Praxis makes perfect?

Hospital formulary committees blend cost-effectiveness analysis, peer review, and continuing medical education to regulate hospital drug purchases and physicians' prescribing patterns in ways that may be instructive to the societal debate on health care reform.

Strategic planning for the management of biotechnologic products: development of a biotech committee

Strategies and tactics for managing biotechnologic products are critical to cope with the increasing number and cost of such products. One strategy is to develop a biotech committee to formulate long-term goals for managing biotechnologic products and to evaluate controversial or extremely expensive new products and recommend their formulary status to the P & T Committee. Involvement of the P & T Committee is crucial to establish strict criteria and monitors to ensure the appropriate and cost-effective use of these products. Involvement of the pharmacy department is also essential to detect usage patterns and reimbursement profiles of approved biotechnologic products in the hospital, as well as their potential financial impact on the hospital's budget.

Formulary considerations in selection of beta-blockers

Selection of beta-adrenergic blockers for formulary addition can be a difficult task, especially with the increasing availability of new beta-blockers, as well as the numerous differences in pharmacodynamic and pharmacokinetic properties of currently available agents. Nevertheless, appropriate evaluation of the important characteristics of beta-blockers should allow selection of the most cost-effective agents for formulary addition. Most importantly, differences in efficacy, product formulation and cost should be carefully considered when making formulary decisions. Notably, evidence from clinical trials indicates differences in efficacy among beta-blockers for post-myocardial infarction prophylaxis, situational anxiety, essential tremor, thyrotoxicosis, migraine prophylaxis and prevention of bleeding associated with oesophageal varices. For many clinical situations, it is also important to select an effective agent that is available in both an oral and intravenous formulation, especially for cardioprotection after acute myocardial infarction and for use in supraventricular arrhythmias. In addition, availability of sustained release products and generic formulations should be considered for their potential to increase compliance and decrease cost, respectively. Comparative drug costs, as well as costs associated with decreased compliance, should also be carefully evaluated. Differences in beta-receptor selectivity, duration of action and presence of intrinsic sympathomimetic activity (ISA) are also important considerations in the selection of beta-blockers for formulary consideration. Although degree of selectivity is relative, beta 1-selective agents may be less likely to induce bronchospasm in patients with chronic obstructive pulmonary disease (COPD) and may be less likely to affect glucose homeostasis in patients with diabetes mellitus. Duration of action of a beta-blocker is an important consideration for evaluation of efficacy throughout the recommended dosage interval. In addition, beta-blockers with a long duration of action can often be administered once or twice daily, potentially leading to increased compliance and thereby improved effectiveness and economic efficiency. The presence of ISA is an important consideration because certain beta-blockers with ISA may be less effective than those without ISA for certain indications. Factors considered to be less important when making formulary decisions of choice of beta-blockers include the route of elimination, lipophilicity and presence of membrane stabilising activity.

Clozapine: an appraisal of its pharmacoeconomic benefits in the treatment of schizophrenia

Clozapine, an antipsychotic agent with relatively weak central antidopaminergic activity, displays atypical pharmacological and clinical properties vis-a-vis the classic antipsychotics. Thus, clozapine is effective against both the positive and negative symptoms of schizophrenia and has a low propensity to cause extrapyramidal effects. Furthermore, clozapine is effective in a substantial proportion (up to 60%) of patients who are refractory to or intolerant of standard antipsychotic therapy. Despite its promising therapeutic potential, the relatively high incidence of clozapine-induced agranulocytosis (approximately 1% of patients) and the associated need for regular haematological monitoring currently restricts the drug's use to the treatment of chronic and severe schizophrenia refractory to standard antipsychotic therapy, and to those patients unable to tolerate such therapy. In the US, the current wholesale price of clozapine (exclusive of monitoring) is $US2.85 per 100mg tablet, amounting to $US4160 annually (1992 dollars) at the most commonly prescribed dose of 400 mg/day ($US2.40 per tablet and $US3510 annually to state programmes through Medicaid reimbursement legislation). In the UK, the annual cost of clozapine (at the average dose of 300 mg/day), inclusive of blood monitoring, is 1806 British pounds sterling (1992 pounds). Although the acquisition cost of clozapine is high in comparison with that of standard antipsychotics, preliminary cost-effectiveness estimates in patients with treatment-resistant schizophrenia suggest that the clinical benefits of the drug (viz. improved psychopathology, social functioning and quality of life) may confer medium to long term economic benefits, primarily by reducing the need for psychiatric hospital services. This effect is most likely to be seen on long term ( greater than or equal to 2 years) maintenance therapy with clozapine. Savings in hospital costs are, however, likely to be offset, at least initially, by increased reliance on outpatient services, and clozapine may therefore confer additional economic costs during the first year or so of treatment. In the longer term, however, the initial cost investment may be recouped in the form of savings to psychiatric institutions and insurers.

Initiation of a clinical pharmacology consult service as a formulary management tool

Establishment of a multidisciplinary clinical pharmacology consult service (CPCS) can be an important adjunct to a successful formulary management system. This article describes the model of a CPCS developed at the University of California Davis Medical Center. The CPCS provides patient-specific consultations, serves a leadership role in directing the medical staff toward hospital-wide drug usage guidelines for high cost pharmaceutical agents, and enforces the P & T Committee adopted criteria on selected high-cost or high risk agents. The mission of the CPCS is to provide the P & T Committee with a multidisciplinary mechanism to educate health care providers, improve patient care, establish drug usage criteria, and enforce those criteria.

Tamoxifen: a review of pharmacoeconomic and quality-of-life considerations for its use as adjuvant therapy in women with breast cancer

Extensive clinical experience, summarised in the recent overview of the Early Breast Cancer Trialists' Collaborative Group (EBCTCG), have confirmed that tamoxifen reduces the rate of both disease recurrence and mortality when administered as adjuvant therapy in women with early breast cancer. Tamoxifen is now established as the preferred adjuvant agent in postmenopausal women; in particular, patients with node-positive, estrogen receptor-positive breast cancer have the most to gain from tamoxifen therapy. Data from a decision-analysis model indicated that tamoxifen monotherapy had a cost-utility ration {$US6000 per additional quality-adjusted life-year (QALY), in 1989 dollars} 5 to 6 times lower than that cited as the cost-acceptability cut-off point in the US. While tamoxifen monotherapy is effective in postmenopausal women, the EBCTCG overview findings indicate that a combined regimen of tamoxifen and antineoplastic chemotherapy has superior efficacy in the same patient group. An issue of current interest is whether the added benefit offered by such a regimen can be justified in terms of added toxicity and cost. Data from a decision-analysis model indicate that combined therapy has a high incremental cost-utility ratio ($US58 000 per additional QALY, in 1989 dollars) compared with no therapy in postmenopausal women. However, the quality-of-life measures TWiST (Time Without Symptoms and Toxicity) and Q-TWiST (quality-adjusted TWiST) indicate that the early toxicity associated with a combined regimen appears to be justified given the superior long term benefits. Patient preference data from 1 study further indicate that the degree of benefit offered by a combined regimen would be acceptable to the majority (73%) of patients. Other areas where pharmacoeconomic analyses may help define more closely the optimal use of adjuvant tamoxifen is in patients at low risk of developing metastatic disease and in determining the optimal duration of therapy. Both areas require further clinical data. In conclusion, tamoxifen adjuvant monotherapy has a low cost-utility ratio in postmenopausal women with node-positive, estrogen receptor-positive breast cancer. Combined therapy in the same patient group has a high cost-utility ratio compared with no therapy but quality-of-life and patient preference data suggest that the costs may be justified. Firm conclusions relating to the use of the drug in other patient subgroups and the optimal duration of therapy await further research.

Antineoplastic agents: comparing off-label uses among authoritative drug compendia

Unlabeled indications for antineoplastic drugs listed in the American Hospital Formulary-Drug Information, United States Pharmacopeia Dispensing Information-Drug Information for the Health Care Professional (Volume 1), and the American Medical Association-Drug Evaluations were evaluated. Specifically, the total number of unlabeled and unique uses (ie, not listed in either of the other two compendia) of 35 antineoplastic drugs were compared. Using a nonparametric analysis of variance to evaluate the results, significant differences in both the average unlabeled indications per drug and unique unlabeled indications per drug were found among the resources checked. The implications of the study results on reimbursement by private insurance carriers of unlabeled antineoplastic drug use is discussed in this article.

Decision analysis in formulary decision making

Although decision making about what drugs to include in an institutional formulary appears to lend itself readily to quantitative techniques such as decision analysis and cost-benefit analysis, a review of the literature reveals that very little has been published in this area. Several of the published decision analyses use non-standard techniques that are, at best, of unproved validity, and may seriously distort the underlying issues through covert under-counting or double-counting of various drug attributes. Well executed decision analyses have contributed to establishing that drug acquisition costs are not an adequate measure of the total economic impact of formulary decisions and that costs of labour and materials associated with drug administration must be calculated on an institution-specific basis to reflect unique staffing patterns, bulk purchasing practices, and the availability of surplus capacity within the institution which might be mobilised at little marginal cost. Clinical studies of newly introduced drugs frequently fail to answer the questions that weigh most heavily on the structuring of a formal assessment of a proposed formulary acquisition. Studies comparing a full spectrum of therapeutically equivalent drugs are rarely done, and individual studies of particular pairs of drugs can rarely be used together because of differences in methodology or patient populations studied. Gathering of institution-specific economic and clinical data is a daunting, labour-intensive task. In many institutions, incentive and reward structures discourage behaviour that takes the broad institutional perspective that is intrinsic to a good decision analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative bioavailability study of acetaminophen solutions used in hospital formulary

To learn the influence of polyethylene glycol (PEG) on bioavailability, this study compared the bioavailability of acetaminophen in the presence of 10% ethanol (acetaminophen-ethanol liquid) to that in the presence of 10% PEG (acetaminophen-PEG liquid) since these two preparations are commonly used in hospital formulary. The results in Thai male volunteers showed there was not significantly different.

Comparison of cefoxitin and ceftizoxime in a hospital therapeutic interchange program

OBJECTIVE

To determine whether (a) ceftizoxime can replace cefoxitin in the prevention and treatment of various infections in a major teaching hospital, (b) a previously applied two-stage intervention program is an effective method of instituting a therapeutic interchange of ceftizoxime for cefoxitin and (c) the replacement of cefoxitin with ceftizoxime results in a more cost-effective therapy.

DESIGN

Two-phase, open, sequential study.

SETTING

Tertiary care teaching hospital.

PATIENTS

One hundred patients who received cefoxitin during the 6 months immediately before the start of the interchange program (phase 1) and 100 who received ceftizoxime during the 6 months immediately after the start of the program (phase 2) were randomly selected.

RESULTS

The demographic characteristics of the two patient groups were similar except for sex (p < 0.05). The cefoxitin doses were usually given every 6 hours (in 33% of the cases) or every 8 hours (in 61%), whereas the ceftizoxime doses were usually given every 12 hours (in 98%). Prescriber distribution was stable throughout the study period, the Department of General Surgery being responsible for about 70% of the orders. Prophylactic indications accounted for over 60% of the treatment courses. The proportion of prophylactic treatment courses that resulted in a successful clinical outcome did not differ between the two groups (cefoxitin 92% and ceftizoxime 91%). Of the empiric or directed treatment courses clinical success or improvement was observed in 89% of the cefoxitin and 91% of the ceftizoxime recipients. Microbiologic eradication was seen in 65% of the cefoxitin and 90% of the ceftizoxime directed treatment courses. Pathogens isolated during therapy were similar in the two treatment groups. Diarrhea was the most common adverse effect, occurring in 8% of the cefoxitin and 10% of the ceftizoxime recipients; no Clostridium difficile or C.-difficile-producing toxin was identified in these patients. The ceftizoxime therapy was 36% less expensive than the cefoxitin therapy on average, and the annual savings was estimated to be $83,123. An estimated 5615 drug doses were avoided annually, for an additional savings of $24,875 in drug administration. Therefore, the total estimated annual cost savings resulting from this two-stage interchange program was $107,998. Given the cost of $4856 to implement and maintain the program, the estimated net savings for the first year was $103,142.

CONCLUSION

Ceftizoxime can replace cefoxitin in the prevention and treatment of various infections. The form of evaluation described herein is valuable when any formulary modification is being considered in a hospital.

Selection of antimicrobial agents for routine testing in a clinical microbiology laboratory

Each clinical microbiology laboratory must establish its own standard battery of antimicrobial agents to be tested routinely on clinical isolates of various organism groups. Some choices are based upon the intrinsic activities of antimicrobial agents for a particular group of organisms, for example, agents primarily active against either Gram-positive or Gram-negative bacteria. For final selection of limited batteries of agents for routine testing, however, it is necessary to use additional criteria based upon physician prescribing patterns and the availability of antimicrobial agents in a particular institution. A fundamental principle in the selection process should be routine testing and reporting of those antimicrobial agents that physicians actually use, that is, the institution's formulary agents. Testing of the most appropriate drugs for an institution may be complicated by lack of availability of some antimicrobial agents among the standard panels offered by automated instrument or commercial test system manufacturers. The laboratory should develop its final test batteries in consultation with the infectious disease and pharmacy services and the pharmacy and therapeutics and infection-control committees of the medical staff. These choices should not be made based upon the most convenient selection of drugs from the laboratory's perspective or based upon pharmaceutical industry promotional efforts.

Sorbitol content of selected oral liquids

OBJECTIVE

Excipients in pharmaceuticals usually are considered inert, and may be overlooked in the differential diagnosis of diarrhea. Sorbitol-containing medicinal liquids are capable of inducing osmotic diarrhea. We reviewed the oral liquids in our formulary to determine their sorbitol content and to evaluate the availability of this information.

DESIGN

The oral liquids stocked by our hospital were determined through a computer search and manual inspection of the pharmacy storeroom. Three common sources of drug information were consulted to determine each product's sorbitol content: manufacturers' product information, American Hospital Formulary Service (AHFS) Drug Information 91, and Facts and Comparisons Drug Information. We then contacted each manufacturer by mail or telephone to verify the information.

SETTING

The study was conducted at the University of Cincinnati Hospital, a tertiary-care, teaching hospital.

RESULTS

A total of 129 products (98 chemical entities) were reviewed. Fifty-four (42 percent) of the products examined contained sorbitol. The frequency of sorbitol presence by liquid type was: solutions (33 percent), suspensions (43 percent), syrups (59 percent), elixirs (43 percent), concentrates (67 percent), drops (33 percent), tinctures (0 percent), and emulsions (0 percent). The percentage of listings indicating the presence of sorbitol was: manufacturer's product information (79 percent), Facts and Comparisons (52 percent), and AHFS Drug Information 91 (13 percent). Only three of the 54 products had the exact sorbitol content stated in any source.

Formularies: the role of pharmacy-and-therapeutics (P&T) committees

Pharmacy-and-therapeutics (P&T) committees have been established by most hospitals and serve as the primary formal communications link between pharmacy and the medical staff. The P&T committee is responsible for all matters related to the use of medications in the institution, including the development and maintenance of the formulary (the continually revised compilation of drug products available to the medical staff). The basic objectives of a P&T committee are to specify drugs of choice and alternatives, based on safety and efficacy; to minimize therapeutic redundancies; and to maximize cost-effectiveness. Procedures necessary to strengthen the role of P&T committees and improve their decision-making processes are discussed. The increasing concern with controlling health care costs will support the continued expansion of P&T committees, formularies, and the formulary system.

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.