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PubMed1990

Grampian Health Board's joint drug formulary.

OBJECTIVE: To develop a model for creating a joint general practice-hospital formulary, using the example of ulcer healing drugs. DESIGN: A joint formulary development group produced draft guidelines based on an earlier hospital formulary, which were sent to interested local general practitioners for consultation. Revised guidelines were then drawn up and forwarded to the health board's medicines committee for approval and distribution. SETTING: Grampian Health Board. SUBJECTS: Nine members of joint formulary development group plus local general practitioners who were invited to comment on a list of 11 ulcer healing drugs. MAIN OUTCOME MEASURE: Degree of coincidence of drugs selected by hospital doctors and general practitioners. RESULTS: The ulcer healing drugs selected by the panel of general practitioners and by hospital doctors were highly coincident. The cost of one day's treatment with drugs varied considerably between hospital and general practice--for example, one drug cost 46p in hospital and 1 pounds in general practice and another cost 1.26 pounds in hospital and 1.01 pounds in general practice. Overall, six drugs cost more in hospital and five cost more in general practice. CONCLUSIONS: A joint formulary for use in hospitals and general practice in a health board can be devised fairly simply by consultation as virtually the same drugs are used in both types of practice. It should influence the health board's expenditure on drugs and affect the choice of drugs when a patient is discharged from hospital or is referred to any hospital in the region.

Anti-Ulcer Agents↗
PubMed1991

Medical audit and formulary management: a policy for rational use of thrombolytic drugs.

In this article we report on the development, introduction, and maintenance of a policy to promote rational use of thrombolytic drugs by hospital doctors. The work was undertaken within the framework of the voluntarily operated Riverside East drugs guide (formulary) management system (FMS). The policy was introduced in October 1988 and revised in November 1989 to coincide with the launch of the new, expensive thrombolytic drugs, alteplase (rt-PA, Actilyse) in 1988 and antistreplase (APSAC, Eminase) in 1989. Streptokinase was recommended as the first-line drug for patients who had not received it within the last 6 months. The policy was communicated to all staff in meetings and a drugs guide bulletin and reinforced by ward pharmacists. Results over a 15 month period show voluntary compliance by prescribers with the recommended policy. One hundred and seventy-four patients (22% cardiac admissions) presented with acute myocardial infarction. Of these 43 (25%) received streptokinase, the first-line recommended drug, 7 received alteplase and none received anistreplase. The savings in drug expenditure from using streptokinase rather than alteplase or anistreplase for the 15-month period of investigation were over pounds 27,000. This work represents an example of the effectiveness of the Riverside East FMS model in influencing prescribing behaviour.

Anistreplase↗
PubMed2006

Oral anticoagulation in a pediatric hospital: impact of a quality improvement initiative on warfarin management strategies.

BACKGROUND: There are potential risks associated with the use of warfarin in children, particularly as the dosing requirements may decrease as patients get older. CONTEXT: Our facility is a 715-bed freestanding pediatric tertiary care center with a large cardiac surgery center. A significant number of patients receive warfarin for treatment or prophylaxis of thromboembolic events while in hospital. KEY MEASURES FOR IMPROVEMENT: Initial dose of warfarin and time taken to achieve goal therapeutic international normalized ratio (INR). STRATEGIES FOR CHANGE: The intervention included: (1) revision of hospital drug formulary so that warfarin dosing was in accordance with the most recent guidelines; (2) warfarin administration restricted to one time of the day (12.00 noon); (3) target therapeutic INR level documented with each warfarin order; and (4) pharmacy computer system mandated that the pharmacist confirmed the target INR, documented the most current INR, and compared the dose with the formulary guidelines. If the warfarin dose was not in accordance with the formulary guidelines, the pharmacist contacted the physician and made dosing recommendations according to the guidelines. EFFECTS OF CHANGE: The number of patients with supratherapeutic INR values during the hospital admission was decreased by more than 50% and goal INR values were documented more frequently in the medical record. There was also an increase in subtherapeutic INR values. The intervention had no effect on the time taken to achieve the goal therapeutic INR. LESSONS LEARNED: Instituting changes in a number of aspects of anticoagulation management and incorporating an intensive educational effort across a breadth of healthcare providers can improve anticoagulation management with warfarin in challenging patient populations such as children. Similar methods could possibly improve anticoagulation with other agents such as unfractionated heparin or low molecular weight heparin.

Administration, Oral↗
PubMed1991

Efficacy and cost-effectiveness of antibiotic monitoring at a Veterans Administration hospital.

A rigorous, continuously monitored antibiotic programme was initiated at our Veterans Administration hospital following evidence of inappropriate antibiotic usage. Seven hundred and thirty-one patients, mainly male, with an average age of 60 years were involved in the study; 378 were evaluable prior to policy implementation and 273 subsequently. The overall prevalence of deaths and average length of antibiotic therapy were less during the post-policy period. The number of antibiotic doses per patient was decreased by 24%. Drug costs were reduced by 32% post-policy, due largely to increased use of the longer-acting cephalosporins ceftriaxone and cefotetan. A 23% reduction in antibiotic acquisition costs was achieved over the 3-year period of the study, without detrimental effects on patient outcome.

Anti-Bacterial Agents↗
PubMed1988

Ethics of nonformulary review in psychiatry.

Quality assurance programs have infiltrated all aspects of patient care. No longer is the clinician immune from outside forces influencing the conduct of treatment. External utilization review may independently determine the length of inpatient stay that will be reimbursed. This month's column discusses how internal review may direct which medications are available for use by the prescribing physician in the hospital. To what extent such review is intended primarily to benefit patients or to control costs is subject to debate. Regardless of motive, the result is considerable ethical controversy.

Drug Utilization↗
PubMed2005

Does a hospital formulary influence prescribing practice in an acute medical admissions unit?

AIM: To assess the extent to which prescribing of cardiovascular medications in a busy medical unit deviates from the local joint primary and secondary care drug formulary guidelines. METHOD: A retrospective audit of the case notes, prescription charts and discharge summaries of 150 randomly selected emergency medical admissions over a 4 month period. RESULTS: No patient receiving a non-formulary cardiovascular drug on admission had the choice reviewed in line with formulary recommendations. One third of new cardiovascular medications commenced in hospital were not compliant with formulary recommendations. Decisions about drug therapy were rarely justfied in the written hospital record. CONCLUSIONS: Our results demonstrate that in a busy acute medical admissions' unit there is a clear failure to amend or query non-formulary prescribing at the time of admission and a tendency to exacerbate it during the inpatient period. This potentially undermines the purpose of a joint drug formulary as a guideline for safe, evidence-based and cost-effective prescribing.

Acute Disease↗