Drug-use Review Research Articles

Multidisciplinary adverse drug reaction surveillance program

Initial experience with a multidisciplinary adverse drug reaction (ADR) surveillance program at a 350-bed community hospital center is described. The pharmacy and quality-review (QR) departments developed a program that was incrementally incorporated into the hospital's overall QR activity. After inservice training, nurses and QR personnel were asked to complete an "alert" card for every suspected ADR and send it to the pharmacy. In addition, medical records were reviewed retrospectively for disease classification codes related to drug toxicity and unspecified adverse effects. Laboratory and utilization-review personnel also conducted retrospective reviews. A pharmacist reviewed all ADR reports and categorized each according to the severity of the reaction and the probability that it was drug related. For each reaction classified as severe, the patient's chart underwent physician peer review for appropriateness of therapy, avoidability of the reaction, and adequate documentation; related patient-care issues were addressed by the medical staff as part of routine quality-review activities. When problems with prescribing were identified, the pharmacy and therapeutics committee intervened with the prescribers or recommended further medical staff review. Drugs repeatedly associated with ADRs became the focus of drug-use reviews. The number of ADR reports increased from 0 to 134 in the first 11 months of the program. A multidisciplinary approach to ADR reporting increased the number and quality of ADR reports.

Use of concurrent monitoring and a preprinted note to modify prescribing of i.v. cimetidine and ranitidine in a teaching hospital

The use of concurrent monitoring and an informational note to modify physician prescribing of i.v. cimetidine and ranitidine is described. The study population consisted of all patients for whom i.v. cimetidine and ranitidine therapy was prescribed by house-staff physicians at an 850-bed, tertiary-care, university-affiliated hospital during February, March, and April 1987. Phase 1 of the trial consisted of an initial drug-use review of all eligible patients receiving therapy. In phase 2, the study population was divided into an intervention group and a control group. When therapy could be changed from the i.v. to the oral or nasogastric (NG) route of administration, an informational note was placed in the chart of the patients in the intervention group. Patients in the control group were also assessed daily for the appropriateness of conversion to oral or NG therapy. The following outcome measures were used to test the effectiveness of the intervention in modifying physician prescribing: mean number of i.v. doses and days of i.v. therapy per patient and mean number of inappropriate i.v. doses and days of i.v. therapy per patient. The drug acquisition costs for both groups were also analyzed. A total of 233 patients were monitored during the study period. The percentage of patients who did not receive oral therapy as soon as possible was not significantly different between the intervention (55%) and control (58%) groups. Patients in the intervention group received three to six fewer i.v. doses than patients in the control group and three to six additional oral doses.(ABSTRACT TRUNCATED AT 250 WORDS)

On the fringes.

The expanded training pharmacists now receive in human pharmacotherapy has led to their increased participation in direct patient care. These activities may be global or specific, and can include drug therapy consultation, pharmacokinetic-based dosing recommendations, drug-use review, participation in nutritional support, and clinical pharmacology research. Such a listing of relatively sophisticated roles makes today's pharmacy practitioners almost unidentifiable with their counterparts of 20 years ago. This rapid transition makes pharmacy somewhat different in the health professions, since in comparison, medicine and nursing have been more stable. Despite these hard-fought advancements, there is a disturbing discrepancy between standards of care in pharmacy and the legal definition of pharmacy practice. Continued and future advancements are tenuous secondary to fear generated from noncompliance with state regulations. The entire profession should strive to develop updated pharmacy acts to prevent individuals from practicing "on the fringes."

The Anesthesia Record

The standard format of preoperative, perioperative, and postoperative patient anesthesia records, the categories of information included, and pharmacists use of this information are described. On the preoperative evaluation form, the anesthesiologist or anesthetist records information on the physical status of the patient and an overall impression of the anesthetic risk. The perioperative record is used for notation of the administration of anesthetic agents, fluids, blood products, and other medications and for recording vital signs, anesthetic and surgical interventions, and airway maintenance; this record shows a dynamic account of the patient's responses throughout the operation. Finally, the anesthesiologist notes postoperative problems related to anesthesia on the postoperative section of the record. The anesthesia record can be used by pharmacists for medication scheduling and therapeutic drug monitoring, assessment of fluid status, evaluation of hemodynamic response to drug and fluid interventions, quality assurance, and drug-use reviews.

Relationship of Productivity Analysis to Departmental Cost-Accounting Systems

Productivity assessment and its relationship to cost-accounting systems (CASs) is described. Hospital pharmacist managers need workload measurement-productivity assessment systems for evaluating their departments' scope of services and their impact on the total cost-quality balance in treating patients. Productivity is measured as the ratio of output (production units) to input (total personnel hours used) during a specified time. "Macro" production units represent a grouping of related tasks that, when combined, identify a service unit (e.g., patient day) or activity (e.g., drug-use review consultation); "micro" production units are derived by weighting macro units on the basis of resource consumption (standard time required). Macro production unit data should reflect both fixed and variable costs and should be easy to obtain. A productivity analysis system may need more than one macro production unit and also some micro production units. Both input and output units should be separated by service category (e.g., distributive, clinical, research) and by personnel category (pharmacist or supportive personnel). ASHP's PharmaTrend workload measurement system fits these criteria and facilitates national and regional comparisons, and data from PharmaTrend reports can be readily incorporated into a CAS. Pharmacy managers can best use workload measurement systems and CASs by observing trends in their ratios and indicator values over time.

Multidisciplinary cost-containment program promoting oral metronidazole for treatment of antibiotic-associated colitis

A multidisciplinary cost-containment program for promoting oral metronidazole in place of oral vancomycin as initial therapy of antibiotic-associated colitis (AAC) is described. The pharmacy department and the division of infectious diseases implemented the program in two phases. In the first phase, a one-year retrospective drug-use review in patients with AAC treated with oral vancomycin was conducted to determine the average cost of therapy per treatment course. In the second phase, the use of oral metronidazole instead of oral vancomycin for initial treatment of AAC was promoted using inservice-education programs and distribution of pocket-size brochures containing AAC treatment guidelines to medical staff. The pharmacy and therapeutics committee supported the program by endorsing metronidazole as the drug of choice for AAC and by distributing follow-up progress reports of the program to medical staff. Pharmacists on the nursing units were responsible for enforcing the program stipulations regarding vancomycin and metronidazole use and for collecting data on patient-specific drug use. Six months after implementation of the program, the average cost of drug therapy for AAC had decreased by 89%, from $343.24 per patient to $37.50 per patient. The projected annual savings resulting from the program was $38,829.02. All prescribing physicians and dispensing pharmacists complied 100% with the program stipulations regarding drug use. The multidisciplinary program described here was successful in promoting the use of oral metronidazole for initial therapy of AAC.

Development and implementation of a comprehensive, criteria-based drug-use review program

A comprehensive drug-use review (DUR) program based on established criteria for use of each drug is described. The DUR program was developed to promote cost-effective drug therapy and satisfy Joint Commission on Accreditation of Hospitals standards for drug-use evaluation. Antibiotic and ambulatory-care drug-use subcommittees composed of physicians, pharmacists, nurses, and clinical laboratory personnel were formed as advisory groups to the pharmacy and therapeutics (P&T) committee. The subcommittees review overall drug-use patterns in their respective areas monthly and investigate the use of specific problem drugs. Drug-use reviews have been facilitated by the implementation of a mandatory antibiotic order form and pharmacy computer systems. Nonformulary drug use is monitored. The procedure for adding drugs to the formulary was modified to require the submission of specific criteria for appropriate drug use; when a drug is added to the formulary, the criteria for use are also adopted. The program has been successful in curtailing inappropriate drug use, reducing drug expenditures, and integrating P&T committee decisions into daily pharmacy practice. The implementation of this DUR program has enabled the P&T committee to conduct ongoing, systematic, criteria-based drug-use evaluations.

Workload measurement of a clinical pharmacy residency program

The types of activities performed by four clinical pharmacy residents and the amount of time spent on each activity were studied using a workload measurement system. A workload measurement system was developed to record all activities performed by pharmacy residents. The system included 50 activities that were grouped under 11 general headings; residents' time was divided among 10 major areas of service. The following data were collected and analyzed each month during the six-month study period: units of work, weighted units of work, total productive hours, total service hours, and productivity. The residents participated in 39 of 50 clinical pharmacy activities. Activities performed most frequently included nursing-home-care-unit drug reviews, drug monitoring, and rounds. The most time-consuming activities were clinical education, administration, and drug-use review. Productivity ranged from 80 to 115% and was influenced by residents' assigned rotations. A workload measurement system for quantifying the time spent by residents performing various clinical pharmacy activities provided objective data that were used to restructure a clinical pharmacy residency program.

Use of explicit criteria and implicit judgments in a drug-use review program

The degree of agreement between implicit and explicit judgments made by a pharmacist in a drug-use review program in an ambulatory-care setting was studied. During a six-month period in 1980, all prescriptions for a group of 19 drugs were reviewed for appropriateness of indication, dosage, and length of therapy by a pharmacist using implicit judgment. The same prescriptions were then reevaluated according to explicit criteria that had been approved by the prescribing physicians. A sample of prescriptions that did not meet either implicit or explicit criteria for use was subjected to review by a committee of four physicians to validate whether these prescriptions were indeed inappropriate. Of the 935 prescriptions evaluated, 36.8% were judged inappropriate by the explicit criteria and 23.5% were judged inappropriate by implicit judgment. The explicit and implicit approaches yielded concordant results for 95.5% of the observations. The proportion of true deviations as validated by the review committee was estimated at 80% for the implicit method and 74.4% for the explicit method. The implicit judgments of a pharmacist appear to be as effective as explicit drug-use criteria for identifying inappropriate prescribing in a drug-use review program. These judgments could be used to increase the efficiency of a drug-use review program when explicit criteria are not available.

Application of drug-use review principles to intravenous administration set use: A preliminary study

A quantitative study of the use of intravenous administration sets in a 556-bed hospital was conducted as a first step in establishing a use-review program for administration sets. Central supply and pharmacy distribution points for i.v. administration sets were identified. Patient use of i.v. administration sets was recorded twice daily for seven-day periods on each of six patient-care units; data for all units were collected within a three-month period. Use of six common administration sets was studied. For each patient-care unit studied, the majority of sets used were of two of the six types; the specific set types differed by unit. More sets were used between the hours of 0801 and 2000. The number of sets per i.v. patient day (one patient receiving i.v. therapy on one day) was greatest in the intensive-care units. Through application of components of drug-use review, the numbers and types of i.v. administration sets used in various patient-care areas were identified.

Microcomputer applications for home health-care services

Principles in selecting a microcomputer system for use in a home health-care (HHC) service and potential applications for an HHC microcomputer system are described. To ensure that the quality of care provided to patients at home is comparable with that provided to inpatients, HHC services must be well organized, provide adequate channels of communication among staff members, and maintain complete and accurate records of the selection, training, therapy, evaluation, and follow-up of all home-therapy patients. A well-designed microcomputer system can increase the efficiency and accuracy with which those goals are met. Selection of a system should be based on the needs of a particular HHC service; factors that should be considered include whether the system will be compatible with other hospital computer systems and whether the majority of users will be able to operate the program easily. Potential applications for an HHC microcomputer system include printing labels for home-therapy products, calculating prices and providing billing data, maintaining prescription files, generating reports for drug-use review, and monitoring inventory levels. By employing an organized approach to the selection and implementation of a microcomputer system for a home health-care service, hospital pharmacists can make an important contribution to improving HHC service operations.

Clinical pharmacy services in Florida hospitals—1984

To ascertain the progress made in the implementation of clinical services in Florida hospitals, a survey conducted in 1977 was readministered in 1984. Questionnaires were sent to the directors of pharmaceutical services of all 256 Florida hospitals. Nine questions on clinical services were identical to the 1977 survey and two additional questions were included on nutritional support services and pharmacokinetic dosing consultations. The directors were also asked if they had conducted studies to document the cost-effectiveness of their clinical pharmacy services. Questionnaires were returned by 75% of the directors. As in the 1977 survey, approximately half of the hospitals had less than 200 beds. Slightly more than 82% of the hospitals had total unit dose systems and about 7% had partial systems, which was considerably higher than the 58% with either total or partial systems found in the 1977 survey. Services such as patient monitoring, inservice education, and drug-use review were being offered substantially more than in 1977. Conducting patient medication histories, attending rounds with physicians, and providing discharge consultations were the least-performed clinical services. The reasons given for not implementing these services were similar in both surveys. However, while the lack of adequately trained pharmacists was frequently cited in 1977, very few respondents cited it as an obstacle in 1984. Several respondents indicated that they had documented cost savings attributable to their clinical pharmacy services. Clinical pharmacy programs are continuing to grow in Florida hospitals; however, pharmacy administrators appear to be having some of the same problems implementing these services as they did previously.

National audit of drug information centers

A comprehensive audit of drug information centers (DICs) was conducted to obtain information on sources of funding, staffing, information resources, computerization, workload, and scope of services and activities and to examine the role of DICs in education, patient care, and research. Responses were obtained from 98 of the 121 DICs surveyed. The scope of activities and services varied considerably between centers and depended on such factors as source of funding, size of institution, academic affiliation, staffing, and workload. Many DICs are involved in writing newsletters, preparing information for pharmacy and therapeutics committee meetings, developing and updating formularies, and providing contract services to other organizations. The patient-care activities of DICs include providing consultations, performing drug-use reviews, monitoring adverse drug reactions, and coordinating investigational drug studies; DICs are also involved in training undergraduate and graduate pharmacy students and residents and conducting research projects. Large workloads and lack of time were cited most often as factors limiting DIC participation in patient-care, educational, and research activities. Because DICs are involved in a wide variety of educational, research, and patient-care activities, more emphasis should be placed on documenting the costs of these services in relation to their benefits to the institution.

Therapeutic drug-use review for the Florida Medicaid program

A program is described in which drug-use review information was provided to prescribers and dispensing pharmacies for the purpose of reducing morbidity related to inappropriate drug therapy. In the Florida Medicaid program, computer-generated medical history profiles were used to identify patients at risk for drug-induced illnesses. Health-care providers were then notified of potential problems with patients' drug regimens and asked for a response. Patient profiles were monitored for changes, and follow-up letters were sent to the health-care providers as warranted. During a nine-month period in 1982-83, drug therapy was changed in 54% of cases after providers were notified of problems. Florida's Medicaid drug-use review program was effective in identifying inappropriate drug therapy that can lead to increased morbidity and higher health-care costs.

The pharmacy computer system at The Ohio State University hospitals

The pharmacy computer system designed, developed, and implemented at The Ohio State University Hospitals is described. The computer system was developed to make more efficient use of hospital facilities and professional staff time. The pharmacy system operates on the mainframe hospital system using computer terminals with light-pen and keyboard access. Current online applications include order entry, patient profiles, pharmacokinetic calculations, and preparation of unit dose cart fill lists. Batch processing functions include drug-use review, drug-drug interactions, and financial management reports. Approximately 95% of unit dose orders and 20% of i.v. orders are conditionally entered by pharmacy technicians for subsequent verification by pharmacists. The system saves considerable staff time in the i.v. admixture and billing areas and has relieved pharmacists from performing many clerical and repetitive tasks. Disadvantages of the system include (1) its dependence on another department for patient admission, transfer, and discharge information and (2) delays in obtaining approval for program modifications and new applications. The advantages of the pharmacy computer system lie in its ability to access information from other computerized databases in the hospital. Future modifications and enhancements to the system are discussed.

Consultant evaluation of a hospital medication system: Synthesis of a new system

Recommendations of consultants for the implementation of a new medication system at a large teaching hospital are described. Based on a previous analysis of the hospital's existing drug distribution and control system that revealed problems in reliability and response time, an interdisciplinary consultant group offered 14 recommendations, which included implementation of a computerized unit dose delivery system and selected clinical pharmacy services. Functions identified for which computerization would produce the greatest benefits included maintenance of patient census data, medication order entry and retrieval, and preparation of a medication administration record for nursing. Recommendations for improving the unit dose system in the hospital consisted of increasing the number of medications packaged in true unit dose form, increasing the frequency of daily deliveries of scheduled medications, sending p.r.n. medications on an on-call basis, decreasing the lead time for preparation of i.v. solutions, and using a pharmacist-manned portable medication cart to reduce workload on the central pharmacy during peak workload periods. Clinical pharmacy services identified as having the greatest cost-benefit ratio were discharge consults, drug therapy monitoring, and drug-use review. Using information from published studies and cost data from the hospital, a net annual savings of over +152,000 was projected with implementation of these services. Improvements in the unit dose system and implementation of clinical pharmacy services were expected to result in substantial cost savings in the study hospital.

Justifying additional pharmacist staff in an era of cost reductions

A proposal is described that justified adding one full-time equivalent (FTE) pharmacist in a 125-bed community hospital that already employed in its pharmacy department 2.5 FTE pharmacists and 5.2 FTE other personnel. The administrative steps taken included identifying the need for an additional staff member and documenting the cost effectiveness of various clinical activities. Literature references were used to justify the proposed ratio of pharmacists to technicians; to show the results of deficiencies in supervision, motivation, and scheduling; and to demonstrate the cost effectiveness of serum concentration monitoring, formulary review, and patient discharge-medication consultations. Results of formulary review, drug-use audits, dosing guidelines, and serum concentration monitoring performed by the pharmacy department were included in the proposal. Prospective drug-use reviews, computerized pharmacokinetic dose determinations, additional educational programs, and tighter purchasing policies were identified as other cost-saving activities that could be performed with an additional pharmacist. A 12-page proposal was submitted in July 1983 to the hospital administrator and the budget review committee, and the additional staff position was approved. The key to maintaining the new pharmacist position will be the continual documentation of cost-saving activities within the department.

Pharmacy management strategies for responding to hospital reimbursement changes

Pharmacy management strategies for responding to hospital reimbursement changes are described. On the assumption that the Medicare prospective pricing system and other fixed-rate reimbursement systems will force hospital pharmacists to reduce their operating expenses, several methods of reducing drug use and drug costs, rather than payroll costs, are described: (1) reduced price per unit purchased, (2) increased use of bid prices, (3) decrease in the size and dollar value of drug inventory, (4) drug formulary restrictions, (5) prescribing sanctions, (6) physician education on the relative costs of alternate therapies, (7) drug-use review, (8) use review applied to drug serum assays, (9) controlled access of drug industry representatives to hospital physicians, and (10) dispensing and drug-distribution efficiencies. Physician resistance to pharmacist intervention in drug prescribing and drug-use review should be anticipated; however, pharmacists should expect the support of hospital administrators in efforts to control drug use.

Evaluation of gentamicin prescribing after drug-use review

Evaluation of gentamicin prescribing after drug-use review

Opportunity for clinical pharmacy in concurrent and prospective drug-use review

Journal Article Opportunity for clinical pharmacy in concurrent and prospective drug-use review Get access Michael H. Stolar, Ph.D Michael H. Stolar, Ph.D ASHP Professional Services Division Search for other works by this author on: Oxford Academic Google Scholar American Journal of Hospital Pharmacy, Volume 39, Issue 6, 1 June 1982, Pages 985–986, https://doi.org/10.1093/ajhp/39.6.985 Published: 01 June 1982