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PubMed1988

Antipsychotics: how strict the formulary?

Seventeen antipsychotic medications are available in the U.S. Antipsychotic formulary considerations include relative efficacy, individual patient response, relative differences in adverse effects, dosage form availability, blood level monitoring, and generic availability. Chlorpromazine, thioridazine, haloperidol, and fluphenazine are recommended for formulary inclusion based on research and clinical considerations. A recommendation for managing a patient receiving a nonformulary antipsychotic is presented.

Antipsychotic Agents↗
PubMed1994

Antiulcer prescribing program in a state correctional system.

OBJECTIVE: To describe a formulary antiulcer agent prescribing program developed as the result of a drug use evaluation (DUE). Program implementation, methods, cost impact, and results of a follow-up DUE are provided. BACKGROUND: The institution is a 51,000-bed correctional system consisting of 40 separate units each containing an ambulatory care clinic. Medication orders are transmitted via mainframe computer system to one of four pharmacies, which collectively dispense an average of 4000 medication orders (30 days' supply) per day. METHODS: Results from the antiulcer agent (cimetidine, ranitidine, sucralfate) DUE revealed that the agents studied were prescribed in dosages and durations exceeding criteria developed by the Pharmacy and Therapeutics Committee. A program designed to reduce dosages to maintenance therapy after eight weeks at treatment dosage was developed by the Pharmacy and Therapeutics Committee with staff physician input. Antiulcer agent use and expenditures were followed and a follow-up DUE was completed seven months after program implementation. Antacid use and frequency of upper gastrointestinal studies that were ordered were followed. RESULTS: The follow-up DUE showed the mean daily dosage for prescribed histamine2-receptor antagonists decreased (cimetidine from 694 to 454 mg, ranitidine from 280 to 183 mg) and the mean duration of therapy decreased from 14 to 10 months. The percentage of patients with potentially significant drug interactions decreased from 14.2 to 6.5 percent. The mean number of antiulcer agents dosage units dispensed per month decreased by 24,461 units, resulting in a projected annual savings of $327,273. There were no identifiable clinically important changes in the use of antacid products or prescribing of upper gastrointestinal studies. CONCLUSIONS: A cost-savings program sponsored by the pharmacy and therapeutics committee decreased costs, corrected prescribing to more closely meet preset criteria, and produced no discernable unfavorable effect on patient care.

Adult↗
PubMed2000

Differences in managed care drug formularies: what can consumers learn?

Pharmaceutical coverage has become an especially important issue in health plan design. This article develops an objective measure of drug coverage generosity in managed care drug formularies. Formulary generosity is important because patients respond differently to drugs within a therapeutic class, and so there is benefit in offering a wide variety of products to prescribing physicians. The measure of coverage generosity considers not only the number of products offered to patients through a formulary, but whether plans systematically exclude more expensive products. The correlation between formulary generosity and health plan member satisfaction is analyzed to see if formulary generosity is perceived by subscribes to be related to perceived health plan quality. The findings are that plans vary widely in offering access to pharmaceuticals but that generosity is not highly correlated with health plan satisfaction.

Decision Making↗
PubMed1993

A comparison of community pharmacists' and general practitioners' opinions on rational prescribing, formularies and other prescribing related issues.

A postal survey of Community Pharmacists (CPs) and General Medical Practitioners (GPs) in the Enfield and Haringey (E&H) and North Yorkshire (N Yorks) Family Health Services Authority (FHSA) areas was carried out to investigate: a. their opinions regarding clinically oriented 'extended' roles for CPs, and the possibility of interprofessional collaboration on them, and b. their views on a range of prescribing related issues. The overall response rate was 67% for CPs and 42% for GPs. There were no significant differences in responses to questions between CPs in both FHSAs, but significant differences in answers to some questions between the two groups of GPs, due to a large proportion of dispensing GPs in N Yorks. Results were therefore expressed as comparisons between total numbers of CPs and GPs, and between dispensing and non-dispensing GPs. The results showed an affinity of outlook between CPs and GPs on a range of prescribing related issues, and considerable goodwill between the two groups on which future cooperation could be founded. GPs were, however, significantly less enthusiastic than CPs about collaboration in areas which would concede a role to CPs in making prescribing decisions. GPs were most favorably disposed to collaboration in areas such as the provision of drug information, which could be considered as within GPs' domain of specialist expertise.

Attitude of Health Personnel↗
PubMed2005

Prescription channeling of COX-2 inhibitors and traditional nonselective nonsteroidal anti-inflammatory drugs: a population-based case-control study.

This pharmacoepidemiologic study was conducted to determine whether risk factors for upper gastrointestinal bleeding influenced the prescription of cyclo-oxygenase (COX)-2 inhibitors and traditional nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) at the time when COX-2 inhibitors were first included in the formulary of reimbursed medications. A population-based case-control study was conducted in which the prevalence of risk factors and the medical histories of patients prescribed COX-2 inhibitors and traditional nonselective NSAIDs were compared. The study population consisted of a random sample of members of the Quebec drug plan (age 18 years or older) who received at least one dispensation of celecoxib (n = 42,422; cases), rofecoxib (n = 25,674; cases), or traditional nonselective NSAIDs (n = 12,418; controls) during the year 2000. All study data were obtained from the Quebec health care databases. Adjusting for income level, Chronic Disease Score, prior use of low-dose acetylsalicylic acid, acetaminophen, antidepressants, benzodiazepines, prescriber specialty, and time period, the following factors were significantly associated with the prescription of COX-2 inhibitors: age 75 years or older (odds ratio [OR] 4.22, 95% confidence interval [CI] 3.95-4.51), age 55-74 years (OR 3.23, 95% CI 3.06-3.40), female sex (OR 1.52, 95% CI 1.45-1.58), prior diagnosis of gastropathy (OR 1.21, 95% CI 1.08-1.36) and prior dispensation of gastroprotective agents (OR 1.57, 95% CI 1.47-1.67). Patients who received a traditional nonselective NSAID recently were more likely to switch to a coxib, especially first-time users (OR 2.17, 95% CI 1.93-2.43). Associations were significantly greater for celecoxib than rofecoxib for age, chronic NSAID use, and last NSAID use between 1 and 3 months before the index date. At the time of introduction of COX-2 inhibitors into the formulary, prescription channeling could confound risk comparisons across products.

Adolescent↗
PubMed2005

Bench-to-bedside review: antimicrobial utilization strategies aimed at preventing the emergence of bacterial resistance in the intensive care unit.

Antimicrobial resistance has emerged as one of the most important issues complicating the management of critically ill patients with infection. This is largely due to the increasing presence of pathogenic microorganisms with resistance to existing antimicrobial agents resulting in the administration of inappropriate treatment. Effective strategies for the prevention of antimicrobial resistance within intensive care units are available and should be aggressively implemented. The importance of preventing antimicrobial resistance is magnified by the limited availability of new antimicrobial drug classes for the foreseeable future.

Anti-Infective Agents↗
PubMed2006

Medication-related clinical decision support in computerized provider order entry systems: a review.

While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.

Contraindications↗
PubMed2003

Interest groups and state Medicaid drug programs.

A simultaneous equations model is estimated to analyze the interaction between state Medicaid pharmaceutical drug reimbursement rates, drug recipients per capita, and expenditures per drug recipient. Interest groups are shown to have a strong positive impact on pharmacy reimbursement rates, which, in turn, have an impact on pharmacy participation rates and drug utilization and expenditure patterns. Finally, a strong inverse relationship exists between expenditures per recipient and program size. The results verify the existence of substantial variation in state Medicaid programs and point to potentially growing disparities as a result of current policies.

Decision Making, Organizational↗
PubMed2004

Influencing prescribing in English primary care: the views of primary care organisations.

OBJECTIVE: The rapid rise of prescribing expenditure is a concern in many industrialised countries and methods to manage medicines are widely employed. The purpose of this study was to identify the approaches to improve primary care prescribing by primary care organisations (PCOs) in the National Health Service (NHS) in England. METHODS: A questionnaire (Management of Medicines, MANMED) was mailed to prescribing advisers and prescribing leads in 332 PCOs. RESULTS: A response rate of 66% (220/332) was achieved. Most PCOs report the improvement of the quality of prescribing as their top priority, followed by budget adherence at both practice and PCO levels. Prescribing advisers typically offer several forms of support: practice visits, prescribing reviews, indicators of prescribing, prescribing newsletters, hands-on support, seminars and local formularies. PCOs are pursuing a wide range of prescribing initiatives, covering, on average, seven different therapeutic areas. National targets are the main driver for prescribing initiatives but other key influences include inappropriate prescribing and clinical governance. Although cost considerations are important, improving the quality of prescribing is perceived as the overriding principle on which PCO prescribing strategy is based. Multifaceted prescribing support is widespread and national targets are the largest single factor influencing choice of therapeutic area for prescribing initiatives. CONCLUSIONS: Diversity in approaches presents the opportunity to improve the evidence base for medicines management. Not only could such research inform PCOs in their central aim of improving the quality of prescribing within the NHS, but it may also offer insights of relevance to other countries if the influence of process and context upon the effectiveness of medicines management is systematically explored.

Budgets↗
PubMed2004

Recognize the role of employers.

Morgan and Willison provide an interesting review of the concept of federally funded catastrophic prescription drug coverage. However, the conclusion reached about government-funded first-dollar and last-dollar coverage tends to oversimplify the issues. In addition, it fails to recognize the role that is currently played by employers who provide plans to their employees. This commentary provides the private sector context and also highlights some of the disadvantages that have been overlooked in the Morgan and Willison paper.

Canada↗
PubMed2000

An overview of the development of nurse prescribing.

This article provides an overview of nurse prescribing in the UK. The initial recommendations for nurse prescribing, perceived benefits of prescribing and the findings from evaluation studies are reported. Current education and training courses available for nurse prescribers are described. The development of nurse prescribing has been slow and, it could be argued, out-dated, as many practitioners are excluded from this initiative. It is important that nurse prescribers receive adequate time and funding to undertake appropriate training and education in this area.

Community Health Nursing↗
PubMedDate not supplied

Establishing a dressings formulary.

Choices have to be made between the multitude of dressings available, and especially between products with the same characteristics and features. This article describes how to compile, maintain, monitor and review a dressings formulary.

Bandages↗
PubMedDate not supplied

The British National Formulary and other medicine indexes.

Brenda, a staff nurse on the children's ward, noticed that a junior doctor had written a patient up for a drug of which she had not heard. She asked the ward sister whether she should administer it. The ward sister said that she was not familiar with the drug but that she could trust that doctor and therefore should administer the drug. What is the law?

Formularies as Topic↗
PubMedDate not supplied

The introduction of nurse prescribing in the community: 1.

A group of district nurses run a children's clinic. The district nurses who have prescribing powers are able, where appropriate, to give the mothers a prescription for any necessary medicinal products. Mavis decided that one child required a preparation for head lice and asked the mother if the child was asthmatic. The mother said no and the nurse wrote a prescription. Mavis said that she had been unable to refer to the child's records as they were not available at this clinic. She subsequently learnt that because of an allergic reaction, the child had suffered considerable harm. Is she liable?

Community Health Nursing↗
PubMedDate not supplied

A tool to aid nurses' decision making in relation to dressing selection.

A multidisciplinary formulary group was established to create a standardized approach to wound management throughout Carmarthenshire. It was felt that a tool to aid nurse's decision making in dressing selection might enhance the process of formulary implementation. This article outlines the development of the tool. An action-research approach was chosen to investigate the idea. The project followed a series of cycles consisting of planning, action, data collection and reflection. The first cycle confirmed the need for such a tool. A reference card was produced. As a result of data collected in the second cycle, the card was reproduced with suggested improvements. The improved tool was then evaluated in the third cycle. Minor adjustments and incorporation of the completed Carmarthenshire formulary took place during the fourth cycle. The Carmarthenshire formulary is now in use and accompanied by the reference card.

Bandages↗
PubMed2000

Wound care guidelines and formulary for community nurses.

Community nursing is experiencing significant change as a result of developments such as improved technology, care in the community and earlier discharge of patients from hospital. Because of this, increasingly complex clinical care is required in the community, and it has been noted that community nurses are 'under considerable pressure' and show 'evidence of high stress and low morale'. Wound care is one area in which community nurses constantly battle to keep abreast of continual change. Growing product availability and diversity of use, changes in dressing techniques and the ever-increasing costs associated with wound care mean decision-making in wound care is often a complex task. In the Grampian region, a handbook of evidence-based practice guidelines with a product formulary was developed and distributed to all community nurses. The handbook was designed to ease the decision-making process by evaluating evidence-based practice and local preferences to recommend and guide nurses towards effective clinical practice and cost efficiency. All grades of district nurse in the region have been issued with their own copy of the handbook. It is presented in an A5 ring-binder format to make it easy to carry and to facilitate updating using loose-leaf inserts. The use of logos, extra information boxes and colour coding makes it easy for users to find specific areas of interest in the handbook. The success of the handbook has led to debate on the potential for development of a similar resource for use by practice nurses and in local community hospitals.

Community Health Nursing↗