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PubMed1996

Pharmacoeconomics and formulary decision making.

Pharmacoeconomic assessment of formulary actions has become increasingly common in local, national, and international formulary decision making. Tactics for managing medication use include formulary management and drug policies. Pharmacoeconomic data can provide support for these formulary decisions. For example, pharmacoeconomic data can support the inclusion or exclusion of a drug on or from the formulary and support practice guidelines that promote the most cost-effective or appropriate utilisation of pharmaceutical products. Various strategies can be used to incorporate pharmacoeconomics into formulary decision making. These include using published pharmacoeconomic studies and economic modelling techniques, and conducting local pharmacoeconomic research. Criteria for evaluating the pharmacoeconomic literature, suggestions for employing economic models, and suggested guidelines for conducting pharmacoeconomic projects are discussed. Although most formularies are viewed as cost-containment tools, formularies should not be a list of the 'cheapest' alternatives. Today's formulary should contain agents that optimise therapeutic outcomes while controlling cost. Pharmacoeconomic assessments of formulary decisions help to ensure that the agents promoted by our formularies yield the highest outcome per dollar spent. A discussion of the process for formulary action in a US hospital, the influence of pharmacoeconomics on US formularies, and strategies for incorporating pharmacoeconomics into formulary decision making are presented in this paper.

Decision Making, Organizational↗
PubMed1997

Overview of the hospital formulary systems in Hong Kong. Princess Margaret Hospital as a baseline.

OBJECTIVE: To investigate the popularity of formulary systems in all Hong Kong hospitals and to compare these with the newly introduced formulary system in a major government hospital, the Princess Margaret Hospital (PMH), as the baseline. DESIGN: Questionnaire and selected interviews by pharmacy students. SETTING: All hospital pharmacies in Hong Kong. PARTICIPANTS: Department managers (directors of pharmacy services) of hospital pharmacies. MAIN OUTCOME MEASURE: The popularity of the hospitals' formulary systems and their formulary decision-making strategies. Calculations of cost savings of the new formulary system in PMH and a comparison of the PMH system with the US standards were also made. RESULTS: Among 38 responding hospitals, 35 (92%) had a formulary handbook and 21 (55.3%) claimed to have a formulary system. The evaluation processes and formulary decision-making procedures were found to be inadequate because basic components in drug evaluation (e.g., standardized criteria for drug evaluation) were not used regularly. However, the formulary system in PMH was found to be comparable with the US standards. Substantial cost savings were made through rejection of less cost-effective drugs by the Formulary Subcommittee in PMH. CONCLUSIONS: In general, comprehensive formulary systems are still not popular in Hong Kong. This may be due to insufficient staffing and lack of administrative and physicians' support. The new formulary system in PMH can be used as a model to develop a successful formulary system in which hospital pharmacists can prove their expertise for the benefit of both hospitals and patients in Hong Kong.

Attitude of Health Personnel↗
PubMed2004

Effect of formulary policy decisions on antimicrobial drug utilization in British Columbia.

BACKGROUND: Formularies are used routinely for management of drug expenditures yet evaluations of their impact remain rare. The objective of this study was to analyse the impact of addition or deletion of antimicrobials from the provincial formulary on drug utilization. METHODS: We obtained data from the British Columbia PharmaNet database on all outpatient oral antimicrobial prescriptions from 1996 to 2000 and converted them to their defined daily dose (DDD) equivalents according to the ATC system. Trends in utilization associated with a changing formulary status of new antimicrobial agents were analysed. Maximum likelihood estimation was used to determine the rate of increase in utilization resulting from addition to the formulary. Models were adjusted for seasonal and temporal trends as well as serial correlation. RESULTS: During this time period, clarithromycin was on formulary, later delisted, and then relisted again. Valaciclovir and famciclovir were also added to the formulary. During the time clarithromycin was off the formulary, the rate of change in its monthly consumption was 0.0061 DDD/1000 population/day; following its relisting, the rate of change increased by 818% to 0.0560 DDD/1000 population/day (P=0.002). After the listing of valaciclovir on the formulary, the rate of change in its monthly consumption increased 57% from a baseline of 0.0014 to 0.0022 DDD/1000 population/day (P=0.07). A similar effect was seen with the addition of famciclovir to the formulary whereby the rate of change in monthly consumption increased from 0.0008 (before addition to the formulary) to 0.0018 (after addition to the formulary) (P </= 0.001). CONCLUSIONS: Listing of antimicrobials on provincial or countrywide formularies is followed temporally with increased utilization. However, before governmental agencies can institute reference-based pricing or co-payment programmes, the effect of such a programme on the emergence of antimicrobial resistance and on patient outcomes needs further study.

Anti-Bacterial Agents↗
PubMed1982

Evaluation of a limited drug formulary in an adult internal medicine clinic.

The utility of a 30-drug, limited formulary in an adult internal medicine, ambulatory-care clinic was investigated. The formulary was developed using a mail survey of a random sample of members of the ASHP Ambulatory Care Pharmacy Practice Special Interest Group. The consensus formulary comprised the 30 most frequently recommended drugs; the utility of the formulary was then tested by chart review in a primary-care internal medicine clinic. Over a two-month period, the charts of alternating patients were reviewed daily; patient data collected included demographic information and prescribed drug therapy. A panel of two physicians and one pharmacist reviewed each patient's data and determined the appropriateness of drug treatment. If an agent was prescribed that was not on the consensus formulary, the panel determined whether an appropriate formulary agent could have been prescribed. Of the prescribed drug orders, 57.8% were for agents in the consensus formulary; by including patients who could have received formulary drugs appropriately, 73.7% of all prescription orders were or could have been for formulary drugs. Age, race, and sex of patients had no significant effect on utility of formulary agents. Had the 30 drugs most commonly prescribed in this clinic been in the formulary, 82.6% of all prescription orders would have been covered. This approach to establishing a new formulary and selecting drugs for inclusion is potentially useful.

Adult↗
PubMed2005

General practitioners choose within a narrow range of drugs when initiating new treatments: a cohort study of cardiovascular drug formularies.

OBJECTIVE: The aims of this study were (1) to develop and evaluate a new method for investigating personal drug formularies in general practice and (2) to test the hypothesis that there is a difference between personal drug formularies for incident and ongoing drug use. METHODS: In 2002, we studied prescribing patterns of beta-blockers, calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin-II antagonists and statins in the County of Funen, Denmark (180 general practices, 472,000 inhabitants). For each practice, we distinguished between an incident drug formulary consisting of prescriptions for new users and an ongoing drug formulary including prescriptions for patients already in treatment. Prescription data were retrieved from the Odense University Pharmacoepidemiologic Database (OPED). Four different formulary measures were evaluated and used for comparing incident and ongoing drug use. RESULTS: General practitioners' (GPs') incident drug formularies comprised significantly fewer drugs than their ongoing drug formularies for all drug groups except angiotensin-II antagonists. The difference in the total number of drugs used was between 1.8 and 3.3. We found differences between 0.5 and 1.6 analogues in the DU 90% (number of analogues accounting for 90% of the prescribed volume measured in defined daily doses) segment and the formulary selectivity index between 0.05 and 0.12. The preference for the most prescribed analogue was 9-18% higher among incident patients. The formulary selectivity index was highly correlated with the other formulary measures and quantified both range and skewed distribution of drug choice. CONCLUSION: Analysing GPs' prescriptions to incident patients is a simple and inexpensive method for studying their own current personal drug formularies. GPs choose within a narrow range of analogues for incident patients.

Adrenergic beta-Antagonists↗
PubMedDate not supplied

Prescription drug formularies in managed care: concerns for the elderly population.

Prescription drug formularies are a key element in the rapidly growing trend of prescription drug benefit management. The use of formularies can increase the quality of prescribing and reduce the costs of prescription drug therapy. This is particularly important to older Americans, who represent about 13% of the population but consume roughly one third of the drugs prescribed in the United States. However, the question of whether the use of formularies affects patient access to pharmaceuticals has not been analyzed sufficiently. This paper identifies benefits and risks to older Americans from the use of prescription drug formularies by third-party payers, analyzes the evidence of those benefits and risks, and proposes areas for future research. An extensive review and synthesis of the literature were performed, focusing on three aspects of drug formulary design: (1) the extent to which health maintenance organizations and insurers consider consumer interests when using formularies; (2) the extent to which formulary design is affected by clinical and economic considerations; and (3) the impact of formularies on the quality of drug care received. Safeguards to guarantee that economic considerations of drug benefit managers do not restrict access to needed drugs are insufficient. Alternatively, no evidence to date shows that the use of formularies adversely affects patients' access to pharmaceutical care. More research is required to understand the process of drug formulary development and the extent to which different formulary recommendations impede on physicians' ability to provide high-quality care.

Aged↗
PubMedDate not supplied

A bitter pill: formulary variability and the challenge to prescribing physicians.

BACKGROUND: Multitiered, incentive-based formularies have been increasingly used as a mechanism to control prescription drug expenditures. Prescribing physicians who manage patients from multiple insurers must be familiar with the variability in their patients' formulary incentives to help patients choose therapy wisely. However, the degree of formulary variability among and within health plans over time is unclear. METHODS: In 6 major health plans in California, we evaluated formulary incentive variability in 4 of the 5 drug classes with the highest expenditures in California: proton pump inhibitors, hydroxymethylglutaryl coenzyme A reductase inhibitors ("statins"), calcium channel blockers, and angiotensin-converting enzyme inhibitors. We categorized 20 branded members of these classes into either "preferred" or nonpreferred/uncovered categories. We calculated the consistency that brands were preferred across health plans and the frequency of changes in formulary status for each drug within plans between 2000 and 2002. RESULTS: None of the branded drugs evaluated were preferred on all formularies in 2002, and 10% were not available on any of the formularies. Formulary status varied greatly across plans, and more than 60% of drugs were preferred on 2 to 4 of the 6 formularies studied. Formulary status within health plans varied between 2000 and 2002 in more than half of the plans in the drug classes evaluated. CONCLUSIONS: In the drug classes evaluated, over a 2-year period, considerable variability was seen among and within formularies over time. This variability poses a challenge to physicians who wish to reduce patients' expenditures by prescribing the least expensive among similarly effective drugs within a drug class. This variability is especially relevant because recent legislation increases the likelihood that more Medicare beneficiaries will receive their medications from private health plans.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2002

Building a better online formulary.

The history of and improvements made to the University of Michigan Health System (UMHS) inpatient online formulary are described. The current formulary at UMHS is the third version of the Web-based formulary. The original effort in 1997 consisted of converting word-processing documents to HTML format and exporting this information to the university's intranet. There was no mechanism to search for formulary items, no therapeutic class cross-referencing, and no cost information. Documents and their conversion had to be manually maintained. The second version incorporated a series of automatic daily computer downloads from the inpatient pharmacy computer system. Web pages were built to dynamically display the formulary information from the database based on users' requests. The formulary enabled searching by brand or generic names, provided therapeutic category cross-references, listed the location of products within automated dispensing cabinets, provided accurate cost information, and was always up-to-date. Maintenance efforts drastically decreased. The current version has incorporated additional logic to meet users' needs. If no matches are found, the system expands its search by automatically linking to UMHS's inpatient pharmacy system repository of all drugs, finding matches to what the user entered, and then returning the names of therapeutically similar formulary agents to the user. A cross-index feature allows the system to return all the drugs that fall under the searched therapeutic category. Dramatic improvements have been made to UMHS's inpatient online formulary in the past two years. The current formulary provides a very low-cost, easily maintainable, and effective means to access the formulary and clinically relevant and timely information specific to each medication.

Computers↗
PubMed1984

Total formulary review--the easy way.

In an effort to minimize drug costs, many hospital pharmacy services have limited their drug inventories through the development of a formulary. Evaluation of drug products for addition to the formulary is the responsibility of the Pharmacy and Therapeutics (P & T) Committee. The deletion of rarely used or outdated products is often overlooked. As a means to "clean up" the formulary, Hamot Medical Center (HMC) underwent a total formulary review. Drugs were separated into classes as defined by the American Hospital Formulary Service (AHFS). Approximately three drug classes were evaluated each month by the P & C Committee. Evaluation criteria was based on the following factors: current formulary status, usage statistics, negative comments appearing in six current publications, hospital acquisition cost, and number of formularies containing each product. A final compilation of all deletions and additions were distributed to all medical staff department and division chiefs. Following receipt of all their comments, a final draft of the formulary was made and prepared for publication. This system is a simple, uncomplicated means of either revising or beginning a formulary. It evaluates a drug based on efficacy, individual hospital usage, and cost of the drug while allowing for input of the medical staff. The end result is a formulary tailored to best fit each institution.

Evaluation Studies as Topic↗
PubMed1985

Ohio hospital formularies: an analysis of structure, process, and outcome.

A cross-sectional survey of Ohio hospital formulary systems conducted in the fall of 1982 is presented. The study describes the current status of formulary systems and formularies and analyzes the relationships between structure, process and outcome variables related to formularies and 21 randomly selected Ohio Department of Public Welfare (ODPW) Drug Efficiency Study and Implementation (DESI)-listed drugs. Fifty-five per cent of the state's hospitals reported having a formulary. Hospitals with formularies appeared to have a lower ratio and number of ODPW-DESI agents in stock. However, two variables maximally discriminated the avoidance of ODPW-DESI drugs: 1) the number of drugs in inventory or on formulary, and 2) the existence of a formulary. The results suggest that having a formulary assists in the avoidance of ineffective drug products, but the study's process variables could not predict formulary existence or positive outcomes.

Drug Evaluation↗
PubMed1992

Survey of formulary system policies and procedures.

A telephone survey was conducted to determine the policies and procedures of hospital formulary systems. Directors of pharmacy at a random sample of 150 community hospitals were interviewed, and letters were sent to each respondent requesting copies of the formulary and drug evaluation form. One hundred thirty hospitals completed the interview (gross response rate of 87%), and 35 evaluation forms and 49 printed formularies were received. Almost all hospitals had a formulary system and a printed formulary; the most frequently stated purposes were to decrease costs and to ensure appropriate therapy. Most formularies received were simple drug lists with no supporting information. The typical pharmacy and therapeutics committee consisted of 11 members, met every month, and reported to the executive committee. About 80% of the responding institutions had formal procedures for considering formulary additions. Less than half had standardized drug evaluation forms. Most hospitals have a formulary system and a printed version of the formulary; however, the formulary often serves primarily as a drug list, with no supporting information.

Data Collection↗
PubMed1996

Formulary revision: eliciting the opinions of users.

BACKGROUND: Few peer-reviewed reports have been published that document the extent and type of use of published formularies in general practice. As publishers of the Practice Formulary of the Royal College of General Practitioners, the Northern Ireland Faculty Board commissioned a large-scale survey to quantify these issues, for the purpose of improving the revision process. AIM: The aim of the survey was to investigate the extent to which general practitioners in Northern Ireland use the Practice Formulary and the ways in which they use it, and to elicit their opinions on ways in which it could be improved. RESULTS: A total of 371 completed questionnaires were received (response rate of 38%), 49 respondents (13%) stating that they had not received the formulary. Out of the 322 respondents who had received it, 84% used the formulary occasionally, and 41% either had or were producing their own practice formulary (32% of these had used the RCGP formulary in its production). Almost all respondents (90%) considered a formulary useful in general practice. The presentation and layout was approved by 273 respondents (85%) and 259 (80%) agreed strongly with the drug selection. The formulary was used as a source of drugs information by 191 respondents (59%) and as a teaching aid by 103 (32%). A total of 65 criticisms or suggestions for improving the next edition were received. Revision is now under way and 18 of the original respondents have volunteered to be members of the revision committee. No judgement was made about the non-respondents. CONCLUSION: The largest survey yet conducted of published formulary use in one region elicited the extent of use, type of use, criticisms and suggestions for improvement. These suggestions are being used as a guide to revision of the next edition.

Attitude of Health Personnel↗
PubMed1994

Drug formularies--good or evil? A view from a managed care provider.

Formularies have been developed in response to specific forces which have affected pharmaceutical utilization and costs. Specifically, this is in response to an increase in the aging population requiring more drugs, inflation in the acquisition cost of drugs, increasing utilization, and the introduction of new technology. Well-researched formularies will provide the drug therapy needs for 85-90% of the population. Patients unresponsive to listed formulary drugs may use nonformulary drugs if appropriate methods of authorization are instigated. Various types of formulary management exist: open, where they can be used as a guideline, and drug benefits are not limited to the formulary; restricted or closed, where only drugs on the formulary or those previously authorized will be paid for; incentive based, where patients pay a higher price for nonformulary drugs, and patient driven, where the patient holds a list of drugs they can be supplied with. Effective formulary performance requires the joint co-operation of the pharmacists, payers, physicians, the pharmaceutical industry, and patients. These clinically based formularies then form an important measure to control costs while providing quality care. This paper will discuss the advantages of a formulary, its development, administration, and management.

Formularies as Topic↗
PubMed1994

Drug formularies--good or evil? The clinical perspective.

Drug formularies, designed to encourage more clinically effective and cost effective prescribing, are now in widespread use in the secondary care system in the UK. Amongst their disadvantages, formularies are expensive to produce and require regular updating and policing. In addition, formularies do not consider alternate non-prescribing cost containment measures, and over-rigid application of formulary systems may alienate senior medical staff. In order to maximize the acceptability of formularies to all doctors, it is essential that the local Drugs and Therapeutics Committee has wide representation and focuses on clinical efficacy rather than simply on cost. Realistically, it is important that formulary committees are sufficiently flexible to allow the introduction of innovative, albeit expensive, new compounds. Enforcement of formularies into general practice is not presently achievable, but many primary care teams, realizing the benefits, have successfully introduced their own formularies to improve clinical drug usage and cost containment. If a reduction in costs is the primary aim, the global introduction of formulary systems may not be the best solution, and specific targeting of drug therapy may prove a more effective alternative. Indeed, in the South Glamorgan Health Authority, the introduction of a targeting system for the ten therapeutic areas with the highest expenditure allowed substantial savings to be made.

Cost Control↗
PubMed1993

The formulary decision-making process in a US academic medical centre.

This article reviews and describes the formulary decision-making process in an academic medical centre. The pharmacy and therapeutics (P & T) committee is the organisational nucleus of the drug use control process in the institutional environment. Thomas Jefferson University Hospital (TJUH), a 720-bed academic medical centre in an urban locality in the US, is used as a model representative of how most of these committees function. Survey responses collected from 29 peer academic medical centres are presented to compare and contrast the structure and function of the P & T committee at TJUH with corresponding procedures in other university hospitals in the US. TJUH is typical of the institutions which comprise the University Hospital Consortium (UHC). The P & T committee of TJUH is composed of 29 members, meets once per month for 10 months of the year, and has a network of 13 subcommittees. TJUH has an intermediately controlled (mixed) formulary, and uses both restricted drugs and treatment guidelines. Of the 29 UHC member institutions responding to the survey, the average P & T membership is 18, the average meeting frequency is 11 times per year, and 83% of these committees have a network of subcommittees. None describe their formulary system as open, 86% have a closed formulary and 14% have a mixed formulary system. There is a restricted drug programme in 76% of the institutions, 79% utilise treatment guidelines, 76% practice therapeutic interchange and all employ generic substitution. Specific areas addressed in this review include the history of the formulary system, the structure and function of the P & T committee, types of formularies, cost containment and the formulary decision-making process, the impact of organisational culture on physician decision making, the role of the pharmacy department, the role of pharmaceutical sales representatives and their impact on prescribing habits, the impact of the Joint Commission on Accreditation of Healthcare Organisations (JCAHO) Agenda for Change on the formulary process, and future challenges.

Academic Medical Centers↗
PubMed2001

Developing a quick reference formulary.

The establishment of the Department of Defense Basic Core Formulary was an attempt by the Department of Defense to equilibrate its pharmacy benefit among military treatment facilities. Department of Defense military treatment facilities are required to make available to beneficiaries items on the Basic Core Formulary. Military treatment facilities may augment the Basic Core Formulary through local pharmacy and therapeutic committee actions that result in different formularies among military treatment facilities. Formulary differences among military treatment facilities also arise because the Coast Guard, which is under the jurisdiction of the Department of Transportation in peacetime, is not required to adhere to the Basic Core Formulary at present. Because of formulary differences, most military treatment facilities make available abbreviated, quick reference versions of their formularies to patients. This article describes the development of a quick reference formulary at a Coast Guard military treatment facility pharmacy.

Formularies, Hospital as Topic↗
PubMed1985

Evaluating a restrictive formulary system by assessing nonformulary-drug requests.

Nonformulary-drug requests were used to evaluate a restrictive formulary system in a large university hospital, and a telephone survey of eight similar hospitals was conducted to assess the restrictiveness of their formulary systems. Nonformulary-drug requests were evaluated by two drug information pharmacists over a 12-month period (January-December 1984) to assess the frequency with which nonformulary items were ordered, the costs associated with the procurement of nonformulary drug products, and the rationales given by physicians when ordering nonformulary products. Of all nonformulary requests, 65% were for drugs previously evaluated by the pharmacy and therapeutics committee and denied admission to the formulary. A cost savings of $1887 would have resulted if formulary alternates had been used instead of nonformulary products. Excluding 22% of nonformulary items that were requested for the continuation of preadmission drug therapy, only 13% of the rationales for the remaining requests were appropriate. Although the eight other hospitals surveyed said they had restrictive formularies, all had frequent requests and procedures for procuring nonformulary items and some formularies included most available drugs. The formulary system at the study hospital was considered restrictive, but procedures for nonformulary-drug requests limited the effectiveness of the system. If any benefit is to result from formulary systems, hospitals must strengthen their enforcement of formulary restrictions.

Costs and Cost Analysis↗
PubMed1994

Attitudes of primary care physicians towards the use of a drug formulary--preliminary results of a study in Germany.

Although the concept of a drug formulary in primary health care is known for more than 10 years it was only recently that the drug budget of the new German Health Legislation has drawn doctors' attention to the use of such formularies. The loose-leaf form "Göttingen formulary" has been specifically compiled for the need of primary care doctors. It contains less than 300 drugs and drug combinations (including pseudo-placebos). This formulary was ordered by 830 colleagues from November 1992 until the end of May. In June 1993 we sent a semi-structured questionnaire to the users to learn about their experience with and attitude towards the formulary and about changes in their prescribing habits. Until the end of August 223 questionnaires have been returned. Seventy-four % of the respondents were general practitioners with considerable experience (more than 10 years in practice: 77%). The majority were satisfied or very satisfied with the drugs selected for the formulary and found the list helpful or very helpful (68%). Sixty-seven % indicated that the use of the formulary changed their prescribing habits; 70% appreciated an official (governmental) positive list. Although this study did not use a representative sample and the response rate was rather low until the cut-off point, it is noteworthy that the overall appreciation of a drug formulary for primary health care was very positive. The great majority of the respondents were convinced that an individual drug formulary does not render an official positive list superfluous.

Attitude of Health Personnel↗