Hospital pharmacy committees in England: Their structure, function, and development

Selection of medicines in Chilean public hospitals: an exploratory study

Background

There is a growing interest in high income countries to control expenditure on medicines by improving the rationale for their selection. However, in middle income countries with differing priorities and needs, little attention has been paid to this issue. In this paper we explore the policies and processes for the selection and use of medicines in a group of hospitals in Chile, a middle income country which has recently joined the OECD.

Methods

A combination of qualitative and quantitative methods was used. A national survey questionnaire was distributed to investigate the role and operation of PTCs (Pharmacy and Therapeutics Committees). Interviews were conducted with key actors in the selection of medicines in large urban public hospitals.

Results

The national survey had an overall response rate of 42% (83 out of 196), whilst 7 out of 14 hospitals participated in the qualitative study. High complexity hospitals are large urban hospitals; all of which claim to have a working PTC. The pharmacy offices are mainly involved in dispensing medicines with little involvement in clinical duties.

The interviews conducted suggest that the formulary of all the hospitals visited is no more than a stock list. PTCs are unable to influence the prescribing practices of doctors. Members do not feel prepared to challenge the opinions of specialists requesting a certain drug, and decisions are based primarily on costs. The inclusion of medicines in the clinical practice of hospitals is as a result of doctors bypassing the PTC and requesting the purchase of exceptional items, some of which are included in the formulary if they are widely used.

Conclusions

There is an urgent need to develop medicine policies in hospitals in Chile. The procedures used to purchase medicines need to be revised. Central guidance for PTCs could help ensure a more rational use of medicines. PTCs need to be empowered to design formularies which cover all the clinical needs of doctors, training members in the analysis of scientific evidence beyond their own specialities. An influential PTC can take the appropriate measures and design workable policies to enforce a cost effective-use of resources.

A multidisciplinary approach to hospital-based drug cost containment

OBJECTIVE

To develop and implement a range of strategies to control rising drug expenditure in a teaching hospital.

METHOD

A multidisciplinary team was established to survey drug use and to identify areas where drug wastage was occurring. Once target areas were identified, strategies were developed and implemented and drug expenditure monitored prospectively.

RESULTS

Communication and education about optimum drug use, efficient drug handling and therapeutic drug substitution were identified as areas for action. Antibiotic prescribing, outpatient prescribing and expenditure on new drugs were identified as target areas for cost savings. Compared to previous years, the rate of increase in drug expenditure on antibiotics was reduced by over 5000 pound sterling, from a baseline of 552 278 pound sterling over the study period compared to an increase of 65 984 pound sterling for the previous corresponding period.

CONCLUSION

We believe that despite the short-coming of the study, which adopted an open design without a control group, it demonstrates that effective cost-containment strategies can be implemented by multidisciplinary teams if they are given sufficient support by senior management.

A review of methods of drug cost management in hospitals

To stem the ever-increasing cost of health-care various strategies are being introduced by health authorities world-wide. Methods to control drug costs are reviewed with a particular emphasis on hospital-centred strategies and the role of the pharmacist. The literature suggests that no one single strategy is consistently successful and that better results are obtained by using a combination of strategies.

[Structure and activities of drug committees in Germany. Results of a survey of 143 hospitals. Pharmaco-economic Study Group and Rational Drug Therapy of the German Society of Clinical Pharmacology and Therapy]

BACKGROUND

To obtain information on the structure, present activities and decision making process of hospital drug committees in Germany in 1995 a questionnaire with 36 items was designed and sent to 450 hospitals in Germany with more than 400 beds. 143 returned questionnaires could be evaluated.

RESULTS

According to hospital size the median value of the annual drug budget 1993 ranged between DM 2.4 Mio for hospitals with less than 500 beds and DM 30.0 Mio for university hospitals with more than 1,000 beds (including blood and blood derived products). In 53% of drug committees a pharmacist held the position of the chairman, followed by medical specialists (32%), (clinical) pharmacologists held this position only in 8% of the hospitals, but in almost 50% of the university hospitals. In most cases all clinical specialties are represented in the drug committee, the number of members ranging between 5 and 40 (median 12). The number of drugs included in the internal drug list ranging between 400 in hospitals with < 500 beds and about 700 in university hospitals was strongly correlated with the number of beds and, interestingly, with the number of drug committee members. Treatment guidelines were implemented mainly for antiinfectives (87%), infusion solutions (30%), antiemetic drugs (5-HT3-receptor antagonists, 27%) and blood and blood-derived products such as intravenous immunoglobulins (23%). However, effective control of these guidelines was only performed in about 50% of the hospitals. A drug information service was provided in most hospitals, where 95% of queries were answered by pharmacists.

CONCLUSION

The results of our survey showed, that German hospital drug committees vary considerably with regard to their function and control mechanisms on drug use. Most of the responders would appreciate a more intensive exchange of current problems and treatment guidelines.

Models of hospital drug policy in the UK

OBJECTIVES

Pharmacists in UK National Health Service (NHS) hospitals have a long tradition of involvement in the development of drug policy. This paper describes various approaches that have been employed in the development and implementation of drug policy in hospitals and examines the evidence for their effectiveness and acceptability in the context of a changing health service.

METHODS

A series of focused interviews was conducted with a range of staff, including doctors, nurses, pharmacists and managers at eight hospitals. Interview sites were selected on the basis of a national survey of clinical pharmacy roles and were broadly representative of UK NHS hospitals. Interview data were analysed using constant comparison and analytic induction.

RESULTS

Three models used in the development of drug policy were identified: a 'traditional' model, in which a drug and therapeutics committee establishes a hospital-wide formulary which is implemented by pharmacists; a 'combined' model, in which there is much more emphasis on tailoring policies and feedback to specialties or clinical directorates; and a 'medical control' model, in which prescribing decisions are made by individual doctors without reference to explicit policies and with little active pharmacy involvement. Pharmacy involvement was seen as vital to the development of effective policies but hospital-specific factors influenced the choice of model at particular sites.

CONCLUSIONS

Hospitals may be moving towards the 'combined' model which could have advantages in the current internal market within the NHS. However, evaluations of the various approaches to drug policy should help inform this decision.

The management of a hospital formulary

This paper describes the management of a hospital formulary that is operated by voluntary co-operation of prescribes. The organizational and philosophical factors associated with the formulary management system in a major teaching hospital environment are discussed. A combination of educative, re-educative, persuasive and facilitative strategies is used to influence prescribing behaviour. Both passive and active methods, including face-to-face intervention methods are practised. The formulary is reinforced with an extensive pharmacy monitoring operation which stimulates facilitative dialogue between pharmacists and prescribers and encourages medical self-audit and peer review. Evidence of compliance with recommended policies, and consequent control of drug expenditure are presented.

Seventeen years' experience of a voluntarily based drug rationalisation programme in hospital

A study was carried out analysing the operation of a drug rationalisation programme in a central London teaching district that had evolved from experience over 17 years. Creation of a limited list of about 700 drugs had been achieved by local consensus. Drug selection was based on appraisal of efficacy, safety, and cost and was undertaken by means of collaborative participation of most consultant specialists in the district. Educative and other non-restrictive strategies for reinforcing the rationalisation policy had achieved a consistently high rate of compliance in prescribing recommended drugs. The concept of selectivity in drug use and its continuous local reappraisal had a beneficial impact on the prescribing habits of doctors at all levels of seniority as well as on the training of medical undergraduates and nurses in the therapeutic use of medicines. Peer review and self audit were encouraged by use of an extensive monitoring system which incorporated continuous "facilitative" dialogue between ward pharmacists and prescribers. Two models of drug rationalisation programme were studied, the second of which together with other local initiatives had been associated with substantial and sustained reductions in drug spending each year over nine years since 1978. It is concluded that the second drug rationalisation programme model substantially improves the cost effective use of drugs in hospital and furthermore has the potential of being extended to general practice, especially in types of prescribing that are common to both forms of patient care.

A survey of drug and therapeutics committees operating in Ireland

A survey of the number and characteristics of Drug and Therapeutics Committees (DTCs) operating in hospitals in Ireland was conducted in 1984. Just under half of the hospitals surveyed had a DTC and half of those had been formed after 1981. Pharmacists and consultant medical staff were present on every DTC and the latter also chaired most DTCs. Formularies or limited lists had been drawn up by half the DTCs identified and the most frequently discussed topics at DTC meetings were concerned with expenditure control. These findings are discussed and compared with the experience of DTC formation and operation in other countries.