Formulary Recommendations Research Articles

Review of lidocaine plaster prescribing and monitoring in primary care

Abstract Introduction Lidocaine medicated plasters (LMPs) are accepted by the Scottish Medicines Consortium (SMC) for restricted use in post-herpetic neuralgia where first-line therapies are ineffective or intolerable.[1] Subsequently, LMPs are restricted for use in post-herpetic neuralgia within a large NHS board with Ralvo as formulary brand due to cost-effectiveness. Despite this, the spend on LMPs is increasing with the cost per 1000 list size above the national average.[2] Aim To review and improve LMP prescribing and monitoring in a general practice. Methods An audit within a GP practice was undertaken by conducting an EMIS search to extract all patients prescribed LMPs within the previous 6 months from December 2022. A baseline audit was completed to determine compliance against the criteria (standards set as 100%), shown in Table 1. Data were analysed using Microsoft Excel. In the interest of improving audit results, a pharmacist then conducted telephone reviews with a view to stopping LMP if appropriate, reducing prescription quantities and/or switching to Ralvo. Post review, criteria were re-audited to determine the impact. Following this, an education session was conducted. Results The results against the standards are shown in Table 1. The LMP reviews resulted in: therapy stopped (n=2; 8%), therapy reduced (n=7; 26%), therapy continued (n=11; 40%), and therapy removed from repeat (n=7; 26%). Reductions were achieved by reducing the number of patches, cutting patches or increasing the patch-free interval. Some patients continued therapy despite off-license indication due to a significant reduction in pain score and benefit in physical function. Following the audit and review of LMP, an informal general practitioner education session was conducted to promote adherence to formulary and SMC recommendations, aiming to prevent LMP initiation for off-license indications. Impact was not studied. Conclusion There is a lack of compliance with SMC and formulary recommendations with all patients in this study being prescribed LMPs for off-licensed indications. Pharmacy involvement in regular reviews could ensure patients are prescribed the most cost-effective brand and ongoing treatment appropriateness assessed, particularly for off-license indications. The study was implemented in one general practice; therefore, there is scope for extrapolation across the National Health Service board with aims to reduce LMP prescription costs and medication burden. Further work is also required to achieve a change in prescribing habits.

Randomized control trial on impact of clinical pharmacist led interventions on antibiotic stewardship program in children 0 to 18 years age in a tertiary care hospital in southern India

A prospective randomized controlled interventional study was conducted at a quaternary care multispecialty hospital in South India with the primary objective of identifying opportunities to improve antibiotic prescribing patterns in neonates, children, and adolescents. The hospital has a robust clinical pharmacist program wherein antibiotic prescriptions were checked for appropriateness of antibiotic dose, route, formulation, duration of therapy, and IV to oral switch. These characteristics of antibiotic use were therefore similar in the 75 children in the control and 75 in the intervention group. The additional clinical pharmacist interventions analyzed in this study included checking if a provisional diagnosis had been made before initiating antibiotics, ensuring that appropriate cultures were sent before starting antibiotics, time taken to optimize antibiotic therapy in accordance to the culture sensitivity report and whether the indication for antibiotics use was as per Indian Acdemy of Pediatrics (IAP) Drug Formulary recommendations. The main outcomes were that all these parameters except the first (all children had a clinical diagnosis before initiating antibiotic/s) were better in the intervention group and there was a significant reduction in the total antibiotic days, an increase in antibiotic-free days, and an improvement in the appropriateness of duration of antibiotic therapy and frequency of the antibiotic dosing. However, since the incidence of severe sepsis was higher in the intervention group, broad-spectrum and restricted antibiotics were used, and thus treatment costs were higher in this group. The results indicate that despite already existing clinical pharmacist interventions, additional ones could further improve antibiotic prescription accuracy significantly; and re-emphasized the need to employ trained pediatric general and subspecialty clinical pharmacists in sufficient numbers to implement a successful pediatric antibiotic stewardship program in a hospital.

Assessment of Antibiotic Resistance Patterns of Bacterial Pathogens Isolated from Blood Culture Specimens at Livingstone University Teaching Hospital in Zambia

Background. Bloodstream infections (BSI) are of public health concern because they are usually associated with high fatality rate if therapy is delayed. A combination of these infections with antibiotic resistance increases healthcare costs. In this study, microorganisms identified from blood cultures at Livingstone University Teaching Hospital (LUTH) between 2019 and 2021 were evaluated for their antibiotic resistance patterns. Methods: This was a single-centre laboratory based retrospective study. Data on isolated organisms from electronic laboratory system generated reports at LUTH microbiology laboratory for a period of 3 years, was analysed with SPSS version 20. Results: A total of 765 specimens were processed and only 331 (43.3%) met the inclusion criteria. Of the 331 specimens, 61.3% and 38.7% were collected from female and male patients, respectively whereas 65.9% came from out-patient departments and 34.1% from in-patient departments. The commonest bacteria isolate was Escherichia coli (27.2%) followed by Enterobacter agglomerans (22.7%), Klebsiella pneumoniae (13%), Klebsiella oxytoca (6.3%), Enterobacter aerogenes (5.4%), Enterobacter cloacae (5.4%), Citrobacter freundii (4.8%), Serratia marcescens (3.6%), Proteus mirabilis (3.3%), and Staphylococcus aureus (2.7%). Of the common utilized antibiotics, ampicillin (92.9%) was the least effective drug followed by co-trimoxazole (82.7%), nalidixic acid (68.3%), penicillin (66.7%), tetracycline (63.5%), and chloramphenicol (50.3%), while imipenem (15.4%), norfloxacin (35.3%), and nitrofurantoin (38.8%) were the most effective. The patient's gender and hospital location may have an impact on antibiotic resistance. Conclusion: The most common bacterial pathogens were Gram-negative Enterobacteriaceae that showed increased resistance to various classes of commonly used antibiotics at LUTH but with low resistance to imipenem. Due to the observed multidrug resistant pathogens for BSI, it is cardinal for healthcare facilities to monitor bacteria resistance patterns regularly and encourage the prudent use of antibiotics. However, antibiotic selection for susceptibility testing should be based on the Clinical and Laboratory Standards Institute (CLSI) and Zambia National Formulary (ZNF) recommendations to only test antibiotics1r for BSI instead of those recommended for other infections like urinary tract infections (e.g., tetracyclines).

The Impact of Clinical Pharmacy Services on Direct Oral Anticoagulant Medication Selection and Dosing in the Ambulatory Care Setting

Background: Off-label dosing of direct oral anticoagulants (DOACs) is both common and associated with adverse patient outcomes. Evidence describing best practices to support optimal direct oral anticoagulant (DOAC) dosing is limited. Objective: To describe the impact of clinical pharmacist intervention on DOAC prescribing. Methods: This retrospective study was a descriptive analysis conducted within an integrated healthcare system with a centralized, pharmacist-led Anticoagulation Management Service (AMS). Patients prescribed a DOAC between January 1, 2020 and December 31, 2020 were included. Pharmacy dispensing reports were generated for pharmacist review and anticoagulant drug therapy changes were recommended to physicians where appropriate. The primary objective was to describe the number and type of recommendations made. Secondary objectives were to determine the provider acceptance rate based on the intervention type and on clinical vs formulary recommendations. Results: Clinical pharmacists made 147 recommendations for 2331 unique patients included in the analysis. Twenty-three recommendations (16%) were to decrease the dose, 46 (31%) were to increase the dose, 14 (10%) were to change the medication due to clinical scenario, 62 (42%) were to change the medication due to cost, and 2 (1%) were another issue. One hundred twenty-three (84%) recommendations were accepted. The provider acceptance rate was similar for clinical and formulary recommendations (85% and 82% respectively). Conclusion: Implementation of report-driven clinical pharmacist intervention led to an improvement in appropriate DOAC medication selection and dosing.

The (Re)Tired Geriatrician

The (Re)Tired Geriatrician

Monitoring QTc in Pediatric Patients Who Receive Low Dose IV Haloperidol in the PACU for Post-operative Nausea and Vomiting (PONV)

<h3>Introduction</h3> Current pediatric PACU practice administering low dose IV haloperidol for post-operative nausea and vomiting (PONV) unresponsive to other interventions for specific pediatric populations varies by anesthesia team. <h3>Identification of the problem</h3> Anecdotally, low dose haloperidol had been used safely in pediatric PACUs. Formulary recommendations for intensive monitoring were based on higher dose haloperidol used for the treatment of psychosis and the potential for QTc prolongation. <h3>QI question/Purpose of the study</h3> To clarify the magnitude of both QT prolongation and therapeutic benefit for PONV in pediatric PACU patients given low dose haloperidol. Those data would inform potential changes to the hospital formulary to differentiate guidelines for low dose IV haloperidol in the PACU from higher dose haloperidol used for psychiatric intervention. <h3>Methods</h3> An interdisciplinary QI project was developed to provide evidence to support proposed changes in the formulary. Data were collected over a six month period including pre- and post-haloperidol administration QTc and BARF scores. Descriptive statistics were used to analyze this data. <h3>Outcomes/Results</h3> During the project period, pre therapy QTc was 430±43msec (range 480-355) with heart rates of 82±16. Two patients had dosing deferred because of clinical QTc ≥ 480 (N=29). Post treatment QTc readings had an average increase of 2±22 msec, with 1 ECG exceeding the QTc cutoff of <490 only on post hoc review. Post-hoc cardiology review measured comparable or shorter QT measurements in 17 (59%) patients, and only 1 had a clinically relevant increase in QTc (3%). Average BARF scores dropped from 7 to 1. No further vomiting occurred in 80% of patients who received IV haloperidol for PONV not responsive to other medications. <h3>Discussion</h3> It is critical for nurses to question and evaluate practice using evidence based guidelines and quality improvement methodology. <h3>Conclusion</h3> Low dose IV haloperidol is effective at limiting PONV and has a low incidence of QT prolongation. The high monitoring environment of a pediatric PACU suggests that it can be used safely in that setting for select populations. <h3>Implications for perianesthesia nurses and future research</h3> This work resulted in developing evidence based changes to the formulary that are consistent with clinical practice. Further research is needed to determine if low-dose haloperidol can be administered safely for a younger population.

Does digoxin cause more harm than good?

Background: The most recent British National Formulary recommends digoxin therapy for patients with heart failure (HF) and/or supraventricular arrhythmias, particularly atrial fibrillation (AF) and atrial flutter. The positive inotropic and negative chronotropic effects of the drug are undoubtedly desirable when managing these conditions, yet the use of digoxin is decreasing in popularity among prescribers. Aim: The aim of this literature review is to evaluate the use of digoxin for treating HF and/or AF. It will highlight the benefits of digoxin as well as its potential risks. These should be considered by all prehospital staff when assessing patients who are prescribed digoxin. Conclusions: Digoxin has shown positive outcomes for reducing hospital admissions for patients with HF and/or AF. However, clinicians should be aware of the narrow therapeutic index, which results in a high incidence of digoxin toxicity. The adverse effects of digoxin use should be considered during prehospital assessment, inclusive of pro-arrhythmic and thromboembolic complications. Whether digoxin may result in harm depends on the age, underlying pathology and renal function of each individual patient.

Prescribing opioids in general practice

In this scenario you are working as a practice nurse in a large GP practice. Your local formulary recommends morphine as the first line strong opioid analgesic. Your practice pharmacist has analysed your prescribing data to check whether prescribing is in accordance with the formulary. The analysis reveals that the practice is prescribing a large proportion of non-formulary or second line strong opioids. In the average UK practice, morphine makes up 30% of all strong opioids prescribed. In your practice, it makes up just 20% of all strong opioids prescribed. Your pharmacist has identified a list of 50 patients on non-formulary or second line strong opioids, all for chronic pain

The Impact of National Formulary on Cough Medicine Prescribing in Three Primary Health Care in Depok

: Objective: To evaluate the use of cough medicine in Acute Respiratory Infections (ARI) patients in three primary health care in Depok in 2015 and suitability with the National Formulary. Method: The study design was descriptive analytic with retrospectively data collection from patient’s prescription, Primary Health Care Management Information System (SIMPUS), and Medicine Management Information System (SIPO). Samples are taken from ARI’s patients prescription from January until December 2015. The analysis was conducted on the prescription that meets the inclusion criteria quantitatively and qualitatively. Quantitative analysis is expressed in DDD and DDD/1000 patients/day. Results: The primary health care that has the biggest quantity of Medicines usage for DDD was in Cipayung (59136, 33g). Then, DDD/1000 patients/day for glyceryl guaiacolate, ambroxol, and dextromethorphan respectively was in Cipayung (14.971g), Limo (1.129 g), and Limo (0,0006g). The primary health care that most suitable with the National Formulary was Conclusion: In conclusion, all the cough medicine use in ARI patients in the three primary health care facilities in Depok in 2015 was unsuitable according to the National Formulary recommendations. Therefore, cough medicine use is needed to be evaluated further.Key words: ATC/DDD, Cough, Cough medicine, Depok Primary Health Care, National Fomulary.

VP208 Informing An Economic Model For Hyperhidrosis: A Clinical Survey

INTRODUCTION:Hyperhidrosis is characterized by uncontrollable excessive sweating, which occurs at rest, regardless of temperature. As part of a wider study exploring the clinical and cost effectiveness of alternative treatments for primary hyperhidrosis, a survey of United Kingdom (UK) dermatologists was conducted to gain a better understanding of current clinical practice in the area and inform economic model inputs.METHODS:The survey was conducted by means of an online survey tool, “Qualtrics”. It was circulated to members of the British Association of Dermatologists. Topics covered included treatments typically administered, medication dosages prescribed, effectiveness of treatments, adverse events related to treatments and resource use associated with individual treatments.RESULTS:Forty-five respondents from forty-two different dermatology units completed the survey. The majority of clinicians (83 percent) prescribed more than one medication - most commonly oxybutynin and propantheline bromide. The next most commonly reported treatments were: iontophoresis, botulinum toxin and curettage.Respondents were asked to indicate dosage, frequency and details about follow-up visits related to medication use. Doses prescribed were largely consistent with British National Formulary (BNF) recommendations. For other treatments, dermatologists were asked to indicate duration of the procedure, job title of the treatment provider and details about monitoring visits. Results were similar to the findings from the literature and previously conducted interviews with clinicians.Respondents were asked to indicate the dropout rates for each type of treatment due to lack of effectiveness and adverse events. Dropout rates were relatively high for both reasons.CONCLUSIONS:The results highlight the wide range of treatments for hyperhidrosis currently administered by dermatologists across the UK, and the variation in current clinical practice. This variation highlights the lack of evidence-based guidance underpinning practice and the importance of clinical surveys as a complement to usual data collection methods.

BNF Recommendations for the Treatment of Wernicke's Encephalopathy: Lost in Translation?

We have written extensively about the diagnosis and treatment of Wernicke's encephalopathy (Thomson et al ., 2008, 2009) highlighting the need for prompt treatment with intravenous thiamine. We are concerned that recent British National Formulary (BNF) recommendations are not clearly written and risk causing confusion and delay in the treatment of patients with this disorder, which is potentially reversible if treated appropriately. Recent NICE clinical guidelines on alcohol-use disorders (CG 100 and 115, NICE 2010, 2011) set out clear recommendations regarding the use of thiamine in the urgent treatment of suspected Wernicke's encephalopathy. Clinical Guideline 100 recommended that thiamine be given in doses ‘toward the upper end of the BNF range’ and that it should be given ‘parenterally’. This NICE guideline was published in June 2010, so it is likely that it was referring to what was written in BNF 58 (September 2009). BNF 58 did not specifically outline the treatment of suspected Wernicke's encephalopathy. It recommended …

The US Food and drug administration: drug information resource for formulary recommendations.

The U.S. Food and Drug Administration (FDA) is the regulatory agency responsible for approving all pharmaceutical products marketed in the United States. While the FDA does not conduct research for developing pharmaceutical products, the agency does review all of the scientific evidence that a pharmaceutical sponsor submits and ensures that it demonstrates U.S. regulatory standards for the product and meets approval requirements. To provide insights, for the managed care pharmacist, into the agency's decision-making process and into the recommendations for appropriate usage and regulatory recommendations for risk mitigation by pharmaceutical sponsors. The FDA website contains a vast amount of clinically useful and meaningful information. This review focused on specific topics within the website that can be useful for the managed care pharmacist, including the following: (a) the FDA's review and evaluation of new drug applications (NDA), supplemental new drug applications (s-NDA), and biological new drug applications (BLA); (b) materials regarding a therapeutic product presented to a public FDA advisory committee meeting; and (c) the postmarket requirements and commitments database that provides information on the studies that a sponsor must conduct to maintain a product's approval for marketing in the United States. This review examined the drug information contained on the FDA's website and summarized the FDA's medical and technical review, analysis and decision processes. Detailed drug information provided to the FDA by the pharmaceutical sponsor demonstrating a product's efficacy and safety is publically available upon the product's approval. For the managed care pharmacist involved with formulary review and recommendations, the FDA's website contains information that is available to provide insight into the agency's evaluation process and decision making for marketed pharmaceutical products. Use of these materials and understanding the regulatory context under which medical products are reviewed and approved may assist managed care pharmacists in making informed recommendations for use of the products within the context of their health systems.

Navy Commander helps military patients near and far

The Department of Defense (DoD) Pharmacoeconomic Center is a hive of buzzing activity and a melting pot of various health care personnel from the U.S. Army, U.S. Navy, U.S. Air Force, U.S. Public Health Service, DoD civil servants, and private contractors. Located in San Antonio and operating within the Military Health System, pharmacists at the center, affectionately dubbed the PEC, manage numerous facets of a world-class pharmacy benefit program. From helping deployed patients in remote locations, to analyzing a wealth of pharmacy and medication data, to overseeing a standardized formulary that stretches across three points of care, the PEC is a diverse environment for pharmacy practice.

Wash &amp; go – but with what? Skin antiseptic solutions for central neuraxial block

Wash &amp; go – but with what? Skin antiseptic solutions for central neuraxial block

Variability of antimicrobial prescribing in patients with acute cellulitis

Clinical guidelines concerning treatment of infection are incorporated into prescribing formularies and antimicrobial stewardship policies. The extent to which these influence prescribing is uncertain. In this study, we sought to examine antimicrobial prescribing patterns in patients with cellulitis. Consecutive adults admitted to hospital due to acute cellulitis between 2008 and 2010 were studied. Data collected were clinical and laboratory markers of sepsis, antimicrobial agent, route of administration, number of i.v. dosages, duration of antimicrobial treatment, and hospital length of stay. Three groups were defined by prescribing that was (i) identical to formulary, (ii) modified appropriately due to microbiological data or prior drug allergy, and (iii) nonformulary prescribing. Comparisons were made between groups using Mann-Whitney tests. There were 306 patients: 167 men (54.6%), median age 66 (range 18-100) years. Prescribing was consistent with formulary recommendations in 253 (82.7%), modified appropriately in 24 (7.8%), and nonformulary in 29 (9.5%). Median [interquartile range (IQR)] duration of hospital stay was 5 (3-8), 7 (5-9, P = 0.026), and 7 (5-14, P = 0.0006) days, and overall duration of antimicrobial therapy was 12 (9-16), 13 (8-15), and 15 (12-19, P = 0.0479) days, respectively. No differences were observed in clinical or laboratory markers of sepsis. Prescribing patterns accorded with prevailing guidelines in the majority of patients. Nonetheless, there was nonformulary prescribing in 10% of patients, and this could not be explained by clinical or laboratory measures of disease severity. Further work is needed to explore the factors that contribute to nonformulary prescribing in this group of patients.

Compliance with gentamicin guidelines at Lewisham Hospital

ObjectivesTo determine the proportion of patients:▶receiving the recommended dose of gentamicin (based on most appropriate guideline)▶having first blood levels of gentamicin measured and recorded at correct date/time▶having details completed on...

Dysrhythmias associated with cocaine overdose

Dysrhythmias associated with cocaine overdose

Efungumab: A Novel Agent in the Treatment of Invasive Candidiasis

To review the use of efungumab as an adjunctive agent in the treatment of invasive candidiasis (IC) and to provide guidance on formulary placement. Searches of MEDLINE (1966-June 2009) and EMBASE (1974-June 2009) were conducted using the terms efungumab, Mycograb, heat shock protein 90, and invasive candidiasis. Other resources included www.clinicaltrials.gov and article bibliographies. All studies and case reports evaluating efungumab use in IC were included. Literature review was limited to the English language. Efungumab is a monoclonal antibody targeted against heat shock protein 90 (HSP 90). It binds to HSP 90, preventing a conformational change needed for fungal viability. In vitro data show that HSP 90 inhibition may decrease resistance against antifungal agents and increase antifungal activity. Efungumab shows activity against Candida spp. when used alone and synergism when combined with fluconazole, caspofungin, and amphotericin B. A randomized controlled trial evaluated combination therapy of efungumab 1 mg/kg twice daily and liposomal amphotericin B versus amphotericin B therapy alone. At day 10, a favorable response was seen in 84% of patients in the efungumab group compared with 48% of patients in the placebo group (OR 5.76; 95% CI 2.4 to 13.8). Mortality at day 33 was also lower in the efungumab group, 4% versus 18%, respectively (OR 0.168; 95% CI 0.036 to 0.797). Although adverse effects were similar in this trial (10% vs 7%), case reports revealed an increased incidence of blood pressure fluctuations. Cytokine release syndrome has also been linked to efungumab use, warranting further exploration of its safety. Efungumab is a new antifungal agent with a novel mechanism of action. Available clinical data and synergy studies support the use of efungumab in combination with other antifungal agents for the treatment of IC. Further safety data are needed before formulary recommendations can be made.

Health facility-based Active Management of the Third Stage of Labor: findings from a national survey in Tanzania.

BackgroundHemorrhage is the leading cause of obstetric mortality. Studies show that Active Management of Third Stage of Labor (AMTSL) reduces Post Partum Hemorrhage (PPH). This study describes the practice of AMTSL and barriers to its effective use in Tanzania.MethodsA nationally-representative sample of 251 facility-based vaginal deliveries was observed for the AMTSL practice. Standard Treatment Guidelines (STG), the Essential Drug List and medical and midwifery school curricula were reviewed. Drug availability and storage conditions were reviewed at the central pharmaceutical storage site and pharmacies in the selected facilities. Interviews were conducted with hospital directors, pharmacists and 106 health care providers in 29 hospitals visited. Data were collected between November 10 and December 15, 2005.ResultsCorrect practice of AMTSL according to the ICM/FIGO definition was observed in 7% of 251 deliveries. When the definition of AMTSL was relaxed to allow administration of the uterotonic drug within three minutes of fetus delivery, the proportion of AMTSL use increased to 17%. The most significant factor contributing to the low rate of AMTSL use was provision of the uterotonic drug after delivery of the placenta. The study also observed potentially-harmful practices in approximately 1/3 of deliveries. Only 9% out of 106 health care providers made correct statements regarding the all three components of AMTSL. The national formulary recommends ergometrine (0.5 mg/IM) or oxytocin (5 IU/IM) on delivery of the anterior shoulder or immediately after the baby is delivered. Most of facilities had satisfactory stores of drugs and supplies. Uterotonic drugs were stored at room temperature in 28% of the facilities.ConclusionThe knowledge and practice of AMTSL is very low and STGs are not updated on correct AMTSL practice. The drugs for AMTSL are available and stored at the right conditions in nearly all facilities. All providers used ergometrine for AMTSL instead of oxytocin as recommended by ICM/FIGO. The study also observed harmful practices during delivery. These findings indicate that there is a need for updating the STGs, curricula and training of health providers on AMTSL and monitoring its practice.

Identification of medication-related problems and health care provider acceptance of pharmacist recommendations in the DiabetesCARE program

To evaluate the efficacy of pharmacist recommendations to health care providers, as part of PharmacistCARE, a single-center, pharmacist-run, diabetes medication therapy management (MTM) service. If the recommendation was accepted, a secondary objective was to measure the length of time for acceptance. Prospective assessment. University of Kentucky (UK), from March 2003 through December 2006. 172 adult patients with diabetes enrolled in the UK Health Plan who participated in the DiabetesCARE program. Pharmacists provided medication therapy-related recommendations to health care providers. Acceptance of pharmacist recommendations by health care providers, length of time to acceptance, and cost savings attained with formulary recommendations. A total of 692 recommendations were sent to health care providers; 425 (61.4%) were accepted. A total of 578 clinical recommendations were related to drug therapy problems; 348 (60.2%) were accepted by health care providers. Median time to acceptance for clinical recommendations was 13.5 days (0-229). Formulary recommendations accounted for 114 (16%) of the total recommendations, 77 (67.5%) were accepted, and median time to acceptance was 47.2 days (0-172). Average monthly cost savings per accepted formulary recommendation was $13.59 for the health plan and $13.85 for the patient. A similar percentage of health care provider acceptance (61.4%) was seen compared with previous studies of pharmacists' interventions in different practice settings. To our knowledge, this is the first study to evaluate time to acceptance of pharmacist recommendations to health care providers, including the resolutions made through collaborative drug therapy management. Lastly, the current study reinforces the assertion that pharmacists can positively affect cost savings for both the patient and health plan, through formulary management.