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PubMed2003

Formulary decision-making about cephalosporins with similar therapeutic uses.

The various costs and intangible factors that enter into formulary decisions in an era of increasingly frequent drug product shortages that can adversely affect patient care and increase treatment costs are described. Pharmacy administration at Carolinas HealthCare System analyzed the costs associated with making a formulary switch from the third-generation cephalosporin ceftriaxone to cefotaxime, which recently became available in generic form and has a similar spectrum of antimicrobial activity and therapeutic uses. Hard dollar costs for purchasing drugs and the supplies needed to administer them; soft dollar costs for staff time spent acquiring, preparing, and administering doses; and intangible factors were considered. A reliable supply of drug product from the manufacturer was an important intangible factor because of frequent drug shortages in the past few years and the adverse effect on patient care and the increased soft dollar costs associated with these shortages. Administrators at Carolinas HealthCare System decided not to make the proposed formulary change after weighing the many factors and costs.

Cephalosporins↗
PubMed2003

Antimicrobial formularies: can they minimize antimicrobial resistance?

The relationship between antimicrobial drug use and resistance rates and the implications for antimicrobial formularies are described. Efforts to restrict antimicrobial drug use to reduce resistance in certain microorganisms have been accompanied by increases in resistance in other microorganisms. Random cycling of a variety of antimicrobial agents to treat infections caused by the same microorganism in different patients within a health care institution has been advocated as a means to reduce antimicrobial resistance. Analysis of actual antimicrobial drug use and resistance data from a network of 40 hospitals revealed wide variability in antimicrobial use. The specific type and volume of antimicrobial agents used appear to play key roles in determining resistance rates. It may be feasible to optimize diversity in antimicrobial drug use and minimize resistance by making judicious changes to the antimicrobial formulary.

Anti-Infective Agents↗
PubMed2003

Formulary management strategies for type 3 serotonin receptor antagonists.

The efficacy of type 3 serotonin (5-hydroxytryptamin) (5-HT3) receptor antagonists in preventing nausea and vomiting associated with cancer chemotherapy, radiation therapy, and surgery and the role of practice guidelines for the use of these agents in controlling antiemetic drug costs without compromising patient care are described. Nausea and vomiting caused by cancer chemotherapy, radiation therapy, and surgery can have a negative impact on quality of life and patient outcomes. The 5-HT3 receptor antagonists are effective for preventing nausea and vomiting from these causes. Oral 5-HT3 receptor antagonist therapy is as effective as intravenous therapy, while usually costing less. Various factors associated wtih the patient and the chemotherapy, radiation therapy, or surgery that increase the risk for nausea and vomiting have been identified. Practice guidelines have been developed in which 5-HT3 receptor antagonist therapy is reserved for patients at high risk for nausea and vomiting based on these various factors. The use of such practice guidelines at Memorial Sloan-Kettering Cancer Center limited antiemetic drug expenditures despite an increase in the number of patients receiving cancer treatment without compromising emetic control or quality of life. The use of special order forms improved compliance with the practice guidelines.

Antineoplastic Agents↗
PubMed2005

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing--2004.

PURPOSE: Results of the 2004 ASHP national survey of pharmacy practice in hospital settings that pertain to prescribing and transcribing are presented. METHODS: A stratified random sample of pharmacy directors at 1183 general and children's medical-surgical hospitals in the United States was surveyed by mail. SMG Marketing Group, Inc., supplied data on hospital characteristics; the survey sample was drawn from SMG's hospital database. RESULTS: The response rate was 41.7%. Compared with the results of the 2001 survey, the number of times pharmacy and therapeutics committees met increased, suggesting an increase in efforts to monitor and manage medication use in hospitals. There was an increase in the use of quality-of-life information to make formulary decisions, indicating a shift away from cost-based formularies. There was a decrease in the rates of formulary compliance, but an increase in the use of evidence-based clinical practice guidelines, suggesting the emergence of more comprehensive approaches to improving prescribing. The use of medication-use evaluations increased in smaller hospitals, suggesting greater use of best practices is occurring in these institutions. The use of drug information services continues to decline, as the use of more efficient and easily accessible online sources of drug information increases. Reading back oral orders to improve accuracy dramatically increased since 2001. The adoption of computerized prescriber-order-entry systems continues to be slow, with fewer than 5% of hospitals reporting their use. CONCLUSION: The 2004 ASHP survey results indicate that pharmacists are continuing to improve medication use at the prescribing and transcribing steps of the medication-use system.

Computer Systems↗
PubMed2005

Results of an antimicrobial control program at a university hospital.

PURPOSE: The results of the first five years of an ongoing antimicrobial control program are reported. METHODS: In 1998, a multidisciplinary antimicrobial subcommittee of the pharmacy and therapeutics committee of a university hospital was formed and charged with making formulary interventions in an effort to reduce rising antimicrobial resistance rates and drug expenditures. In 1999, a number of measures were implemented for controlling antimicrobial use. Selected antimicrobials with the potential for inappropriate use or whose inappropriate use had been documented were placed in the control of physicians in the infectious diseases (ID) division. Prior approval by an ID physician was required before the pharmacy could dispense these agents. Other key interventions included removal of ceftazidime and cefotaxime from the formulary, restriction of vancomycin and carbapenem use, and replacement of ciprofloxacin with levofloxacin as the sole fluoroquinolone on the formulary. Data regarding antimicrobial use and expenditures between 1998 and 2002 were compared and analyzed. RESULTS: Antimicrobial use was reduced by 80% for third-generation cephalosporins and 15% for vancomycin following the implementation of the new antimicrobial policies. Antimicrobial-resistance patterns for many important gram-negative pathogens, including Pseudomonas aeruginosa, demonstrated a reversal of previous increases. In addition, the rate of methicillin-resistant Staphylococcus aureus decreased by an average of 3% each year from 1999 to 2002. Pharmacy expenditures for all antimicrobials, including antiviral, antifungal, and antibacterial agents, decreased 24.7%, with a cumulative cost saving of 1,401,126 US dollars, without inflation assumptions. CONCLUSION: The implementation of an antimicrobial control program decreased the use of selected antimicrobial agents and resulted in substantial reduction of expenditures for antimicrobials.

Anti-Infective Agents↗
PubMedDate not supplied

Strategic antibiotic decision-making at the formulary level.

The proliferation of antimicrobial agents introduced for the treatment of increasingly complex infectious diseases, coupled with the obligation to provide the best possible medical care in keeping with hospital fiscal constraints, has created a need for strategic decision-making about antibiotics at the formulary level. The following experience at the Hartford Hospital, a 1,000-bed tertiary-care facility, represents an example of an antibiotic management system based on a multidisciplinary approach that utilizes infectious disease physicians, clinical microbiologists, hospital epidemiologists, and pharmacists.

Anti-Bacterial Agents↗
PubMed1996

Increased incidence of Clostridium difficile-associated diarrhea following decreased restriction of antibiotic use.

Removal of antimicrobial agents from formulary restriction status at our center was followed by an increase in the incidence of Clostridium difficile-associated diarrhea. The mean monthly incidence of C. difficile diarrhea for the 12-month period before institution of decreased restriction of antibiotic use was 3.4 infections per 1,000 admissions and rose to 6.2 infections per 1,000 admissions during the following 4-month period (P < .05). Patients who developed disease before and after decreased restriction of antibiotics were similar in terms of the mean number of antimicrobial agents administered and mean duration of therapy. The most commonly administered agents whose use preceded the onset of disease were cefazolin, trimethoprim-sulfamethoxazole, ampicillin, ticarcillin/clavulanate, and gentamicin (the latter drug was always used in combination with other agents). Immunoblot typing indicated that there was no association between C. difficile strains and administration of specific agents. There was no coincidental epidemic to account for the increased incidence of infection. The increased incidence of C. difficile disease is a potential problem that may occur following removal of extended-spectrum antimicrobial agents from formulary restriction status.

Adult↗
PubMed2001

Pharmaceutical cost-containment policy: experiences in Shanghai, China.

BACKGROUND: In the decade after 1983, the annual growth rate of drug expenditure was about four times as high as that of per capita gross domestic product (GDP) in Shanghai. In 1993 and 1994, a drug list policy and hospital revenue capping policy were introduced in Shanghai to contain drug expenditure. We studied the impact of these two policies, as a model for similar policies in other parts of China and elsewhere. METHODS: Quarterly drug expenditure data were collected from 1992 to 1996 and more detailed drug expenditure flow was obtained at seven selected hospitals. Twelve focus group discussions were organized to obtain opinions from all stakeholders. RESULTS: The research findings showed a dramatic and continuing decline in the growth rates of total medical and drug expenditures after the implementation of the two policies. The proportion of total medical expenditure attributable to drugs declined from 67% in 1992 to 51% in 1996. The annual growth rate of drug expenditure per ambulatory visit and per bed-day was reduced as well. Drug revenue as a proportion of total hospital revenue declined gradually in all seven hospitals. The two policies did not alter the equity of drug utilization between the insured and non-insured. The government, insurance authority and state-owned drug enterprises all favoured the new policies, while hospital administrators, professionals, joint venture and foreign manufacturers wished for the reimbursement mechanisms to be improved, for retention of their freedom of choice, and for the drug list to be further expanded. CONCLUSIONS: The drug list and capping policies in Shanghai appear to have achieved their objectives of containing the escalation of drug expenditure and improving the rational use of drugs without loss of equity. The underlying causes of the escalation of drug expenditure in China need to be further elucidated.

Ambulatory Care↗
PubMed1993

Antibiotic guidelines and antibiotic utilization in Dutch hospitals.

In April-May 1991 the availability of antibiotic formularies in Dutch hospitals was analysed as well as data available on antibiotic susceptibility patterns. In addition data on the use of different groups of antimicrobial agents (aminoglycosides, beta-lactam compounds including aztreonam and imipenem, co-trimoxazole, vancomycin and fluoroquinolones) were collected by a questionnaire. Thirty-eight formularies were received which were used in 78 hospitals. No formulary was available from 31 hospitals: 15 hospitals did not intend to set up antibiotic guidelines, nine hospitals were using their first formulary and seven used a revised version of the existing one. Fifteen formularies dated from 1987 or earlier. The availability of antibiotic susceptibility patterns ranged from no data at all (n = 14) to extensive data per species, per agent and per ward (n = 5). From 20 hospitals data on antibiotic usage as well as on antibiotic guidelines were obtained. Because several hospitals used the same formulary, 15 different formularies were analysed from 20 hospitals. Fluoroquinolones were used in all hospitals, but were only mentioned in the formularies of six hospitals. The data in the present study underscore the need for a collaborative approach of medical staff, hospital pharmacy and microbiologist in order to maintain a relatively low level of antibiotic resistance in Dutch hospitals.

Anti-Bacterial Agents↗
PubMed1994

Antibiotic policies in Dutch hospitals for the treatment of patients with serious infection.

In order to assess the guidelines available in Dutch hospitals for the treatment of patients with serious infection of unknown aetiology, 39 antibiotic formularies used in 88 hospitals were analyzed. The recommendations considered were those for the treatment of sepsis for which the source was not apparent or which originated in the urinary tract, respiratory tract or abdomen. beta-Lactam antibiotics (most commonly amoxycillin and cefuroxime) were the preferred agents for empirical therapy of infections of all types; an aminoglycoside was also included in the majority of regimens, irrespective of the clinical presentation. However, there were wide variations in the choice and dosages of the drugs administered. Because of the absence of local data for the susceptibilities of blood culture isolates, the appropriateness of the recommendations could not be properly evaluated.

Anti-Bacterial Agents↗
PubMed1996

Trends in hospital antibiotic prescribing after introduction of an antibiotic policy.

Trends in antibiotic prescribing in Grampian were monitored prospectively for seven years from 1986 using computerised ward stock lists and laboratory data relating to all in-patient and out-patient treatments in all Grampian hospitals serving a population of 500,000. The main outcome measures were the number of antibiotics available for routine and restricted uses, annual expenditure and defined daily doses (DDDs) of high expenditure antimicrobial agents. An antibiotic committee introduced a policy and formulary in the third year of the study which had only limited success in controlling prescribing. During the period of the study 30 new antibiotics were considered for inclusion in the hospital formulary, but only seven were incorporated, and all for restricted use only. Despite this, expenditure on antibiotics has more than doubled since 1986, two thirds of the increase being due to the use of new drugs. There was also an increased use of older antibiotics (DDDs increased by 33%), often for no clear reasons, and an overall increase of 46% in DDDs. Antibiotics have increased from 11.9-18.7% as a proportion of the drug budget. These findings highlight the current difficulty in controlling prescribing budgets, the increasing use of antibiotics and the consequent spread of resistance.

Anti-Bacterial Agents↗
PubMed2000

Trends in hospital antimicrobial prescribing after 9 years of stewardship.

Trends in antibiotic prescribing in Grampian have been monitored prospectively for 11 years from 1986 using computerized ward stock lists and laboratory data relating to all in-patient and out-patient treatments in all Grampian hospitals. The main outcome measures were the number of antibiotics available for routine and restricted use, annual expenditure and defined daily doses (DDDs) of high expenditure antimicrobial agents. An antibiotic committee introduced a policy and formulary in the third year of the study which has had only limited success in controlling prescribing. This report updates the audit from 1992/3 to 1996/7. During this period 22 new antibiotics were considered for inclusion in the hospital formulary. Seventeen, including seven antiretroviral agents, were incorporated, all for restricted use only. Despite this, expenditure on antibiotics has more than trebled since 1986/7 and increased 50% since 1992/3, two-thirds of the latter increase being due to the use of new drugs, namely anti-HIV drugs, lipid amphotericin derivatives and teicoplanin. Big increases in the use of co-amoxiclav, acyclovir, ciprofloxacin and cefotaxime account for the remainder of the increased expenditure. There was an overall increase of 16.9% in DDDs between 1992/3 and 96/7 to 424.0 DDDs/1000 patient days (393.4 DDDs for antibacterials). These findings highlight the current difficulty in controlling prescribing budgets, the increasing use of antibiotics and the consequent increase of antimicrobial-resistant microorganisms.

Anti-Infective Agents↗