using clinical evidence of efficacy, taking into account all available preparations, choosing the most cost effective formulation of the drug, and as far as possible complying with formularies implemented by other health institutions. Planning process and preparation time are fundamental to formulary development work. A restrictive drug policy in the hospital environment will save time in the pharmacy, as fewer drugs are handled, and will improve prescribing as the staff have fewer drugs to familiarize themselves with. The potential benefits from increased generic prescribing, lower stock levels, and closer working relationships between members of the formulary team should all be considered. The benefit of this interdisciplinary approach to drug therapy will be rapidly recognized.

Monitoring drug use in palliative care

A computerized system for monitoring drug use which makes use of the British National Formulary (BNF) drug categories and a departmental formulary (DF) has been developed. Data entry takes less than one week of secretarial time per annum. Details of drug use in 385 patients three weeks after referral to a National Health Service palliative care unit over five years form the basis of this report. The median number of drugs per patient was five, with a maximum of 11; 97% of the drugs were from the DF. Analgesics were the commonest category of drugs used. The 10 most commonly used drugs included three analgesics (morphine, co-proxamol, flurbiprofen), two laxatives (co-danthrusate, lactulose), dexamethasone, metoclopramide, ranitidine, temazepam and amitriptyline/dothiepin. Seventeen per cent of patients received two preparations from the same second level BNF category (analgesics excluded). The concurrence was questionable in about half of these, and mostly related to the use of laxatives or to hypnotics and anxiolytics. Several unexpected inclusions in the top 10 drugs illustrate the need for quantification rather than pontification about drug use in palliative care. Examination of duplicate prescribing provides a forum for examining ways of simplifying drug regimens.

Application of decision analysis in antibiotic formulary choices

OBJECTIVE

To introduce the reader to the fundamentals involved in using decision analysis as a tool in evaluating the associated costs and effectiveness of comparable therapeutic agents.

DATA SOURCES

Currently available literature citations were used to provide the reader with basic references whose purpose is to provide a step-by-step approach for using Decision Analysis in conducting a cost-effective comparison of three commonly used antibiotics. Data were gathered from a previously conducted retrospective chart review where the three antibiotics were used for either prophylactic, empiric, or documented infections. Although this study was limited by its retrospective nature, the reader can use the data to appreciate the fundamentals of decision analysis.

CONCLUSIONS

The continually changing climate in healthcare and the added visibility of pharmacologic agents in the treatment and prevention of disease has increased pressure on pharmacy departments to provide therapeutic agents that are cost-effective. Decision analysis can be used to compare therapeutic agents, in terms of financial as well as clinical outcomes, in a structured fashion that all members of the health care team can understand. The application of Decision analysis is appropriate for many therapeutic agents, not just antibiotics.

The use of pharmacoeconomic data in formulary selection

Pharmacists are encouraged to improve their knowledge and use of pharmacoeconomic data in formulary selection. The formulary selection process has changed significantly in recent years. Among its most significant uses is its potential for cost containment strategies. An overview is presented of the origin as well as the potential impact of pharmacoeconomic data. The need to balance the economic benefit with the clinical advantages for any proposed new drug for formulary inclusion remains the most critical decision to be made by pharmacists.

Prevalence of sorbitol in multiple-dose activated charcoal regimens in emergency departments

STUDY OBJECTIVES

To determine the availability and use of premixed activated charcoal in sorbitol preparations during multiple-dose activated charcoal therapy in the emergency department.

DESIGN AND SETTING

A prospective telephone survey of all 911 receiving hospitals within the catchment area of one poison center.

TYPE OF PARTICIPANTS

Hospital pharmacy supervisors and ED charge nurses.

INTERVENTION

Hospital pharmacy supervisors were surveyed about the available preparations of activated charcoal on their hospital's formulary, and ED charge nurses in these same hospitals were surveyed about the prevalence of sorbitol use in multiple-dose activated charcoal regimens.

MEASUREMENTS AND MAIN RESULTS

Eleven hospitals (16%) stocked only activated charcoal in sorbitol preparations. Twenty-one hospitals (31%) had both activated charcoal in sorbitol preparations and activated charcoal without sorbitol preparations, and 35 hospitals (52%) had only activated charcoal without sorbitol preparations. Repeat dosing of sorbitol during multiple-dose activated charcoal therapy occurred in 33 of 67 (49%) of the EDs surveyed.

CONCLUSION

Sorbitol dosing is often repeated with activated charcoal during multiple-dose activated charcoal therapy in the ED because of the ready availability (and sometimes exclusive availability) of premixed activated charcoal in sorbitol preparations.

Hospital drug formularies and use of hospital services

Many hospitals have introduced formularies to reduce hospital pharmacy expense, among other reasons. This study provides empirical evidence of the influence of hospital formulary restrictions on pharmacy charges, all other hospital charges, and on length of stay, using a survey of hospital drug policies and hospital discharge data from Washington State in 1989. Limiting the number of drugs in particular therapeutic categories reduced total charges incurred for gastrointestinal disease and asthma patients, increased total charges for cardiovascular disease patients, and had no effect on charges for infectious diseases patients. Restricting availability of drugs reduced pharmacy charges, but these savings tended to be offset by increases in other charges. Combining the categories, we found that restricting availability of drugs did not affect charges. We conclude that across-the-board restrictions do not result in cost savings, although savings may be realized for particular drug categories.