Formulary Management Research Articles

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing--2001.

Results of the 2001 ASHP national survey of pharmacy practice in hospital settings that pertain to prescribing and transcribing are presented. A stratified random sample of pharmacy directors at 1091 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. The response rate was 49.0%. During 2001, nearly all hospitals are estimated to have pharmacy and therapeutics (P&T) committees that meet an average of seven times per year. It is estimated that more than 90% of P&T committees are responsible for formulary development and management, drug policy development, adverse-drug-reaction review, and medication-use evaluation. More than 90% of hospitals use clinical and therapeutic, cost, and pharmacoeconomic information in the formulary management process, while nearly two thirds consider quality-of-life issues. Nearly 70% use clinical practice guidelines in the formulary management process, and 78% have a medication-use evaluation program designed to improve prescribing. Pharmacists in more than 75% of hospitals provide consultations on drug information, dosage adjustments for patients with renal impairment, antimicrobials, and pharmacokinetics. Further, a majority of hospitals ensure accurate transcription of medication orders by clarifying illegible orders before transcription or entry into medication administration records (MARs), using standardized prescriber order forms, requiring prescribers to countersign all oral orders, and reconciling MARs and pharmacy patient profiles at least daily. In 2001, large hospitals are most likely to use prescriber order-entry systems to improve patient safety and are least likely to require the reentry of medication orders into the pharmacy computer system. The 2001 ASHP survey results suggest that pharmacists in hospital settings have positioned themselves well to improve the prescribing and transcribing components of the medication-use process.

Characterization of extended spectrum β-lactamase-producing Klebsiella pneumoniae from Beijing, China

Fourteen clinical isolates of Klebsiella pneumoniae with extended-spectrum β-lactamases (ESBLs) were detected by the double disk synergy test and the Etest ESBL strip. Co-resistances included high MICs for aminoglycosides, fluoroquinolones, tetracyclines, and trimethoprim/sulphamethoxazole. Co-resistance was not observed in five of the 14 strains. These isolates were all genetically distinct as determined by the automated ribotyping method. Isoelectric focusing documented the presence of multiple β-lactamases (one to four per isolate) with pIs ranging from 5.4 to 8.4. The majority of isolates contained β-lactamases with pI values of 7.6 and 8.4 consistent with SHV-type ESBLs and an Amp C enzyme, respectively. Emerging ESBL strains in K. pneumoniae compromise the use of agents such as cefotaxime, ceftriaxone, ceftazidime in China; leading to the expansion of quality infection control practices and formulary management programmes to minimize clonal expansion.

Pharmaceutical cost control in Canada: does it work?

Governments in Canada have instituted mechanisms intended to control drug prices. These include the establishment of a semi-judicial body by the federal government to control factory-gate prices and of various measures at the provincial level, such as formulary management, use of generics, reference-based pricing, price freezes, and limits on markups. To a large extent, these measures have been effective in price control. Total drug spending in the country continues to rise, however; clearly, mechanisms other than price controls will need to be developed if drug spending is to be better managed.

Prevention of pressure damage at the Queen's Medical Centre.

The Wound Management Policy Group is a sub-committee of the Nursing and Midwifery Development Group and has an important role at Queen's Medical Centre, both in providing support to the tissue viability clinical nurse specialist and in providing a multiprofessional perspective on the development and evaluation of policies, protocols, strategies and guidelines in all aspects of tissue viability. The four major recent projects are: the Nottingham Wound Care Formulary and wound management guidelines; the strategy for the prevention and management of pressure damage; the policy and procedure for obtaining pressure-relieving equipment; and the development of group protocols. These projects are described below. The Wound Management Policy Group promotes the use of evidence-based practice across Queen's Medical Centre to ensure the provision of high-quality care in all aspects of wound management.

Prevention and Management of Chemotherapy-Induced Nausea and Vomiting, Part 2

Credit This lesson is good for 0.3 CE units, with a passing grade of 70%. Goal The goal of this program is to inform the participant about cost-effective ways to prevent, identify, and manage nausea and vomiting induced by antineoplastic agents. Objectives At the completion of this program the participant will be able to: 1. List antineoplastic agents associated with a high incidence of nausea and vomiting. 2. Identify patient-specific risk factors for developing chemotherapy-induced nausea and vomiting (CINV) and how these factors may influence treatment of this syndrome. 3. Compare the three major types of CINV, including the pathophysiologic mechanism, time of onset, and symptom duration of each type. 4. Explain the mechanism of action and appropriate place in therapy for each type of antiemetic agent. 5. Differentiate between pharmacologic regimens for the prevention and treatment of CINV in adults. 6. Identify drug-specific factors that must be considered when developing a formulary management strategy for the antiemetic agents. 7. Describe specific information that the pharmacist can share with patients to help them understand and manage CINV.

Prevention and Management of Chemotherapy-Induced Nausea and Vomiting, Part 2

Credit This lesson is good for 0.3 CE units, with a passing grade of 70%. Goal The goal of this program is to inform the participant about cost-effective ways to prevent, identify, and manage nausea and vomiting induced by antineoplastic agents. Objectives At the completion of this program the participant will be able to: 1. List antineoplastic agents associated with a high incidence of nausea and vomiting. 2. Identify patient-specific risk factors for developing chemotherapy-induced nausea and vomiting (CINV) and how these factors may influence treatment of this syndrome. 3. Compare the three major types of CINV, including the pathophysiologic mechanism, time of onset, and symptom duration of each type. 4. Explain the mechanism of action and appropriate place in therapy for each type of antiemetic agent. 5. Differentiate between pharmacologic regimens for the prevention and treatment of CINV in adults. 6. Identify drug-specific factors that must be considered when developing a formulary management strategy for the antiemetic agents. 7. Describe specific information that the pharmacist can share with patients to help them understand and manage CINV.

This CE is published through an unrestricted educational grant from Bristol-Myers Squibb

Credit This lesson is good for 0.2 CE units, with a passing grade of 70%. Goal The goal of this program is to inform the participant of costeffective ways to prevent, identify, and manage nausea and vomiting induced by antineoplastic agents. Objectives At the completion of this program the participant will be able to: 1. List antineoplastic agents associated with a high incidence of nausea and vomiting. 2. Identify patient-specific risk factors for developing chemotherapyinduced nausea and vomiting (CINV) and how these factors may influence treatment of this syndrome. 3. Compare the three major types of CINV, including the pathophysiologic mechanism, time of onset, and symptom duration of each type. 4. Explain the mechanism of action and appropriate place in therapy for each type of antiemetic agent. 5. Differentiate between pharmacologic regimens for the prevention and treatment of CINV in adults. 6. Identify drug-specific factors that must be considered in developing a formulary management strategy for the antiemetic agents. 7. Describe specific information that the pharmacist can share with patients to help them understand and manage CINV.

How to Evaluate and Interpret Outcome Studies

The pharmacoeconomic literature is a vast and powerful source of information for pharmacists and others who must make decisions about services and products. Published studies can provide data quickly and inexpensively, but they may not necessarily meet criteria for quality and may not be generalizable to a specific situation. Guidelines are available that are intended to standardize study methods, minimize potential bias, and increase the comparability and credibility of data. Before relying on a published study, decision-makers should ensure that it meets criteria related to objective, perspective, pharmacoeconomic method, design, interventions, costs, outcomes, discounting, results, sensitivity analysis, extrapolation from conclusions, and sponsorship. A sound study can be used to support decisions in such diverse areas as individual patient treatment, formulary management, drug-use guideline development, disease management initiatives, and pharmaceutical service evaluation. A decision-maker may be able to use the results by applying them at face value, employing a sensitivity analysis, performing a meta-analysis, incorporating the data into a pharmacoeconomic model, or reproducing the study on a smaller scale. The selection of an application strategy should be based on the potential impact of the decision on the quality and cost of care, with more rigorous and complex strategies reserved for more extreme impacts. Published pharmacoeconomic data can help pharmacists make better and more informed decisions about pharmaceutical services and products.

Lipid Clinics as Disease Management Programmes in the United States

Aggressive lipid disorder therapy in both primary and secondary prevention has been shown to reduce progression of coronary heart disease, reduce mortality and clinical events and ultimately reduce healthcare costs. Outpatient cardiac centres, diabetic treatment clinics, multispecialty medical groups, primary care medicine, and health management organisations currently have a unique opportunity to establish cost-effective lipid management programmes. Lipid clinics involve more than drug therapy and formulary management. Lipid clinics fit well within the genre of disease management; they target algorithmically driven therapy to high risk populations using intensive patient education, frequent follow-up and proven behaviour change strategies. Properly planned and organised, lipid clinics significantly enhance therapeutic compliance and lipid goal achievement compared with usual care. Successful lipid clinic operation also requires judicious staffing, sufficient patient volume, efficient referral mechanisms, tracking of outcomes measures, business development skills, and eventual integration with more comprehensive cardiovascular disease risk reduction services. This systematic approach to lipid management and cardiovascular disease risk reduction will afford meaningful opportunities for physician groups and integrated healthcare systems who aspire to reduce the unnecessary burden of premature cardiovascular disease.

Impact of Disease and Health Management Strategies on Formulary Design and Management

Recent changes in the healthcare system have prompted the growth and management of disease and health management strategies in the US. Most of the initiatives include a heavy emphasis on the pharmacotherapy component as it has been noted that effective therapies can lead to improvement in care and in some cases lower overall healthcare costs.

Formulary management of low molecular weight heparins.

Low molecular weight heparins (LMWHs) are increasingly being utilised as anticoagulants in healthcare settings. These agents offer several advantages over standard unfractionated heparin. Indications for LMWHs include deep vein thrombosis and pulmonary embolism prophylaxis, deep vein thrombosis treatment, use in coronary procedures associated with a high risk for bleeding, and in acute coronary syndromes. Prior to being added to formularies, LMWHs should be evaluated for efficacy, safety and economic benefits over other anticoagulants. Institutions should be prepared to conduct their own economic assessments in the absence of readily available studies. There is clear evidence that LMWHs are cost saving or are at least cost effective as thromboprophylactic agents in major orthopaedic surgery. The economic benefits of LMWHs in other surgical situations is less clear. Consistent evidence from several countries indicate that LMWHs are cost saving as anticoagulants for the initial treatment of DVT. Further studies are needed to evaluate the efficacy, safety and economics of LMWHs in other conditions besides hip and knee arthroplasty and general surgery.

Applied pharmacoeconomics: evaluation and use of pharmacoeconomic data from the literature.

The evaluation and use of published pharmacoeconomic data are discussed. The pharmacoeconomic literature is a vast and powerful source of information for pharmacists and others who must make decisions about services and products. Published studies can provide data quickly and inexpensively, but they may not necessarily meet criteria for quality and may not be generalizable to a specific situation. Guidelines are available that are intended to standardize study methods, minimize potential bias, and increase the comparability and credibility of data. Before relying on a published study, decision-makers should ensure that it meets criteria related to objective, perspective, pharmacoeconomic method, design, interventions, costs, outcomes, discounting, results, sensitivity analysis, extrapolation of conclusions, and sponsorship. A sound study can be used to support decisions in such diverse areas as individual patient treatment, formulary management, drug-use guideline development, disease management initiatives, and pharmaceutical service evaluation. A decision-maker may be able to use the results by applying them at face value, employing a sensitivity analysis, performing a meta-analysis, incorporating the data into a pharmacoeconomic model, or reproducing the study on a smaller scale. The selection of an application strategy should be based on the potential impact of the decision on the quality and cost of care, with more rigorous and complex strategies reserved for more extreme impacts. Published pharmacoeconomic data can help pharmacists make better and more informed decisions about pharmaceutical services and products.

Formula to help select rational antimicrobial therapy (FRAT): its application to community- and hospital-acquired urinary tract infections

The selection of antimicrobial agents is guided by the use of formularies which often constrain prescribing options. There are several factors which influence the inclusion of specific agents. Two of the most important factors are microbial etiology of a disease and the incidence of antibiotic resistance. Various surveillance programs have highlighted the regional differences in antimicrobial susceptibility/resistance among various pathogens. This simple formula enables individual physicians, pharmacy and therapeutic committees and managed care formulary managers to harness local etiology and susceptibility information. In this paper the formula is applied to community- and hospital-acquired urinary tract infections.

Reply

We appreciate the comments of Dr Peets because they enable us to address and reiterate important issues raised in our article, “Nondermatologists Are More Likely than Dermatologists to Prescribe Antifungal/corticosteroid Products: An Analysis of Office Visits for Cutaneous Fungal Infections, 1990-1994.”1Smith ES Fleischer Jr, AB Feldman SR. Nondermatologists are more likely than dermatologists to prescribe antifungal/corticosteroid products: an analysis of office visits for cutaneous fungal infections, 1990-1994.J Am Acad Dermatol. 1998; 39: 43-47Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar The data clearly documented that nondermatologists prescribe combination corticosteroid/antifungal agent therapy more commonly than do dermatologists. Dr Peets questions an assumption of our analysis, that single agents are more cost-effective than combination products. We must address this point because our conclusion, that dermatologists may be more cost-effective than nondermatologists for simple skin problems, is based on this premise. In addition to the references cited in our article, the citations provided by Dr Peets support our conclusion. In two of the studies, single-drug agents exhibited greater antifungal efficacy than the combination product, and they are of lower cost.2Evans EGV James IGV Seman RAJ Richardson MD. Does naftifine have anti-inflammatory properties? A double-blind comparative study with 1% clotrimazole/l% hydrocortisone in clinically diagnosed fungal infection of the skin.Br J Dermatol. 1993; 129: 437-442Crossref PubMed Scopus (39) Google Scholar, 3Katz HI Bard J Cole GW Fischer S McCormick GE Medansky RS. SCH 370 (clotrimazole-betamethasone diproprionate) cream in patients with tinea cruris or tinea corporis.Cutis. 1984; 34: 183-188PubMed Google Scholar In one of the citations, the mycologic cure rate of betamethasone diproprionate/clotrimazole was only 65%.3Katz HI Bard J Cole GW Fischer S McCormick GE Medansky RS. SCH 370 (clotrimazole-betamethasone diproprionate) cream in patients with tinea cruris or tinea corporis.Cutis. 1984; 34: 183-188PubMed Google Scholar By contrast, monotherapy antifungal agents including topical naftifine, econazole, and terbinafine provide reported cure rates of 80% to 83% for tinea corporis and tinea cruris.4Millikan LE Galen WK Gewirtzman GB Horwitz SN Landow RK Nesbitt Jr, LT et al.Naftifine cream 1% versus econazole cream 1% in the treatment of tinea cruris and tinea corporis.J Am Acad Dermatol. 1988; 18: 52-56Abstract Full Text PDF PubMed Scopus (38) Google Scholar, 5van Heerden JS Vismer HF. Tinea corporis/cruris: new treatment options.Dermatology. 1997; 194: 14-18Crossref PubMed Scopus (13) Google Scholar Aside from clinical trials, we dermatologists regularly see the patients in whom combination products fail as treatment of tinea. We also see patients in whom atrophy develops from inappropriate use of this product.6Fleischer Jr., AB Lotrisone: a negative report.Schoch Lett. 1993; 11Google Scholar These personal experiences are supported by the findings of our study showing that dermatologists choose single agents at 96% of the visits for common fungal infections. Because dermatologists can diagnose common fungal disorders accurately and decisively, they are able to prescribe these cost-effective measures. Because other specialists do not have this special expertise, they must rely on less effective, less safe, and more costly treatment. Dr Peets cites data from a Schering-sponsored study suggesting that “cost savings for follow-up care of patients receiving the combination drug offset the higher initial costs of treatment.” The investigation by Thompson, Schultz, and Oster 7Thompson D Schultz N Oster G. Comparative antifungal therapy: outcomes and costs.J Formulary Management, P and T. 1994; 19: 790-795Google Scholar has several weaknesses. First, the study compares betamethasone diproprionate/clotrimazole primarily to miconazole and clotrimazole, which are not as efficacious as newer antifungal agents. Next, this study did not limit the analysis to the treatment of tinea. Betamethasone diproprionate/clotrimazole is widely used to treat inflammatory conditions. The National Ambulatory Medical Care Survey (1990-1994) estimates that the most common diagnosis treated with Lotrisone (clotrimazole-betamethasone dipropionate) was contact dermatitis, accounting for 798,005 physician visits (12.3% of all use). The next most frequent diagnosis for which this agent was used, tinea corporis, accounted for 388,650 visits (6.0% of total use). Thus, to compare the cost of combination antifungal/corticosteroid treatment with the cost of antifungal monotherapy, without controlling for the diagnoses being treated, is scientific poppycock. Despite its weaknesses, the study of Thompson, Schultz, and Oster advances our thesis that dermatologists are more cost effective because, in addition to our finding that dermatologists prescribe more cost-effective drug therapy, the Thompson group demonstrated fewer required follow-up visits when therapy was initiated by dermatologists. Because dermatologists understand the cost-effectiveness of products for the treatment of tinea, and because they can make the diagnosis of tinea with certainty, they are able to choose the most cost-effective agent. Physicians and the public need to be aware of the special expertise offered by dermatologists, expertise that makes a discernible difference, even for patients with common, “simple” skin disorders.

Activities, functions, and structure of pharmacy and therapeutics committees in large teaching hospitals.

The results of a survey on the activities and functions of hospital-based pharmacy and therapeutics (P&T) committees are presented. Questionnaires were mailed to the pharmacy director or the person responsible for the pharmacy's drug information service at 267 teaching hospitals throughout the United States in 1994 and 1995. The survey questions covered P&T committee composition, functions, roles of members, policies and procedures, and formulary-maintenance activities. The overall response rate was 70%. The mean number of members on the P&T committees was 19.3, of whom 91% were allowed to vote. There was an average of 12.3 physicians on the committees. Each P&T committee had at least one pharmacist member, with an average of 3.2 pharmacist members; 69.5% of the institutions reported having a committee secretary, who was almost always a pharmacist. On almost all committees, pharmacists wrote the minutes, prepared the formulary review documents, and were responsible for monitoring formulary activities outside the meeting. The P&T committee functioned in a very formal manner. Most (87.7%) of the respondents reported that their institutions had a closed formulary. At all hospitals, the attending medical staff could request additions to the formulary, but at only 62.4% of the hospitals could pharmacy staff make a similar request. The committees were active in changing the formulary. P&T committees in large teaching hospitals are active in formulary management, are large and diverse, and consist mainly of physicians, although pharmacists play an important role in the meetings.

Understanding attitudes about biotechnology drugs

The fruits of biotechnological research are having a growing impact on the pharmaceutical market. However, a recent study found that doctors don’t apply the same decision-making process to biotechnological products as they use for conventional pharmaceuticals. The study suggests that understanding these differences could help purchasers and prescribers work together to optimise outcomes when using biotechnology drugs. For example, formulary management strategies for biotechnological products should place greater emphasis on clinical and humanistic outcomes than cost.

ASHP national survey of pharmacy practice in acute care settings: prescribing and transcribing--1998. American Society of Health-System Pharmacists.

Results of the 1998 ASHP national survey of pharmacy practice in acute care settings that pertain to prescribing and transcribing practices are presented. Pharmacy directors at 1058 general and children's medical-surgical hospitals in the United States were surveyed by mail. Data on hospital characteristics were supplied by SMG Marketing Group, Inc.; the survey sample was drawn from SMG's hospital database. The response rate was 51.8%. Respondents reported that at least 90% of hospital and health-system pharmacy and therapeutics (P&T) committees are responsible for formulary development and management, drug policy development, medication-use evaluation, adverse-drug-reaction reporting, and medication error monitoring. More than 90% of the facilities use pharmacoeconomic, clinical and therapeutic, and cost information in formulary development; 83% have a medication-use-evaluation program designed to improve prescribing; more than 95% have P&T committees, infection control committees, and quality control committees; and more than 80% provide pharmacist consultations on drug information, dosage adjustments for patients with renal impairment, antimicrobials, and pharmacokinetics. A majority of respondents reported that accurate transcription of medication orders is ensured by use of standardized physician order forms, clarification of illegible orders, reconciliation of medication administration records (MARs) and pharmacy profiles at least daily, and use of computer-generated MARs. The 1998 ASHP survey results suggest that pharmacists in acute care settings have positioned themselves well to improve the prescribing and transcription components of the medication-use process.

Rational pharmacotherapy in The Netherlands: formulary management in Dutch hospitals.

A survey regarding the management of rational pharmacotherapy was conducted among all Dutch general hospitals in 1998. The response was 99% (n = 120). The presence of a drugs and therapeutics committee and antibiotic policies in Dutch general hospitals appears independent of hospital characteristics. However, formulary agreements and treatment guidelines are less likely to be present in hospitals that employ only 1 pharmacist or those served by community pharmacies. More than half of the hospitals claim to have restrictive formulary agreements. Large hospitals, hospitals in the eastern and southern provinces and those served by hospital pharmacies more often tend to have restrictive agreements compared to small hospitals, hospitals in the northern, central, and western provinces, and those served by community pharmacies. Various methods to impose restriction and ensure formulary compliance are mentioned. It must be noted that hospitals tend to operate rather solely regarding the large number of different formularies. Surprisingly just a small majority of pharmacists evaluates formulary agreements positively as a management tool. Many drawbacks appear to be present. The results of this survey indicate that in the future Dutch hospitals will favour disease management (treatment guidelines) over drug management (formulary agreements) in the management of rational pharmacotherapy and that information technology will be used to influence clinicians' prescribing behaviour.

Formulary management of proton pump inhibitors.

The management of dyspepsia has been radically altered by the discovery of the role of Helicobacter pylori and the advent of proton pump inhibitors (PPIs). The use of PPIs alone as antisecretory agents and as part of triple therapy regimens for H. pylori eradication accounts for a significant percentage of any healthcare system's drug budget. Thus, it is important to take into account a variety of factors when devising a formulary and considering which PPIs to include. Consideration of 3 factors are particularly crucial in this process, namely therapeutic efficacy, tolerability and cost but several other clinical and economic parameters should also be considered. The mechanisms of action of all 4 PPIs currently available (omeprazole, lansoprazole, pantoprazole and rabeprazole) are very similar, with any small differences in pharmacological properties unlikely to be of clinical significance. Therapeutic efficacy in patients with acute reflux oesophagitis is again very similar for all 4 PPIs at their standard dosages; all agents are superior to H2-antagonists. Data on maintenance therapy for reflux oesophagitis also suggest similar efficacy for omeprazole and lansoprazole; data on pantoprazole and rabeprazole are awaited. For the treatment of H. pylori-related ulcers, the consensus at present is for PPI-based triple therapy. Again, all PPIs seem equally efficacious for this indication but pantoprazole and rabeprazole have yet to receive licences for H. pylori eradication therapy (HPET) in most countries. Drug tolerability is another critical issue to consider in formulary inclusion decisions. As a class, the PPIs are well tolerated. Minor drug interactions are reported for omeprazole, lansoprazole and rabeprazole but not for pantoprazole. However, whether or not this is significant in clinical practice is open to debate. Most of the pharmacoeconomic data in these indicators, to date, relate to omeprazole and, to a lesser extent, lansoprazole. Certainly, the studies on these 2 drugs confirm the superior cost effectiveness of PPIs over H2-antagonists in the treatment of reflux oesophagitis and peptic ulceration in both the short and long-terms. Although data are awaited, there is no reason to suggest that this will be any different for pantoprazole and rabeprazole. PPI-based triple therapy for H. pylori eradication appears to be the most cost-effective treatment option for H. pylori-related peptic ulcer disease. It is clear that PPIs are superior in several regards to previously used medications in the treatment of dyspepsia. Which PPI(s) to include in a particular formulary is a more difficult decision. On review of many criteria involved in formulary decisions, differences between the individual PPIs appear minimal. The relative acquisition costs of the PPIs vary nationally and internationally and this may be a critical factor in formulary inclusion decisions. However, one should not ignore non-economic factors, as these should form the basis of any sound drug policies.

A US Military Perspective

This paper discusses lipid therapy decision-making at the population level within the United States (US) Military Health Services System. The US Military Health Services System serves approximately 8.2 million beneficiaries fairly representative of the general population. Of its $680 million annual pharmacy expenditure, $45–$50 million is spent on lipid-lowering drugs. The military Medical Treatment Facilities (MTF) carry a Tri-Service Drug Formulary list, which serves as a bare minimum to which individual facilities may add other agents. The Department of Defense Pharmacoeconomic Center (PEC) performs cost-effectiveness analyses, establishes the Tri-Service Drug Formulary list and the National Mail Order Pharmacy formulary list, and provides drug treatment guidelines. Hyperlipidemia treatment guidelines published by the Pharmacoeconomic Center in 1995, which recommend the use of niacin, colestipol, and pravastatin, are currently under revision to take into consideration new drugs and new information in the field of lipid-lowering therapies. Future changes to the MTF outpatient formulary management may include the introduction of a Basic Core List of essential agents and a Master Pharmaceutical Agent List comprising the only drugs from which facilities may choose to add to their Basic Core List. These changes are designed to standardize drug availability across military facilities to leverage market share for lower drug prices.