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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 The deletion of rarely used or outdated products is often overlooked.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↗

The long-term value of the selected list as a method of controlling drug costs in a district general hospital.

The results of a study aimed at evaluating the long-term effects of the Limited List (now officially referred to as the Selected List Scheme) on inpatient drug costs in a district general hospital (DGH) are presented. Study periods of six months duration were examined before, shortly after, and a further year after implementation of the List on 1 April 1985. Eight therapeutic classes affected by the regulations were examined; in four of these (antacids, expectorants, mucolytics and anxiolytics, hypnotics and sedatives) statistically significant reductions in costs were demonstrated over the study periods. There was no significant change in the costs of the other four classes (vitamins, laxatives, nasal preparations and analgesics). Overall, inpatient expenditure for the hospital showed no significant change. The changes in cost demonstrated can be attributed to the Selected List and occurred despite the prior existence of a local formulary.

Cost Control↗

Drug usage review of cefamandole at a teaching hospital.

A drug usage audit of cefamandole was conducted at a 900-bed teaching hospital. Health records of all in-patients receiving cefamandole during a three-month period (November 1, 1985 to January 31, 1986) were retrospectively reviewed. Treatment of lower respiratory tract infections accounted for 35 (44%) of the 79 treatment courses examined. Surgical antimicrobial prophylaxis for cardiovascular procedures involved 26 (33%) courses of therapy and 15 (19%) courses were associated with biliary tract procedures. The three remaining treatment courses (4%) included therapy for septicemia, orthopedic surgery prophylaxis, and a leg ulcer. Twenty-eight percent of all treatment courses were deemed to be appropriate. Thirty-two percent were considered controversial, and 40 percent inappropriate. The majority of the suboptimal use identified involved prescribing cefamandole for cardiovascular surgery prophylaxis. The role of cefamandole in the acute hospital setting is reviewed with reference to other available first, second and third-generation cephalosporins. General recommendations for its use are outlined.

Anti-Bacterial Agents↗

Cefotaxime and ceftriaxone use evaluation in pediatrics. Considerations of cost effectiveness.

In 1993, there was a change from ceftriaxone to cefotaxime in the inpatient pediatric division of the Johns Hopkins Hospital. The annual cost savings resulting from this change were estimated. The educational efforts of the pediatric division pharmacists resulted in an increase in appropriate drug selection from 55% to 93%. The estimated annual cost saving was $18,618.

Bacterial Infections↗

Prescribing at the interface between primary and secondary care in the UK. Towards joint formularies?

The current divisions in managing prescribing between primary and secondary care in the UK arise from separate budgetary arrangements. These divisions are neither sensible, organisationally efficient nor cost effective. Transition of patients across the interface of primary and secondary care has always been problematic, hindered by poor communication and coordination. Joint formularies would improve overall care and raise awareness of the need to consider overall costs within a unified National Health Service (NHS). There are, however, few examples of successful working of a joint formulary in the UK. It is likely that harmonisation of drug use in hospitals and in primary care will come about because of contracting and commissioning, and that it will largely be led by primary care, through the developing primary care groups (PCGs). Local decisions around availability and use of drug therapies will increasingly be superseded by the national decisions emanating from the newly formed National Institute for Clinical Effectiveness.

Drug Prescriptions↗

Drug formularies--good or evil? A view from the EEC.

The use of standard treatment schemes is believed to provide easier, safer, and more rational prescribing of drugs. Provision of neutral information on relative costs and merits of individual therapies may induce physicians to prescribe more rationally and cost effectively. A drug formulary must be developed by using clinical evidence of efficacy, taking into account all available preparations, choosing the most cost effective formulation of the drug, and as far as possible complying with formularies implemented by other health institutions. Planning process and preparation time are fundamental to formulary development work. A restrictive drug policy in the hospital environment will save time in the pharmacy, as fewer drugs are handled, and will improve prescribing as the staff have fewer drugs to familiarize themselves with. The potential benefits from increased generic prescribing, lower stock levels, and closer working relationships between members of the formulary team should all be considered. The benefit of this interdisciplinary approach to drug therapy will be rapidly recognized.

Belgium↗

Assessment of formulary development in a small hospital.

The development of a formulary system in a 138 bed hospital is evaluated. A description of the process used in completing the formulary is provided as well as the assertion that the small hospital has advantages in initiating this process. The results of the study show a 40% decrease in the number of drug line items and a $14,901 (36%) reduction in inventory. Improvement in departmental organization is noted as well as a positive psychological impact. As the prospective payment system increases the need to control costs and improve efficiency, the formulary system is seen as an important step in addressing these concerns.

Cost Control↗

Group purchasing: an overview.

The various types and operational methods of purchasing groups are described, and evaluation of groups is discussed. Since group purchasing is increasing in popularity as a method of controlling drug costs, community and hospital pharmacy managers may need to evaluate various groups to determine the appropriateness of their services. Groups are categorized as independent, system based, or alliance or association based. Instead of "purchasing," some groups develop contracts for hospitals, which then purchase directly from the vendor. Aside from this basic difference between groups that purchase and groups that contract, comparisons among groups are difficult because of the wide variation in sizes and services. Competition developing from diversification among groups has led to "super groups," formed from local and regional groups. In evaluating groups, advantages and disadvantages germane to accomplishing the member's objectives must be considered. To ensure a group's success, members must be committed and support the group's philosophies; hospital pharmacists must help to establish a strong formulary system. To select vendors, groups should develop formal qualification and selection criteria and should not base a decision solely on price. The method of solicitation (bidding or negotiating), as well as the role of the prime vendor, should be studied. Legal implications of group purchasing, especially in the areas of administrative fees and drug diversion, must also be considered. The most advantageous group for each organization will include members with common missions and will be able to implement strategies for future success.

Biological Availability↗

Converting an integrated hospital formulary into an object-oriented database representation.

Controlled Medical Vocabularies (CMVs) have proven to be extremely useful in their support of the tasks of information sharing and integration, communication among various software applications, and decision support. Modeling a CMV as an Object-Oriented Database (OODB) provides additional benefits such as increased support for vocabulary comprehension and flexible access. In this paper, we describe the process of modeling and converting an existing integrated hospital formulary (i.e., set of pharmacological concepts) into an equivalent OODB representation, which, in general, we refer to as an Object-Oriented Healthcare Vocabulary Repository (OOHVR). The source for our example OOHVR is a formulary provided by the Connecticut Healthcare Research and Education Foundation (CHREF). Utilizing this source formulary together with the semantic hierarchy composed of major and minor drug classes defined as part of the National Drug Code (NDC) directory, we constructed a CMV that was eventually converted into its OOHVR form (the CHREF-OOHVR). The actual conversion step was carried out automatically by a program, called the OOHVR Generator, that we have developed. At present, the CHREF-OOHVR is running on top of ONTOS, a commercial OODB management system, and is accessible on the Web.

Databases as Topic↗

Impact of removing oral neuroleptic liquids from the formulary of a large psychiatric hospital.

Oral liquid formulations of neuroleptic medications have been claimed to offer advantages in treatment of psychotic patients, particularly as a means of ensuring compliance. After a review of the literature, this 900-bed psychiatric facility found no substantial support to indicate that liquids are superior to solid dosage forms. Because of their higher cost, liquid neuroleptics were removed from this formulary. Few changes in prescribing practices were measured after removal of liquids; dosages remained constant and injectable neuroleptic and sedative use actually decreased. Replacing liquid neuroleptic dosage forms with solid dosage forms resulted in an estimated annual savings of nearly $60,000 at this institution. The authors conclude that liquid neuroleptics appear to offer no benefits over solid dosage forms in adult psychiatric patients and can be removed from drug formularies without disruptive effects on psychotropic prescribing practices or clinical care. However, further research is needed to determine the benefits of liquid neuroleptics in special clinical or psychiatric settings.

Antipsychotic Agents↗