Medication management in English National Health Service hospitals

The right drug, but from whose perspective? A framework for analysing the structure and activities of drug and therapeutics committees

PURPOSE

During the last five decades drug and therapeutics committees (DTCs), have evolved from mainly hospital-based groups of experts in pharmacotherapy and drug logistics into an arena for healthcare professionals employing evidence-based methods of promoting rational drug use. The purpose of this study was to suggest a framework for analysing the structure and activities of DTCs.

METHODS

A literature search was carried out in the Medline, Cinahl and Web of Sciences databases for the period 1993-2012.

RESULTS

A total of 207 articles were included. Based on these articles a framework for the analysis of the DTCs based on the role of the DTC, target groups, budget perspective and type of economic decisions could be suggested.

CONCLUSIONS

In order to respond to future demands the DTCs will have to develop their skill in pharmacoeconomics. Their processes will have to be standardised and made more transparent in order to be better adapted to evidence-based decision-making. They will also have to embrace the possibilities created by electronic health records in both influencing the decisions of physicians, and in improving quality assurance programmes and longitudinal follow-up of drug therapy and outcomes. They will have to find new ways of interacting with the public and policy makers in order to get the resources needed for their work. Finally, they will have to handle the conflict among national, regional and local decision-making processes and the relationship between formularies and therapeutic guidelines.

Drug and therapeutics committees in Danish hospitals: a survey of organization, activities and drug selection procedures

To implement rational pharmacotherapy in hospitals, it is important to develop, implement and evaluate hospital drug formularies (HDFs). A report from Denmark recommended standardizing activities of the drug and therapeutics committees (DTCs) in Denmark, but little is known about their current organization. The aim of the study was to describe the organization of DTCs in Denmark, how HDFs are developed and implemented, and to what extent policies that support the use of HDFs exist. A questionnaire was developed based on previous research and guidelines and contained 20 questions, which were divided into the following subjects: structure, activities, drug selection and implementation. The questionnaire was sent to the chairmen of the nine DTCs in Denmark. The response rate was 100% (9/9). The DTCs varied in structure and activities; meetings were held between 2 and 6 times annually, and the duration of the meetings lasted between 1 and 2.5 hr. Eight (89%) DTCs developed HDFs, policies and guidelines (P&Gs) that supported the use of HDFs. Eight (89%) had established criteria for inclusion of drugs on the HDFs, and seven had developed criteria for generic substitution and therapeutic interchange. The number of trade names on the HDFs varied between 116 and 1195. The nine DTCs in Denmark varied considerably regarding structure and activity. The main activity was to develop formularies, and most of the committees developed policies that supported medication use.

[Classification and variability of drug assessment reports on the GENESIS group (SEFH) webpage]

OBJECTIVE

To analyse the assessment reports published on the GENESIS webpage (Group for Innovation, Assessment, Standardisation and Research in the Selection of Drugs) and assess the variability of the group's proposals to include drugs in the Formulary.

METHOD

We analysed reports published by hospitals on the GENESIS webpage between 2004 and 2007. Data were collected on drugs and indications, ATC group, open or restricted access publications, hospital, and publication date. We drafted a questionnaire that would measure to what extent to what extent the 9-section model recommended by GENESIS was included in each report. For drugs with two or more reports, we analysed whether the recommendation coincided and the possible cause in the event of conflict.

RESULTS

We analysed 416 reports corresponding to 185 different drug indications. 93% included 6 or more of the recommended sections, a number which increased over time. The most frequently included sections were: approved indications (92%), mechanism of action (95%), and references (86%) (percentages from 2007). Sections which had an increasing but lower percentage were: differential characteristics (60%), literature search method (40%) and conclusions with a summary of efficacy, safety and cost data (52%). 73% of which had definite recommendations, which coincided for 42 out of the 67 drugs with more than one recommendation report.

CONCLUSIONS

The work carried out by the GENESIS group has enabled Spanish hospitals to share their drug assessment reports and making them more complete, although there are still some aspects that can be improved.

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.

Policies to enhance prescribing efficiency in europe: findings and future implications

Introduction: European countries need to learn from each other to address unsustainable increases in pharmaceutical expenditures. Objective: To assess the influence of the many supply and demand-side initiatives introduced across Europe to enhance prescribing efficiency in ambulatory care. As a result provide future guidance to countries. Methods: Cross national retrospective observational study of utilization (DDDs – defined daily doses) and expenditure (Euros and local currency) of proton pump inhibitors (PPIs) and statins among 19 European countries and regions principally from 2001 to 2007. Demand-side measures categorized under the “4Es” – education engineering, economics, and enforcement. Results: Instigating supply side initiatives to lower the price of generics combined with demand-side measures to enhance their prescribing is important to maximize prescribing efficiency. Just addressing one component will limit potential efficiency gains. The influence of demand-side reforms appears additive, with multiple initiatives typically having a greater influence on increasing prescribing efficiency than single measures apart from potentially “enforcement.” There are also appreciable differences in expenditure (€/1000 inhabitants/year) between countries. Countries that have not introduced multiple demand side measures to counteract commercial pressures to enhance the prescribing of generics have seen considerably higher expenditures than those that have instigated a range of measures. Conclusions: There are considerable opportunities for European countries to enhance their prescribing efficiency, with countries already learning from each other. The 4E methodology allows European countries to concisely capture the range of current demand-side measures and plan for the future knowing that initiatives can be additive to further enhance their prescribing efficiency.

Differences between the United States and the United Kingdom in the treatment of rheumatoid arthritis: analyses from a hand arthroplasty trial

Previous studies have found differences in rheumatoid hand surgical practice around the world. The specific aim of this study is to compare baseline characteristics of rheumatoid arthritis (RA) patients in the United States (US) and the United Kingdom (UK) that may be influenced by the two different health-care systems. Patients were recruited from three sites (two in the US and one in England) as part of a National Institutes of Health funded study to examine outcomes of silicone metacarpophalangeal joint (MCPJ) arthroplasty in RA patients. Outcomes measurements included biomechanical assessments (grip strength, pinch strength, and mean ulnar drift and extensor lag at the MCPJs of all four fingers), a health-related quality of life questionnaire (the Michigan Hand Outcomes Questionnaire), and a medication assessment. American patients have a significantly higher income level (p<0.001) and have completed higher levels of education (p<0.001) than British patients. There were no significant differences in terms of self-reported disease severity or deformity at the MCPJs. RA patients in the US are more likely to take biologic medications (p<0.001), steroids (p=0.02), and Cox-2 inhibitors (p=0.02). Patients in the UK are significantly more likely (p<0.001) to take nonsteroidal anti-inflammatory drugs. There are differences in the demographic characteristics and medication use of RA patients with hand deformities in the US and UK. These differences may be influenced by the private versus socialized health-care systems. However, the perception of hand disease severity in participants in this study appears to be comparable between these countries.

Impact of the Hospital Pharmacy Initiative for promoting prudent use of antibiotics in hospitals in England

OBJECTIVES

In July 2003, the UK Department of Health announced an allocation of 12 million pounds sterling to hospital pharmacists to improve the monitoring and control of anti-infective use over the ensuing 3 year period (the Hospital Pharmacy Initiative, or HPI). Chief Pharmacists were asked to use this money for developments to promote prudent antibiotic use and monitoring of antimicrobials within their Trusts. This study aimed to evaluate the impact of the HPI funding, which at the time had been in place for nearly 2 years, on pharmacy activities in this area.

METHODS

A postal questionnaire was sent to the pharmacy department of each acute hospital Trust in England, aiming to provide a descriptive overview of the activities of hospital pharmacy staff in the field of anti-infectives and to explore the extent to which these activities were made possible by the HPI funding.

RESULTS

One hundred and forty-one specialist antimicrobial pharmacy staff were employed in 130 responding Trusts; 89% were pharmacists, 7% pharmacy technicians and the remainder administrative staff. Three-quarters of these staff had been employed due to the funding, resulting in review of antimicrobial prescribing guidelines, antibiotic audit projects and multidisciplinary work with Microbiology/Infectious Diseases staff. Thirteen Trusts gave details of drug acquisition cost savings; over the course of a year, these Trusts saved 1.1 million pounds sterling in total.

CONCLUSIONS

The HPI funding has facilitated greater interaction between Pharmacy and Microbiology/Infectious Diseases departments than was previously possible. Significant reductions in antibiotic acquisition costs have been demonstrated, though further work is warranted to fully establish the impact of pharmacy activities on clinical and microbiological outcomes.