Concerns of a pediatric hospital's P & T Committee: quality care emphasized over cost considerations

One of the greatest challenges faced by the P & T Committee at Children's Hospital of Denver--a full-service, regional pediatric referral center--is the absence of pharmacologic and pharmacokinetic data for many drugs that are on the market for the treatment of adults but are unapproved for pediatric use. To acquire the needed information, Children's Hospital will rely on its P & T Committee to conduct numerous drug usage evaluations. In addition, the committee is undertaking a cooperative data-exchange venture with other children's hospitals across the U.S. and Canada. Although cost issues must be addressed at Children's Hospital, issues such as quality of care--and even how various formulations taste--are top priorities at this hospital.

Drug formularies: myths-in-formation

Drug formularies are pivotal tools for delineating and directing prescribing to the "drugs of choice." Full realization of their potential has been hampered by insufficient comparative data on drug efficacy/safety and local resources for formulary development. However, misconceptions concerning fundamental formulary concepts pose an even more formidable obstacle. This article identifies statements illustrating formulary misconception a) made by physicians attending Pharmacy and Therapeutics Committee meetings during a three-year period and b) appearing in published sources. The paper highlights basic objectives and operational requirements of an effective formulary, and contrasts this definition with 20 myths and misinformation culled from these two sources. Not only does such misinformation impair formulary development, many critics are so preoccupied with alleged shortcomings that progress in minimizing the real limitations of formularies has been impeded.

Clinical services provided by staff pharmacists in a community hospital

A program for developing staff pharmacists' clinical skills and documenting pharmacists' clinical interventions in a large community teaching hospital is described. A coordinator hired in 1984 to develop clinical pharmacy services began a didactic and experiential program for baccalaureate-level staff pharmacists. Fourteen educational modules are supplemented by journal and textbook articles and small-group discussions of clinical cases, and the clinical coordinator provides individual training on the patient-care units for each pharmacist. Monitoring of clinical pharmacy services began in June 1987; each intervention provided by a pharmacist is recorded on a specially designed form. A target-drug program is used to document cost avoidance achieved through clinical services. Information collected through these monitoring activities is used to educate the pharmacy staff, shared with the pharmacy and therapeutics committee, and used to monitor prescribing patterns of individual physicians. The data are used in the hospital's productivity-monitoring system. All pharmacists who were on staff in 1984 have completed the educational modules, and all new employees are in the process. Since monitoring began, the number of clinical interventions has averaged 2098 per month. Cost avoidance has averaged $9306 per month. Over a five-year period, the development of staff pharmacists' clinical services raised the level of professional practice, produced substantial cost avoidance, and increased the number of pharmacist interventions in medication use.

An intravenous potassium policy with concurrent physician evaluation

Hospitals have an ethical, as well as a legal, duty to provide safe care to patients. Responsibility for providing care involving medications is distributed to practitioners within the institution including physicians, nurses, and pharmacists. Each practitioner plays an essential role in the provision of safe intravenous potassium supplementation. A procedure is described which incorporates drug usage evaluation into a safe, simple, intravenous potassium policy.

Pharmacy-coordinated program that encourages physician reporting of adverse drug reactions

A pharmacy-coordinated program for encouraging physician reporting of adverse drug reactions (ADRs) is described. The ADR surveillance program at the Medical Center Hospital of Vermont, a 500-bed tertiary-care hospital, is in its fifth year. Key elements are close interaction between physicians and pharmacists, feedback, program promotion, and financial incentive. The program is promoted chiefly to house staff physicians. A physician may identify a suspected ADR, or he or she may be alerted by a pharmacist. The physician completes the first part of a form, which requests information on the patient, the severity of the reaction, the actions taken, and any predisposing factors. A pharmacist reviews the incident independently and in consultation with the reporter and then completes the second part of the form, which asks the pharmacists to assess the probability that the drug caused the ADR and to classify the reaction. A summary is sent to the physician and may be reported to the FDA and the manufacturer. Each report earns the reporter a $5 stipend. Information from the ADR forms is entered into a dBASEIII PLUS computer program for later retrieval and analysis. During a 12-month period, 175 ADR reports (out of a total of 249 reports) were received from house staff members, compared with about 4 voluntary reports received annually before the program began. The ADR surveillance program has increased physician reporting of ADRs and produced a reliable database that can be used to influence hospital policy and promote education.

Formulary decision making in a specialty hospital: effective management of potent and costly drug therapies

Substantial progress has been made in the treatment of cancer in the past few decades. Complex drug therapy regimens, supportive-care therapies, and therapeutic complications--namely, infection--have made clinical management challenging, however. In this exclusive Hospital Formulary interview, Michael Keating, MD, and William Dana, PharmD, Chairman and Secretary, respectively, of the University of Texas M.D. Anderson Cancer Center's P & T Committee, discuss successful methods of maintaining an effective formulary in a cancer center. Although efficacy and toxicity of therapy remain the primary considerations when evaluating drugs, with a formulary weighted with cancer chemotherapeutic agents, antibiotics, and other supportive intravenous formulations, cost is also critical. These health professionals describe how they balance the issues associated with rational, yet cost-effective drug therapy.

Multidisciplinary adverse drug reaction surveillance program

Initial experience with a multidisciplinary adverse drug reaction (ADR) surveillance program at a 350-bed community hospital center is described. The pharmacy and quality-review (QR) departments developed a program that was incrementally incorporated into the hospital's overall QR activity. After inservice training, nurses and QR personnel were asked to complete an "alert" card for every suspected ADR and send it to the pharmacy. In addition, medical records were reviewed retrospectively for disease classification codes related to drug toxicity and unspecified adverse effects. Laboratory and utilization-review personnel also conducted retrospective reviews. A pharmacist reviewed all ADR reports and categorized each according to the severity of the reaction and the probability that it was drug related. For each reaction classified as severe, the patient's chart underwent physician peer review for appropriateness of therapy, avoidability of the reaction, and adequate documentation; related patient-care issues were addressed by the medical staff as part of routine quality-review activities. When problems with prescribing were identified, the pharmacy and therapeutics committee intervened with the prescribers or recommended further medical staff review. Drugs repeatedly associated with ADRs became the focus of drug-use reviews. The number of ADR reports increased from 0 to 134 in the first 11 months of the program. A multidisciplinary approach to ADR reporting increased the number and quality of ADR reports.

P & T Committee perspectives: maintaining a successful formulary system in a private community hospital

Institution of an effective formulary and P & T Committee is a difficult but critical task for many private hospitals. In this exclusive Hospital Formulary interview, Drs. Benner, Mykita, and Brown, members of Sutter Memorial Hospital's Pharmacy, Formulary, and Therapeutic Review Committee (their name for the P & T Committee) emphasize the need for a sound formulary system in order to survive the current changes in health care. Sutter Memorial is sophisticated in its delivery of healthcare services, which include advanced neonatology and state-of-the-art heart transplantation. Although good patient care remains the foremost concern, these committee members acknowledge that care must be affordable as well as therapeutically sound. Key to their committee's success is the cooperative effort among the pharmacy, nursing, and medical staff. They foresee the issue of rational therapeutics as a major challenge in the 1990s.

Integration of clinical and administrative strategies to reduce expenditures for antimicrobial agents

A comprehensive program of clinical and administrative strategies to reduce expenditures for antimicrobial agents is described. Clinical intervention strategies include the use of antimicrobial order sheets, standardized dosage regimens, restriction policies for certain antimicrobial agents, and position statements on the use of restricted agents. A cornerstone of the program is the support for cost-reduction interventions offered by the pharmacy and therapeutics committee and its subcommittee on therapeutics; that support is demonstrated through endorsement and enforcement of pharmacy programs. Physicians are reminded of the cost-reduction programs through periodic articles in the pharmacy newsletter and an "antibiogram" card supplied by the division of epidemiology. The effectiveness of these interventions has been demonstrated by progressive decreases in expenditures for antimicrobial agents during 1987 and 1988. Antimicrobial agents also account for increasingly smaller percentages of the total drug budget. This combination of clinical and administrative strategies reduced expenditures for antimicrobial agents by more than $700,000 over two years without the use of clinical specialists or any apparent sacrifice in the quality of patient care.

P&T Committee review of nifedipine GITS: new modality for angina and hypertension

The nifedipine gastrointestinal therapeutic system (GITS) was recently approved for use in the treatment of angina and hypertension. According to the experts in this roundtable discussion, the GITS formulation provides continuous delivery of nifedipine, ensuring relatively constant drug levels and 24-hour efficacy with a once-daily dosage regimen. Nifedipine GITS also has a favorable side-effects and drug-interaction profile. This formulation will be useful for both inpatients and outpatients and may benefit patients in whom therapeutic levels previously could not be reached due to side effects.

P&T Committee review of fluconazole: an effective alternative to antifungal therapy

Fluconazole is a new antifungal agent available in both oral and parenteral formulations. According to the experts in this roundtable discussion, fluconazole represents a major clinical advance in the treatment of candidiasis and cryptococcosis in cancer patients, patients with AIDS, organ transplant recipients, and other patients at risk for opportunistic mycoses. The pharmacokinetic profile for fluconazole permits infrequent dosing and also makes it ideal for tissue site infections. Fluconazole's low toxicity gives it an advantage over currently available antifungal therapy and will permit prompt presumptive treatment of selected infections.

Formulary-control procedures in a staff-model health maintenance organization

Efforts to promote cost-effective drug prescribing in a health maintenance organization (HMO) through (1) revision of the formulary, (2) education, and (3) drug-use evaluations (DUEs) are described. New programs and procedures to promote more cost-effective prescribing were implemented in 1987 at a staff-model HMO with seven health-care centers and 40,000 members. Support to the pharmacy and therapeutics committee in developing formulary recommendations was enhanced, the formulary was revised and the number of listed drugs reduced by half, the focus of pharmacists was changed from purchasing and inventory control to education of physicians about cost-effective prescribing, and the most expensive drug categories were identified and educational efforts instituted. During the next two years substantial changes in the prescribing of oral contraceptives, nonsteroidal anti-inflammatory drugs, antiulcer agents, and anti-infectives, but not antihypertensive drugs, were identified through DUEs. Evaluation of cost savings was limited by the lack of an automated, integrated patient database, and it was difficult to assess the effect of changes in patient population. Revision of the formulary coordinated with enhanced educational efforts and DUEs resulted in more cost-effective prescribing in an HMO without placing severe restrictions on physicians or patients.

Formulary conversion of cefoxitin usage to cefotetan: experience at a large teaching hospital

The pharmacy and therapeutics committee at Hartford Hospital recommended replacement of cefoxitin with cefotetan, based on data reported in the literature regarding antimicrobial activity, pharmacokinetic profile, and adverse reactions. Once the recommendation was approved by the medical staff, an intense educational program was instituted, and all orders for cefoxitin were converted to cefotetan with appropriate dosage modifications. A total of 960 patients were treated in the first year; no major patterns of ineffectual therapy or adverse events associated with cefotetan usage have emerged. The mean cost of cefotetan therapy was $180.59, which is $130.26 less per patient than a comparable regimen of cefoxitin (mean cost of therapy $310.85). Based on the data analysis of cefotetan usage for a 12-month period, the actual annual savings due to therapeutic substitution of cefotetan for cefoxitin was $124.961. To further evaluate the clinical efficacy, safety, and savings of this therapeutic interchange, two separate retrospective reviews of patient medical records were performed. The first audit has been previously published in its entirety. In the subsequent audit, 284 additional patient medical charts have been reviewed. These patients received either cefotetan therapy or concomitant therapy of an aminoglycoside combined with either clindamycin or mezlocillin. Clinical outcomes were classified as an empiric cure or improvement for 99.4, 98.5, and 92.9 percent of patients, respectively. In this audit, elevated prothrombin time/partial thromboplastin time values and bleeding episodes were noted infrequently, as were other adverse reactions.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of education by clinical pharmacists on physician ambulatory care prescribing of generic versus brand-name drugs

The physician prescribing of generic versus brand-name drugs to ambulatory care patients was compared between the time periods before and after rendering clinical pharmacist education. Copies of all written outpatient prescriptions were used for the comparison. Physicians significantly increased their generic prescribing after clinical pharmacist education.

[Interstitial pneumopathies: criteria of drug side-effects. Results of consensus meetings]

Since 1984, the use of the official method for determining the responsibility of drugs in side-effects has been compulsory in France. This method offers, but does not define, different qualificatives for chronological and semeiological criteria. Consensus workshops have been set up to define the undesirable side-effects themselves and the different qualificatives in each of the principal fields of pathology. As regards drug-induced interstitial pneumonia, chest specialists from university hospitals, members of the national system of pharmacovigilance and representatives of the Roussel-Uclaf central department of pharmaco-vigilance have determined: the limits of time elapsed between the beginning and end of drug administration and the occurrence of the adverse reaction; how to interpret various courses of the side-effect with and without temporary discontinuation of the drug, and how to interpret a possible readministration. A list of investigations aimed at excluding the main possible causes of interstitial pneumonia has been drawn up.

A multicenter model for examining in vitro susceptibilities of bacteria to antibiotics

In vitro bacterial susceptibility data are often considered in both hospital formulary and antibiotic prescribing decisions. In this multicenter study, susceptibility data from 105 United States hospitals resulted in a database containing 211,142 isolates for 31 different bacteria and 38 antibiotics. To identify susceptibility patterns of bacteria to antibiotic alternatives, this computerized database was subjected to confidence interval analysis, while controlling for potential sources of random error. This paper describes the multicenter study design and provides several examples of the type of information the analysis can provide to P & Committee members and to practitioners who ultimately must make decisions regarding antibiotic use, sometimes without the benefit of complete hospital-specific historical antibiogram data. Limitations on the interpretation of aggregate in vitro susceptibility data gained from multiple institutions are also discussed.

Influencing prescribing behavior by adapting computerized order-entry pathways

A program is described in which informational text was inserted into a computerized drug order-entry pathway to alter prescribing patterns and contain costs. In April 1986 the pharmacy and therapeutics committee at a 700-bed teaching hospital recommended that cefonicid be used instead of cefuroxime to treat adult patients with community-acquired pneumonia in which infection with Haemophilus influenzae or gram-negative enteric rods was suspected; substantial cost savings were projected. A paragraph recommending cefonicid was inserted into the cefuroxime order-entry screen in November 1986. In February 1987 the screen was further modified to allow the physician to select the cefonicid alternative without returning to the drug index. A final change was made in November 1987 to allow the physician to select ampicillin or erythromycin directly from the cefuroxime screen as well. The cost and relative use of cefonicid and cefuroxime were examined in specific patients with pneumonia--those assigned to diagnosis-related group 89--for whom either drug was prescribed. From January 1986 to December 1987, the percentage of these patients who were prescribed cefuroxime decreased from 100% to 22%, while the percentage of patients receiving cefonicid increased from 0% to 78%. The average acquisition cost of the two antibiotics per patient decreased from $123 to $48. Although other variables may have affected prescribing patterns and this method of drug therapy intervention has some disadvantages, such as the need for physician cooperation, the concept warrants further attention. Adaptation of computerized order-entry pathways may increase the ability of pharmacy to influence prescribing behavior and control costs.

Sterility assurance based on validation of the sterilization process using steam under pressure. Committee on "Microbial Purity". F.I.P. (International Federation of the Pharmaceutical Industries)

The F.I.P. has long been involved in the practical aspects of microbial quality in pharmaceuticals. This report deals with steam sterilization. A group of European experts from official laboratories and pharmaceutical industries has compiled this text which successively reviews the different pharmacopeias, defines some essential sterilization concepts and parameters, reviews the current approaches to steam sterilization and advises, for each of them, practices in validation and in-process control.