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PubMed1984

Strengthening the formulary system by implementing a drug usage guidelines program.

The development and implementation of a Drug Usage Guidelines (DUG) program in a 1,200-bed, federal teaching hospital are described. The program was designed to promote effective formulary control through established procedures for the review and evaluation of drugs submitted to the Pharmacy and Therapeutics (P & T) Committee for addition to the formulary. The procedures required the submission of the DUG and an oral presentation to the Committee prior to any final vote on the request. Anticipated potential benefits of the DUG program are to: (1) stimulate rational drug therapy, (2) provide reliable drug information to the professional staff in a usable format, (3) promote a thorough evaluation of therapeutic agents before approving for formulary inclusion, and (4) provide physician-generated guidelines for use as criteria in drug utilization review audits.

Drug Utilization↗
PubMed1990

Cefoxitin use review.

Due to an increase in cefoxitin use at The Mississauga Hospital, a Drug Utilization Review (DUR) was conducted as part of the DUR program. The study was designed to determine the cefoxitin prescribing pattern, assess the appropriateness of use, calculate the cost associated with inappropriate use, and estimate future potential cost savings. Two evaluators (pharmacist and infectious disease specialist), reviewed cefoxitin use retrospectively during a four-month period for 82 patients who received a total of 100 courses of therapy. The appropriateness of cefoxitin use was assessed according to the predefined criteria that were developed and accepted by the hospital pharmacy, infectious disease and medical staff. Cefoxitin was prescribed more frequently by the department of surgery (45%) of the courses studied, while the medical and obstetric and gynecology services were responsible for the remainder of courses (24% and 31% respectively). Overall, 42% of the courses were deemed inappropriate and 11% were questionable, based on the choice of agent (62%) and the duration of treatment and prophylaxis (33%). The observed inappropriate use represented 22% of the amount spent on the total cefoxitin treatment of the 82 study patients. If cefoxitin had been prescribed appropriately, an estimated $11,873 could potentially have been saved annually by the hospital. Based on these results, recommendations for improving the quality and quantity of cefoxitin use were developed. Follow-up concurrent DUR's with pharmacist interventions were initiated and found to be cost-effective.

Cefoxitin↗
PubMedDate not supplied

Alternate financial incentives in multi-tiered formulary systems to improve accountability for outcomes.

BACKGROUND: Drug manufacturer rebates paid to health plans and pharmacy benefit management companies have come under increased public scrutiny. Over the past several years, numerous articles have appeared in the literature encouraging a shift to a more quality-based decision-making process for health plan drug formularies. OBJECTIVE: To propose a new basis for formulary placement decisions that would include consideration of health-plan-specific measures (clinical outcomes, total cost, adherence, and appropriateness of care) and align incentives for health plans, physicians, pharmacists, and pharmaceutical companies to promote high-quality care. SUMMARY: The proposed approach builds on key components of the Pharmacy's Framework for Drug Therapy Management in the 21st Century and the Academy of Managed Care Pharmacy's Format for Formulary Submission, including a focus on patient outcomes and evidence-based decision making. The proposed approach would lessen the influence of drug manufacturer rebates on formulary placement by shifting the focus to appropriateness of care, clinical outcomes, patient adherence, and total cost of care. Pharmaceutical manufacturers would benefit from the focus on adherence to drug therapy and total cost of care. Health plans and pharmacy benefit management companies would gain in that they may be able to reduce efforts in drug utilization review as pharmaceutical manufacturers are given incentives to market their drugs more appropriately. Physicians and pharmacists would benefit because the rebate money would be used to provide quality-based financial incentives related to adherence and appropriate use of drugs. CONCLUSION: The implementation of this approach would be difficult and require cooperation from employers, pharmacists, pharmaceutical manufacturers, health plans, and pharmacy benefit management companies. Aspects of this approach could be incorporated into existing pharmacy benefit management processes to encourage the delivery of high-quality health care.

Cyclooxygenase Inhibitors↗
PubMed2003

Effect of age on the conformity rate to short-acting beta-agonist use criteria in asthma.

STUDY OBJECTIVES: Assess compliance to asthma guidelines and influence of age concerning inhaled short-acting beta2-agonist (SABA) utilization in 5 to 45-year-old asthmatic subjects in the province of Quebec. DESIGN: Population-based retrospective drug utilization review using a computerized database of claims submitted to a private prescription drug insurance plan. PATIENTS: Subjects who received at least one outpatient prescription of SABA (age range, 5 to 45 years) for the treatment of asthma between January 1996 and December 1997. MEASUREMENTS: Percentages of patients whose use was appropriate according to the criteria regarding the average daily dose of SABA. Use was considered appropriate if the consumption rate corresponded to a maximum of two puffs per day (Salbutamol equivalent) in subjects who did or did not use inhaled corticosteroids (ICS) at an estimated maximum dose of 800 mcg/day of Beclomethasone (BDP) equivalent for the 5 to 11-year-olds and 1000 mcg/day for the 12 to 45-year-olds. RESULTS: In 1996, use was found to be appropriate for 74.4% of the 394 patients who received an SABA without ICS as compared with 70.7% for 593 patients in 1997. If we consider those who received an ICS at low to moderate doses, appropriate use was found for 51% of the 375 patients in 1996 and 57.6% for 254 patients in 1997. If we exclude patients who did not renew their SABA, appropriate use drops to 46.3% for 1996 and 34.3% for 1997 for the group who receive SABA without ICS (29.4% and 37.6%, respectively, for those with ICS). There is a relationship between age and appropriateness; the percentage of appropriateness was higher for the younger ones (5 to 14-year-old group; 83% in 1996 and 86% in 1997 for the patients who received a SABA without IS and 58.5% in 1996 and 73% in 1997 for the patients who received a SABA using ICS (p < 0.05). CONCLUSION: Our results indicate that adherence to asthma guidelines concerning SABA is poor. SABA are still overused, particularly among ICS users, which might be explained by undertreatment or poor compliance. Appropriate SABA use was significantly more common among younger groups (p < 0.05). This can be explained by better treatment in that age group, better compliance or less severe asthma.

Administration, Inhalation↗
PubMed1989

Developing pharmacy applications using a microcomputer relational database in a long-term care psychiatric hospital.

The database applications developed with a microcomputer for a 1000 bed long-term care forensic psychiatric care hospital are described. The implementation of a microcomputer system was instituted as an interim measure prior to the development of a hospital wide minicomputer system. Primary emphasis was placed on increasing the efficiency of professional staff while enhancing clinical therapeutic monitoring. The system operates on an IBM-AT with 30 megabyte hard disk drive and an Epson FX-100 dot matrix printer. A relational database manager, Team-Up, was utilized in the development of applications that included census maintenance, scheduled drug inventory, drug regimen review, drug utilization protocols and a skilled nursing unit dose patient profile. Other ancillary functions included generation of stock labels, a literature abstract database and an on-line policy and procedure manual. Advantages of the system include an increase in staff productivity through the use of information that is readily attainable from the patient database. Possible disadvantages are the programming and hardware limitations imposed by a microcomputer system. Long term care psychiatric facilities may be able to enhance staff efficiency by computerizing existing manual systems. Because of the diverse and specialized requirements of long term care facilities, a microcomputer used in conjunction with a programmable relational database can be easily customized to fulfill this need.

California↗
PubMed1997

Inappropriate drug prescriptions for elderly residents of board and care facilities.

OBJECTIVES: Using 1993 data, this study examines the prevalence of presumptively inappropriate prescriptions among residents, aged 65 and older, of board and care homes. METHODS: Inappropriate drug prescriptions were identified through the use of established criteria developed for application to older nursing home residents and to community-dwelling elderly. This research used a sample of 2054 elderly residents from 410 facilities in 10 states. Weighted analyses were performed with SUDAAN, which accounted for the complex, multistage sampling design. RESULTS: Depending on the criterion applied, between 20% and 25% of residents had at least one inappropriate prescription. Propoxyphene, long-acting benzodiazepines, dipyridamole, and amitriptyline were prescribed most frequently. Residents with inappropriate drug prescriptions had more complex drug regimens prescribed on a routine basis. CONCLUSIONS: The results are a conservative estimate of the extent of inappropriate drug prescribing and utilization in board and care facilities. Increased involvement by pharmacists and physicians in systematic drug utilization review is warranted.

Aged↗
PubMed1999

A multiple-dose safety and bioequivalence study of a narrow therapeutic index drug: a case for carbamazepine.

BACKGROUND AND OBJECTIVES: Carbamazepine is among those drugs that have been considered to have a narrow therapeutic plasma concentration range, that is, a narrow therapeutic index. Although the US Food and Drug Administration has approved new generic products based on standard single-dose bioequivalence studies, several state formularies, including the New Jersey Drug Utilization Review Council, have recently established additional criteria for acceptance of bioequivalence of narrow therapeutic index drugs, limiting the use of some approved generic drugs in specific states. To further validate the adequacy of single-dose studies for the determination of bioequivalence of narrow therapeutic index drugs, a multiple-dose study was conducted that more closely reflected therapeutic use. METHODS: A single-center, multiple-dose, randomized, open-label, 2-way crossover bioequivalence study was conducted in 32 fasting volunteers at steady state. Subjects received the test and reference products as a 200 mg carbamazepine tablet 3 times a day in a crossover fashion. Concentrations of carbamazepine and carbamazepine-10,11-epoxide in plasma were measured by a validated specific HPLC method. RESULTS: A total of 28 subjects completed the study. Pharmacokinetic parameters and measures of fluctuation for both products at steady state were similar, with 90% and 95% confidence intervals falling within 90% and 110%. CONCLUSION: The multiple-dose study provided reliable safety and bioequivalence data under rigorous statistical conditions and confirmed bioequivalence of test and reference products determined by a single-dose study.

Adult↗
PubMed1979

Pharmacists expand their roles through clinical services.

This article highlights various educational forums that were held at the 13th annual Midyear Clinical Meeting of the American Society of Hospital Pharmacists. Among the areas covered by the article are justification for clinical pharmacy services, administrative considerations in a drug utilization review program, and the expanding role of the pharmacist in the emergency department.

Congresses as Topic↗
PubMed1986

Evaluating the impact of education by a clinical pharmacist on antibiotic prescribing and administration in an acute care state psychiatric hospital.

An antibiotic utilization review program was implemented by a clinical pharmacist in an acute care state psychiatric facility. Antibiotic utilization was concurrently audited in 61 antibiotic orders, written for 48 patients, in order to determine antibiotic prescribing and administration practices and problems. Interventions, consisting of educational presentations, problem-solving meetings, and distribution of written educational materials, were provided by a clinical pharmacist to improve antibiotic prescribing and administration practices. A second audit of 68 antibiotic orders written for 47 patients was concurrently audited after completion of the interventions. When prescribing problems were detected, the clinical pharmacist made recommendations to the prescribing physician. Statistically significant changes in the use of culture and sensitivity tests, appropriate dosage regimens, correct antibiotic administration, and selection of cost-effective therapy were found after all educational interventions were provided. A positive trend not resulting in statistical significance was noted for documentation of infectious disease and selection of appropriate antibiotic agents. This study demonstrates a drug utilization review role for clinical pharmacist's involvement in the acute care psychiatric facility, and illustrates one method by which clinical pharmacists can provide educational programs to improve nonpsychotropic drug prescribing and administration in this setting.

Adolescent↗
PubMed1999

Drug use and prescribing problems in four state Medicaid programs.

In this article the authors present population-level prevalence rates for 61 specific drug-related problems occurring in three State Medicaid programs (Maryland, Iowa, and Washington) from 1989 through 1996 and a fourth (Georgia) from 1994 through 1996. The findings represent the first application of a consistent drug utilization review (DUR) screener program to Medicaid data across States. The study finds major differences in DUR failure rates among the four States with the lowest rates in Georgia and the highest in Washington. Only Iowa showed any population-level reduction in DUR failure rates during the study period, however, rates for community-dwelling elderly fell in most States.

Drug Therapy↗
PubMed1999

Pharmacy practice acts: a decade of progress.

OBJECTIVE: This 10-year follow-up study of previously published surveys of pharmacy practice acts examines 50 state and the District of Columbia pharmacy practice acts to assess the range of statutory definitions and determine the direction and magnitude of statutory changes since 1988. DATA SOURCES: State codes for 50 states and the District of Columbia, with attention focused on the pharmacy practice acts; Puerto Rico and the Virgin Islands were excluded. DATA EXTRACTION: The focus on each statute was the statutory definition of the "practice of pharmacy." DATA SYNTHESIS: Comparing 1998 with 1988, codification of interpreting and evaluating prescriptions increased 22% (1998; 39/47, four states contain no definition of the practice of pharmacy), compounding 8% (47/47), consultation 19% (41/47), dispensing 2.5% (47/47), drug administration threefold (24/47), drug product selection twofold (45/47), drug utilization review 70% (35/47), patient assessment 6.5-fold (6/47), pharmacokinetic services threefold (3/47), pharmacist prescribing 4.6-fold (15/47), and participation in drug research 10.5-fold (10/47). CONCLUSIONS: Since 1988, state pharmacy practice acts have increased the codification of pharmaceutical care services as integral pharmacy functions. Although substantial progress has been made over the past decade, a number of states have not incorporated definitions of pharmaceutical care functions into their state statutes. Enactment of the National Association Boards of Pharmacy Model State Pharmacy Act is one way for pharmacists' practice to expand with the evolution of the practice of pharmacy.

Humans↗
PubMed2003

[Computerized physician order entry, a tool for added safety in the hospital].

DRUG-RELATED IATROGENIC NOSOCOMIAL ILLNESS: Remains a matter of concern in the public health area. Responsibility of hospitals is challenged by the ever increasing number of patients' claims. Dysfunction in the drug-prescribing and delivery system account, to a large extent, for medication errors, some of them resulting in adverse drug events. Most generally, medication ordering by the physician is handwritten, without nominative recapitulating prescriptions, and followed by nurse transcriptions and a global medication order is transmitted to the pharmacy. This system does not integrate the pharmaceutical analysis of the prescription, before distribution of the drugs. THE COMPUTERIZED DRUG ORDER ENTRY PROCESS: The prescription is entered directly and is displayed on the computer screen, together with the previous prescriptions for the same patient. Transcription is hence eliminated. Depending on the sophistication of the software, the prescription undergoes a series of tests; warnings and reminders can be displayed online before the physician validates the prescription. Moreover, various guidelines in some aspects of drug therapy may be presented online before the prescription is completed. POSSIBILITIES: The pharmacist's access to the complete prescriptions permits analysis of the quality and safety of the prescriptions and the adequation with eventual current applicable recommendations. Prospective drug utilization review, with immediate feedback to the prescribing physician in case of concern, may be undertaken, further improving the quality of drug therapy. Moreover, a work sheet is printed out for the nurses, further enhancing the safety of drug administration and validation. The computerized drug network also permits the development of other functions. A TOOL FOR SAFETY: Currently available reports in the literature suggest that computerized drug prescription reduces the incidence of prescribing errors, improves the appropriateness of drug choices, optimises therapeutic follow-up, and reduces the incidence adverse drug events and leads to substantial reduction in drug expenditures.

Computers↗
PubMed1995

Psychotropic use among older residents of board and care facilities.

OBJECTIVE: To describe patterns of psychotropic use as well as clinically relevant and concurrent nonpsychotropic use among older residents of board and care facilities in 10 states. METHODS: Weighted use rates were based on data from a sample of 2054 residents aged 65 and older from 410 facilities in 10 states, drawn via a complex, multistage sampling design. Data, including drug name, use frequency, and PRN use, were collected on all drugs taken by the resident during a 7-day period. During face-to-face interviews with residents and/or proxies, data were also collected on resident characteristics. SUBJECTS: The majority of subjects were female, white, and widowed. Average age was 82 years. Approximately 25% had a current mental or emotional condition, and 8% had been hospitalized for a psychiatric condition during the year before admission. More than half needed help with at least one activity of daily living. Forty percent had moderate or severe cognitive impairment, and 18% had received mental health care during the previous year. ANALYSES: Weighted descriptive analyses were performed with Software for Survey Data Analysis (SUDAAN), which accounts for the complex, multistage sampling design. RESULTS: Approximately 35% of the older residents used at least one psychoactive agent, with 30% of psychotropic users receiving two to four different psychotropic medications. Use rates decline with age, for psychotropics overall and for therapeutic classes. Results revealed potentially problematic polypharmacy in relation to drug duplication within therapeutic classes, use of multiple psychotropics across classes, and concurrent nonpsychotropic use. CONCLUSIONS: Compared with community-dwelling older adults, this study revealed high psychotropic use rates among older board and care facility residents. Overall, our results suggest that serious consideration be given to the apparent need for systematic drug utilization review, a potentially useful program that is mandated in other settings.

Aged↗
PubMed1992

A computerized system for identifying and informing physicians about problematic drug use in nursing homes.

With growing concern over the quality of medication use in nursing homes, physicians, administrators, pharmacists, and regulators are looking for effective and efficient methods to improve it. Pharmacy consultation alone appears to be ineffective in controlling the use of inappropriate drugs. We describe here a computerized drug utilization review system designed for use in nursing homes. The system evaluates the appropriateness of medication use by criteria developed through the consensus of experts in geriatrics and specifically designed to address the pharmacological needs of elderly, nursing home residents. The program not only determines the frequency of inappropriate prescriptions, but produces written, educational statements to be given to prescribing physicians. These statements can also be given to nurses to educate them about issues in geriatrics pharmacology. Additionally, the system produces medication order forms that may help focus physicians' attention on the need to evaluate drugs individually.

Clinical Pharmacy Information Systems↗
PubMed1981

A multicenter study of ICU drug utilization.

As part of a view of hospital practice a sample of medical records of 15 intensive care units were analysed for the following items: reason for and origin of admission, age, sex, full pharmacological history, length of stay, clinical outcome, discharge diagnosis. Antibiotic therapy, steroid use for shock, problems of hemostasis, and cardiovascular drugs are areas where an active intervention appears to be specifically needed. Interhospital differences in diagnostic and general care criteria, documentation of inappropriate therapeutic practice, lack of reliable data registration gave occasion for an extensive discussion with clinicians leading to decisions on exclusion of drugs from hospital formularies, organization of information programs and of controlled clinical trials. The application of simple techniques of drug utilization review has proved a useful, inexpensive tool for creating favourable conditions for wide scale improvement of therapeutic practice.

Adolescent↗
PubMed1988

Paediatric drug therapy. I--Medication use in hospitalized patients.

Medication use was studied prospectively in 97 hospitalized paediatric patients at a children's hospital. An average of 4.8 scheduled drugs were used per patient. Antibiotics and anticonvulsants were the two most commonly used drug classes. Penicillins, anticonvulsants, aminoglycosides, cephalosporins, and theophylline were most frequently prescribed in our patients. A wide range of doses was used for drugs with narrow therapeutic indices. Most potential drug-drug interactions involved an anticonvulsant with another drug. These data may assist in targeting drug utilization review studies and educational programs justifiably to retain existing positions or create new opportunities within the departments of pharmacy to optimize patient care.

Adolescent↗
PubMed2001

Effective strategies for managing pharmacy benefits.

Prescription drug costs are among the fastest-growing healthcare costs. Effective plan design and benefit management strategies can help pharmacy benefit plans manage costs while maintaining quality and customer satisfaction. These strategies include using formulary management, intervention techniques, and cost sharing to encourage the use of generic drugs; employing a mail-service pharmacy benefit for maintenance medications; and implementing concurrent and retrospective review programs to ensure eligibility and plan compliance, identify practice patterns, and encourage appropriate drug selection.

Cost Sharing↗
PubMed1989

Retrospective evaluation of piperacillin use in a university hospital.

A retrospective review was conducted to evaluate the appropriateness of empiric and definitive piperacillin use and to determine if less expensive, more appropriate antibiotics could have been used. The criteria were approved by the chief of infectious diseases and the drug utilization review committee at this institution. One hundred courses of piperacillin use in adult patients were reviewed. Therapy was categorized as appropriate in 78 of the 100 courses: 21 were appropriate empiric, 32 were appropriate empiric changed to definitive due to culture and sensitivity reports, and 25 were appropriate definitive. Reasons for this high percentage of appropriate use include: 1) 40% of the infections involved Pseudomonas aeruginosa; 2) 18% of the organisms that were sensitive to piperacillin were resistant to ticarcillin and mezlocillin; and 3) 64% of the courses of therapy involved critically ill patients with diagnoses such as neutropenia secondary to cancer chemotherapy, burns, sepsis, and hospital-acquired pneumonia. Although only 19.7% of the 11,845 grams of piperacillin used were categorized as inappropriate, the cost is relatively high (annualized to $19,648) and cost savings could be realized if piperacillin use were monitored more closely.

Adolescent↗