Hospital Formulary Research Articles

Trends and patterns of antimicrobial consumption at Benjamin Mkapa Zonal Referral Hospital, Dodoma, Tanzania: a cross-sectional retrospective analysis

ObjectiveThis study assessed the trends and patterns of antimicrobial consumption (AMC) from 2020 to 2021, 2021–2022 and 2022–2023 at the Benjamin Mkapa Zonal Referral Hospital (BMH) in Dodoma, Tanzania.DesignA retrospective cross-sectional study was conducted to collect AMC data for three financial years with respective denominators. The data were computed using the AMC Tool 2019 v1.9.0 and defined daily dose per 1000 inhabitants per day (DID).SettingThe BMH, Dodoma, Tanzania.ParticipantsThis study surveyed quantities of antimicrobials procured at the BMH. It did not have any human participants.Outcome measuresAMC was quantified in DID. The comparisons were made based on the DID of all surveyed antimicrobials, taking into account oral and parenteral administration and based on pharmacological classes. Further, DIDs were presented based on the 2023 WHO Access (A), Watch (W) and Reserve (R) (AWaRe) classification.ResultsIn 29 assessed antimicrobials, the DIDs for 2020–2021, 2021–2022 and 2022–2023 were 3.0852, 3.5892 and 3.9213, respectively. The average DID per year was 3.5319, with a mean of 2.4207±1.9765 DID per year. The topmost consumed antimicrobials over the 3 years (doxycycline, azithromycin, amoxicillin/beta-lactamase inhibitors, ampicillin/cloxacillin, amoxicillin/flucloxacillin, ceftriaxone, nitrofurantoin and clarithromycin) account over 90% of consumption. The most highly consumed therapeutic classes were beta-lactam antibacterial penicillins (34.71%), macrolides, lincosamides, streptogramins and others (25.75%), followed by tetracycline (23.88%). The AWaRe categorisation and antimicrobials not recommended (ANR) distribution were as follows: Access-51.61%, Watch-31.96%, Reserve-0.00%, and ANR-16.43%, respectively.ConclusionFor every 1000 patients attending the BMH per day, our study found 2.4207±1.9765 DIDs of an antimicrobial were consumed. The most consumed antimicrobials include doxycycline, azithromycin, amoxicillin/beta-lactamase inhibitor, ceftriaxone and metronidazole. To combat antimicrobial resistance effectively, it is imperative to institute a hospital policy for antimicrobial stewardship that prioritises the utilisation of a hospital formulary and antibiograms for the procurement of antimicrobials at the BMH.

Estimating the value of new antibiotic treatment strategies in Zhejiang province, China: cost-effectiveness analysis based on a validated dynamic model

ObjectivesThis analysis aims to better reflect the value of new antibiotic treatment strategies, thereby informing clinical antibiotic use, antimicrobial reimbursement and/or hospital formulary decision-making in China.DesignWe adapted a published and...

Benzodiazepine Prescription Patterns After Mild Traumatic Brain Injury inU.S. Military Service Members.

Clinical practice guidelines (CPGs) and clinical recommendations (CRs) are developed to aide and guide providers in treating a variety of conditions, including traumatic brain injury (TBI). There is little knowledge on the impact that CPGs and CRs have on provider practice. One TBI recommendation that was able to be tracked in medical record codes was the use of benzodiazepines (BZD). Because of potential for misuse, diversion, addiction, cognitive impairment, and brain healing interference, the DoD and Department of Veterans Affairs (VA) jointly discourage prescribing BZD after TBI. As part of an effort to look at translation of CPG guidance into clinical practice, our objective was to examine the issuance of BZD prescriptions, including dose, type, and prescribing provider, prescribing setting, and primary diagnosis at issuance among U.S. service members with mild Traumatic Brian Injury (mTBI). Using DoD data sourced from the Comprehensive Ambulatory/Professional Encounter Record (CAPER) databases of the Military Health System (MHS) Medical Data Repository (MDR), we identified all U.S. service members with a first lifetime diagnosis of mTBI from October 1, 2015 to September 30, 2016. Data on prescriptions issued to this group during a period of active treatment for a mTBI were obtained from the Pharmacy Detail Transaction Service (PDTS) databases of the MDR and identified BZD prescriptions based on the American Hospital Formulary Service (AHFS) therapeutic classification system. We validated coding assumptions through structured review of the clinical record contained within the Armed Forces Health Longitudinal Technology Application (AHLTA) of 30 randomly selected cohort members. Among U.S. service members, 4.5% filled a BZD prescription while under active medical treatment for a recent mTBI. These service members were more likely female and older when compared to their counterparts not prescribed BZD. Among service members under active treatment for mTBI during the study period, 52.6% (n = 7,935) filled a prescription; of these, 8.5% (n = 676) filled a BZD prescription. Of U.S. service members filing a BZD prescription while undergoing active treatment for an mTBI, 64.6% (n = 437) filled prescriptions for BZD and antidepressants, 54.9% (n = 371) filled prescriptions for both BZD and NSAIDS, and 42.2% (n = 285) concurrently filled prescriptions for BZD and opioids. This effort to examine the translation of CPG recommendations into practice through evaluation of medical record data indicates that providers are prescribing BZD to patients under active treatment for an acute mTBI. The mTBI CPG recommends that the BZD class of medications be avoided in patients healing from brain injury. However, the team recognizes there are confounding factors that may impact the medications that are prescribed for patients with mTBI. Additional work to understand how CPGs and CRs are received and utilized by providers may elucidate opportunities to close the gap between clinical practice guidance and clinical practice.

Prevalence of key potentially inappropriate drugs use in pediatrics: a cross-sectional study

BackgroundAppropriate drug prescribing in the pediatric population is challenging, given this age group’s unique pharmacokinetics. This has inevitably led to a high incidence of adverse drug reactions in this population. To address this issue, the Pediatric Pharmacy Association (PPA) compiled a list of 67 drugs that are inappropriately used in the pediatric population called the Key Potentially Inappropriate Drugs “KIDs list”.AimTo estimate the prevalence of potentially inappropriate medications (PIM) use in pediatric wards based on the KIDs list criteria.MethodsA retrospective observational study was conducted and included pediatric patients who were admitted to five pediatric wards during 3 years (2019–2021). The drugs in the KIDs list were matched to the hospital formulary and 11 matched drugs were included in the study. For each individual drug, the patient’s electronic file was reviewed to determine the prescription appropriateness according to the KIDs list criteria.ResultsAmong 3,166 pediatric patients admitted to pediatric wards, a total of 415 patients received a PIM listed in the KIDs list. The mean age was 8.6 (± 4.9) years old, and 60.0% (n = 251/415) were males. The overall prevalence of PIM use was 13.0% (n = 415/3166). Among the prescribed PIM, metoclopramide was the most commonly prescribed PIM 42.8% (n = 178/415), followed by tramadol 37.6% (n = 156/415).ConclusionGiven the high prevalence of inappropriate medication use in the pediatric wards, future research on strategies and interventions should be recommended to limit the use of PIMs and provide safer alternatives for the pediatric population.

Benefits of Biosimilars in the Management of Patients with Inflammatory Bowel Disease: An International Survey.

Background/Objectives: The development of biosimilar drugs has revolutionized the management of patients with inflammatory bowel diseases (IBD), significantly reducing healthcare costs. However, the impact of biosimilar availability on patient care is unknown. We conducted a survey to investigate the benefits of using biosimilars in patients with IBD. Methods: Physicians involved in the IBD care were invited to participate in an anonymous online survey. The questionnaire consisted of 42 questions addressing availability, cost, recommendations, and positioning regarding the use of biosimilars. Results: A total of 233 physicians (88.4% gastroenterologists) from 63 countries worldwide participated in the survey. Most respondents had >10 years of practice (202/233, 85.9%). Biosimilars were available in almost all cases (221, 94.8%), and over two-thirds of respondents had more than one biosimilar of adalimumab or infliximab on hospital formulary. In most cases, adalimumab and infliximab biosimilars had a reduced cost of at least 30% compared to the originators. The savings resulting from the use of biosimilars allowed physicians to improve patient care (3/233, 1.3%) or to improve research (2/233, 0.8%) in only a few cases. Interestingly, for about 50% of respondents, the cost of biologics was a limitation for patient access to therapy. For the majority of participants, the availability of biosimilars did not influence treatment decisions in Crohn's disease (70/165, 42.4%) and ulcerative colitis (83/165, 50.3%). Conclusions: The reduced cost of biosimilars compared to reference products is the main driver of choice in IBD. The impact of biosimilars of ustekinumab and vedolizumab in improving access to therapies and changing the treatment algorithm remains to be defined.

Understanding how a non-National Institute for Health and Care Excellence technology appraisal drug is added to the hospital drug formulary

Abstract Introduction In England, only medications listed in a hospital formulary can be used to treat patients in a National Health Service (NHS) hospital. Medications approved by the National Institute for Health and Care Excellence (NICE) via technology appraisal (TA)1 are included in hospital formularies.[1] Non-NICE TA medications need to be reviewed by the hospital’s drug and therapeutics committee (DTC) for inclusion in the hospital formulary. Research shows that different DTCs make contrary decisions concerning the same non-NICE TA drug request for inclusion in the hospital formulary, contributing to postcode prescribing and inequality in medication access.[2] To understand how and why different DTCs make different decisions, it is vital to understand how a non-NICE TA drug is added to a hospital formulary. Aim To identify the process and variations when adding a non-NICE TA drug to a hospital formulary. Methods As part of a larger study, the DTC of a tertiary centre where this research was based developed and sent a questionnaire exploring DTC processes to Chief Pharmacists (via Microsoft Forms) of ten large tertiary centres in England. After completing the questionnaire, a semi-structured interview was conducted with each Chief Pharmacist to clarify ambiguity in the questionnaire responses. Only data regarding how a non-NICE TA is added to the hospital formulary was used in this study. A hierarchical task analysis (HTA) was developed; data were analysed using inductive thematic analysis to identify subgoals, tasks and subtasks required to add a non-NICE TA drug to the hospital formulary. The HTA was developed iteratively. Results A total of ten Chief Pharmacists (100% of those approached) completed both the questionnaire and interview. Adding a non-NICE TA drug starts with the applicant requesting and completing an application package, followed by obtaining approval to submit the application package for review. Once approval is granted, the application package goes through three review levels: initial, preliminary, and final review. The non-NICE TA drug is added to the formulary once the application package is clinically and financially approved. This process involves over 100 tasks and subtasks. The process described varied from one centre to another with the following main variations: 1. application package components, 2. how the application package is submitted for approval, 3. the depth of review the application package receives, and 4. how the final review is conducted. Conclusion Adding a non-NICE TA drug to a hospital formulary is complex and varied across each centre, indicating a lack of national standardisation in the process. The variations identified could contribute to health inequalities as all patients may not have equal access to the same medications. Therefore, further research is required to study the impact of these variations on patient access to medication via the NHS. Currently, there are no studies in the literature that described the process of adding a non-NICE TA drug to the hospital formulary across the tertiary centres in England. The study only included tertiary centres in England and there should be caution when considering the transferability of the findings to other types of hospitals.

Does the introduction of an infliximab biosimilar always result in savings for hospitals? A descriptive study using real-world data

BackgroundBiosimilars are biologic drugs that have the potential to increase the efficiency of healthcare spending and curb drug-related cost increases. However, their introduction into hospital formularies through initiatives such as non-medical switching must be carefully orchestrated so as not to cause treatment discontinuation or result in increased health resource utilization, such as additional visits or laboratory tests, among others. This retrospective cohort study aims to assess the impact of the introduction of CT-P13 on the healthcare expenditures of patients who were treated with originator infliximab or CT-P13.MethodsGastroenterology, immunoallergology and rheumatology patients treated between September 2017 and December 2020 at a university hospital in Western Switzerland were included and divided into seven cohorts, based on their treatment pathway (i.e., use and discontinuation of CT-P13 and/or originator infliximab). Costs in Swiss francs were obtained from the hospital's cost accounting department and length of stay was extracted from inpatient records. Comparisons of costs and length of stay between cohorts were calculated by bootstrapping.ResultsSixty immunoallergology, 84 rheumatology and 114 gastroenterology patients were included. Inpatient and outpatient costs averaged (sd) CHF 1,611 (1,020) per hospital day and CHF 4,991 (6,931) per infusion, respectively. The mean (sd) length of stay was 20 (28) days. Although immunoallergology and rheumatology patients had higher average costs than gastroenterology patients, differences in costs and length of stay were not formally explained by treatment pathway. Differences in health resource utilization were marginal.ConclusionsThe introduction of CT-P13 and the disruption of patient treatment management were not associated with differences in average outpatient and inpatient costs and length of stay, in contrast to the results reported in the rest of the literature. Future research should focus on the cost-effectiveness of non-medical switching policies and the potential benefits for patients.

A newly developed algorithm for switching outpatient medications to medications listed in the hospital formulary: a prospective real-word evaluation in patients admitted electively to hospital

PurposeIn many countries, outpatient and inpatient care are separated. During hospitalization, therefore, switching the outpatient medication to medication of the hospital formulary is required.MethodsWe newly designed a switching algorithm in six switching steps (S0–S5) and conducted a study at Bundeswehr Hospital Hamburg (300 beds, 80% civilians). We performed (i) a medication reconciliation to obtain information on outpatient medications and (ii) a medication review to solve drug-related-problems, e.g., drug-drug interactions. We applied (iii) the algorithm to switch medications to the hospital formulary.Results(i) We identified 475 outpatient medications (median per patient: 4; Q25/Q75 2/7) in 100 patients consecutively admitted to hospital (median age: 71; Q25/Q75: 64/80 years). Of 475 medications, the switching algorithm could not be used since product names were missing in 23.9% and strength in 1.7%. In 3.2%, switching was not required since medication was not prescribed during the hospital stay. (ii) Drug-drug interactions were identified in 31 of 79 patients with more than one medication. (iii) Of 475 medications, 18.5% were on the hospital formulary and therefore did not need to be switched (S0), 0.2% were on a substitution-exclusion list not allowing switching (S1), 42.0% were switched to a generic medication of the hospital formulary (S2), 1.7% to a therapeutically equivalent medication (S3), 0.4% were patient-individually switched (S4), and for 8.2% a standardized/patient-individual switching was not possible (S5).ConclusionsDespite comprehensive medication reconciliation, patient- and medication-related information for switching medications to the hospital formulary was often missing. Once all the necessary information was available, standardized switching could be easily carried out according to a newly developed switching algorithm.

Development of Hospital Formulary for an Emergency Drug List in Tertiary Care Teaching Hospital

Background: In an emergency situation, timing is an important factor that requires sound knowledge about the patient's health condition, diagnosis, and treatment, as well as the administration of an appropriate drug at the appropriate time, which helps save a patient’s life. To ease the workflow, we decided to develop an emergency drug formulary. The study aims to develop a hospital formulary for an emergency drug list and compare it with the WHO standard formulary and the National Formulary of India. Methods: A prospective observational study was carried out at Vivekananda General Hospital, Hubballi, for a period of six months. A monograph of emergency drugs was drafted based on the needs of the hospital and prepared by referring to various different sources of data. The developed hospital formulary was made into electronic copies and handbooks, and a review was obtained from healthcare professionals. Results: The results showed that there were 130 drugs in the emergency drug formulary. It includes various categories of medication given in the case of different emergency conditions (cardiac emergencies, neurological emergencies, endocrine emergencies, poisoning emergencies, respiratory emergencies, fluid and electrolyte emergencies, and miscellaneous emergency drugs). While comparing the contents of the monograph with other formulary monographs, we found that the formulary that we had developed was more effective. There were five fixed-dose combinations (FDCs), 27 drugs that are safe to use during pregnancy, 84 drugs that should be used with caution while pregnant, and 1 drug that was contraindicated. We also found that there were 59 drugs that were compatible with breastfeeding; 63 needed to be used with caution; and 12 should be avoided during breastfeeding. Conclusion: The developed emergency formulary acts as a quick reference, helps in selecting the appropriate drug at the appropriate dose and time, and also helps in selecting low-cost alternative brands.

The Evaluation of Drug Management and Improvement Strategies Using the Hanlon Method in the Pharmacy Installation of the Bahteramas Hospital Southeast Sulawesi

Drug management is a drug management cycle which includes these stages as follows: selection, procurement, distribution and use. Ineffectiveness and inefficiency may negatively impact hospitals both medically and economically. This study aims to evaluate drug management in the selection, procurement, distribution and use of drugs at the Bahteramas Hospital, Southeast Sulawesi,
 with Hanlon method as strategic improvement. This study has done with a descriptive method with data collected retrospectively in 2022 and prospectively, both primary (management record) and secondary (interviews). Results of this study about drug management showed there were 4 indicators that do not comply with standards. Meanwhile, other 10 indicators could comply with the standards. The improvement strategy using the Hanlon method in drug management is to prioritize repairing problems sequentially starting from the average percentage of drug waiting time, suitability of the national formulary and hospital formulary, as well as the percentage of dead stock.

Comparing Drug Handling Efficiencies and Expenses for Short- Acting Granulocyte-Colony Stimulating Factor Injection Originators and Biosimilars from the Perspective of Hospital Resource Management in Formulary Decision-Making

Background/Aim: With the availability of biosimilars, hospital formulary drug selection among biologics extends beyond clinical and safety considerations when comes to hospital resource management, to factors like human resource allocation and financial sustainability. However, research assessing the time and cost of labor, supplies, and waste disposal of biologics from the standpoint of hospitals remains limited. This study focuses on short-acting granulocyte-colony stimulating factor originators (Granocyte® and Neupogen®) and biosimilar (Nivestim®), comparing them based on mean total handling times per dose and total annual expenses. Materials and Methods: Ten nursesfrom a Taiwanese cancer centerwere recruited; they each prepared three doses of each drug. Results: Findings showedthat the mean total handlingtimes per dose of Granocyte® and Neupogen® were significantly higherthan that of Nivestim®. Handling Nivestim® required the lowest total annual expense. Conclusion: Nivestim® is an advantageous alternative to Granocyte® and Neupogen®, benefiting hospital resource management.

The evaluation of drug management (selection, procurement, and lead time of drug order) in hospital during COVID-19 in Indonesia

In the current COVID-19 era, one of the critical factors influencing the quality of hospital services is drug management, with planning and procurement being particularly pivotal to avoid drug shortages. This study aimed to examine the selection, procurement, and lead time aspects of drug management at the pharmacy installation hospital in Jakarta during the COVID-19 pandemic. Conducted as a descriptive study with retrospective data, total sampling was utilized to collect data, incorporating 1,413 drugs. The data, collected on observation sheets, underwent univariate analysis using Microsoft Excel. Results indicated that out of the seven measurable indicators, two met the standards: the percentage of allocated funds for drug procurement at 70.5%, and the frequency of errors in orders occurring five times. However, five indicators fell below the standards: the suitability of drug items with the National Formulary at 14.15%, the suitability of drug items with the Hospital Formulary at 68.15% (with an 80% benchmark), the frequency of each item's procurement in a year at a low category of 43.45%, the percentage of conformity between planning and reality at 99.61%, and the achievement of lead time for ordering drugs at 5.08 days. In conclusion, the selection, procurement, and lead time aspects of drug management at the "X" Hospital Pharmacy Installation did not fully meet the established standards. Therefore, it is recommended that healthcare management implements and adheres to robust drug management system regulations, particularly during pandemic situations, to ensure optimal hospital services.

Medicine formulary writing for hospitals: A systematic review on development, approval, dissemination, and review

Background: A hospital formulary is a guiding manual developed to enhance the rational prescribing of medicines based on the local prevalence of diseases and hospital settings. This systematic review aimed to identify and evaluate the existing literature on hospital formulary development and management to ensure the availability of safe, cost-effective, quality, and efficacious medicines that all practitioners must use. Methods: A qualitative evidence and experience synthesis approach was chosen to create evidence on the development and use of hospital formulary. PubMed was the database used to search for similar reviews using Boolean operators. Results: Out of 1,347 potentially relevant literature and abstracts identified and screened, 25 publications were used in developing the hospital formulary. The hospital formulary should be developed and reviewed after using the current STG/NEMLIT to use updated medicine lists and indications. Medicines selected for the model are “medicines of choice.” The development of hospital formularies should be based on a comprehensive and transparent process that involves a multidisciplinary team of experts, a clear selection criterion, a reliable and updated source of information, and a regular evaluation of the clinical and economic outcomes. Conclusion: Hospital formularies promote the rational, safe use of medicines to improve the quality and efficiency of healthcare.

Pengelolaan Obat di Unit Farmasi RSUD Tengku Sulung

Pharmaceutical service is a direct and responsible service to patients related to pharmaceutical preparations with the intention of achieving definite results to improve the quality of life of patients. The purpose of this study was to obtain in-depth information on drug management in the Pharmacy Unit of RSUD Tengku Sulung. The research method used descriptive qualitative with purposive sampling with the number of informants 7 people. Data collection through in-depth interviews, direct observation and document review using content analysis. The results, on the input component obtained information that the lack of human resources, facilities and infrastructure are inadequate and there is no depot and SIM RS. Policies have been made in the form of Drug Management Guidelines in the Pharmacy Unit. In the process component, information is obtained that selection is based on the hospital formulary and national formulary, planning using the combination method, procurement using e-catalog and direct purchase, receipt is carried out by checking and adjusting the order letter, order invoice, and the drug received, storage based on dosage form, classification of types of drugs, medical devices, B3 and arranged alphabetically with the FIFO and FEFO systems, distribution using individual prescribing and Floor Stock systems, deletion is carried out by involving third parties, control is carried out by controlling drug inventory and quality, administration based on recording, reporting and financial administration. The output component obtained by the availability of drugs is still not effective and efficient. In conclusion, the pharmaceutical supply management system in the Pharmacy unit of RSUD Tengku Sulung is not in accordance with the established standards. Suggestions, the need for additional human resources, the fulfillment of infrastructure such as depot procurement and SIMRS, monitoring and evaluation, improved communication during drug selection and budget planning in the fulfillment of facilities and infrastructure.

ANALISIS PELAYANAN BIDANG FARMASI MENGGUNAKAN INDIKATOR LAYANAN BERBASIS WHO: TINJAUAN SISTEMATIS

Pharmaceutical services in hospitals are an inseparable part of the hospital's health service system that is oriented towards patient service, the provision of quality and affordable pharmaceutical preparations, medical devices, and consumables for all levels of society including clinical pharmacy services. The purpose of this study is to systematically review the implementation of pharmaceutical services based on WHO indicators. The articles used were selected from the Google Scholar journal database published from January 2013 to December 2023. Keywords for the study included "service" or "pharmaceutical" or "pharmacy" or "indicator" or "hospital" or "WHO". A total of 476 articles were generated from the initial search, the author identified 8 articles on pharmaceutical services based on WHO indicators. Based on a systematic review, most hospitals have implemented pharmaceutical services based on WHO indicators. Based on a systematic review, the implementation of pharmaceutical services in accordance with WHO standards is the selection stage: conformity with the hospital formulary; procurement: frequency of procurement of each drug item annually and on an EOQ basis; distribution: the degree of availability of the drug; Usage: percentage of generic prescriptions, percentage of drugs delivered, percentage of drugs labeled complete and average time spent serving prescriptions.

The role of medicines and therapeutics committees structure in supporting optimal antibacterial use in hospitals in Uganda: A mixed method study.

Although the roles of Medicines and therapeutic committees (MTCs) have been expanding, there is limited information on the role of their structure in optimal antibacterial use in hospitals, especially in low-and-middle-income countries. Our study explored the structure and role of MTC in supporting antibacterial use in regional referral, general hospitals and tertiary private not-for-profit (PNFP) hospitals in Uganda. We conducted an explanatory sequential mixed-method approach with triangulation to explore the structure and functional role of MTCs from August 2019 to February 2020 in hospitals in Uganda. Quantitative data was collected using an interviewer-administered questionnaire among chairpersons or secretaries of MTCs and was analysed using descriptive statistics. We conducted key informant interviews using an interview guide among long-term serving members of MTCs to collect qualitative data which triangulated the quantitative data. The study revealed that sixteen hospitals had successfully established MTCs with an average duration of the MTCs' existence of 5.6 (+2.7) years. The membership of the MTCs varied between 7 and 14, with a median value of 10, and the majority of members in MTCs were pharmacists (15 out of 16) and clinical specialists (13 out of 16). The most frequent subcommittees of the 16 hospitals MTC were supply chain (n = 14), antimicrobial stewardship (n = 13), and infection control (n = 12). Majority (14 out of 16) of the MTCs supported availability and access of antibacterial use by selecting and evaluating antibacterials agents for their formulary lists using established criteria. Additionally, 15 out 16 MTCs conducted antimicrobial stewardship activities to support optimal antimicrobial use. In our study, MTC membership and subcommittees were critical structural components that aided the selection and evaluation antibacterials on hospital formulary lists and they supported optimal antibacterial use through implementing various antimicrobial stewardship activities. There is a need for the Ministry of Health to conduct more training on operationalising MTCs structures in all hospitals.

Laxative-prescribing habits: a summative impact evaluation of a constipation programme implemented in two hospitals in New Zealand.

To evaluate the impact of a multifaceted intervention aimed at improving adherence to a list of preferred laxatives in two hospitals in New Zealand. A constipation programme was developed at Capital & Coast District Health Board to improve adherence to safe and effective (preferred) laxatives over potentially dangerous and less effective (non-preferred) agents. The intervention included a new constipation guideline, a poster of preferred laxatives, a patient information leaflet, hospital formulary adjustments and staff education. The evaluation compared the number of dispensations of each laxative during two periods: a 12-month period prior to programme implementation and a 12-month period following programme implementation. Data were retrospectively gathered from multiple sources on all laxatives dispensed on 14 adult wards across two New Zealand hospitals. Prior to the programme, there were 111,771 laxatives dispensed, the majority of which (62%) were non-preferred agents. Following the programme, there were 91,005 laxatives dispensed, the majority of which (82%) were from the preferred list, indicating a large shift in prescribing habits. Inpatient laxative prescribing habits require attention and are amenable to quality improvement initiatives. This may reduce waste, prevent harm and improve patient outcomes.

Feasibility and Implementation of an out-of-Pocket Cost Calculator for Pre-Treatment Financial Counselling in Cancer Patients

Introduction Public healthcare in Singapore is funded by a combination of subsidies, insurance, which includes national basic coverage (MediShield, MSL) and optional private coverage, pensions (MediSave, MSV) and out of pocket (OOP) costs. In Sep 2022, spiraling cancer costs led to a shift in national policy with the introduction of a Cancer Drug List (CDL) of cost-effective treatments. OOP costs are now determined by multiple factors such as subsidy status, financial resources, insurance claim limits, residency status, drug subsidy tier, therapeutic indication, dose and cost. To simplify this complex manual process, we developed ChemoCalc, a digital calculator for individualized OOP estimates. We hypothesize that it will increase OOP cost estimate accuracy, improve efficiency and have high uptake. Methods The study was performed in a Singapore tertiary cancer center. ChemoCalc was developed with a multi-disciplinary team comprising physicians, pharmacists, operations administrators, patient service associates and medical social workers. Data sources were consolidated and hierarchical logic determined for calculating regimen and patient-specific OOP cost. Data sources included the CDL, hospital formulary, chemotherapy protocols, chemotherapy facility fees and various national subsidy schemes. These were encoded into an algorithm by a third-party developer. The user interface and experience (UI/UX) was envisioned by the team with iterations based on feasibility testing. FCs were trained on using ChemoCalc and data was collected pre and post-ChemoCalc implementation. Feasibility outcomes were demand, acceptability, practicality and integration (the extent to which ChemoCalc could be deployed in a secure hospital IT environment). These were assessed through employee focus groups (FG). Reporting officers were not present during the FG. Implementation outcomes were adoption (percentage of eligible users using ChemoCalc for FC), engagement (percentage of returning users), efficiency (median time taken to perform FC) and accuracy (percentage of bills which are within ±10% of the FC estimate). For accuracy, 10 bills were randomly selected each month and compared against the pre-treatment FC. Results Prior to the development of ChemoCalc, the demand for automated FC was identified through employee engagement. ChemoCalc (Figure 1) was developed and iterated from Aug - Sep 2022. Feasibility assessment identified that simplicity underscored a good UI/UX. To reduce UI clutter and improve ease-of-use, an algorithm was encoded to ensure that only variables relevant to a particular regimen need to be entered (Figure 2). All data fields were accessible via the hospital electronic medical record. The final version of ChemoCalc was deemed acceptable and practical by FG. It was integrated into the hospital environment seamlessly and accessible from all hospital computers and personal mobile devices. Data collection for implementation outcomes took place from 1 Oct 2022 to 31 Mar 2023. ChemoCalc was used by 72 different members of staff from all job groups. On average, the prices of 2,484 regimens (mean 11 regimens per patient) were generated each month, with a total of 17,385 price estimates generated. 91% of price estimates were for subsidized patients and 9% for private patients. For staff performing FC, the adoption and engagement rate was 100%. ChemoCalc improved efficiency for the FC process with an accuracy of 95% (baseline 35%, 270% increase). Time spent computing OOP reduced from a median of 8 min (range 4.5 - 13) to 44 seconds (range 15 - 20) for simple regimens, and 23 min (range 15.5 - 44) to 1 min (range 0.3 - 1.3) for complex regimens respectively. Due to the convenience and simplicity, there was 100% uptake for pre-treatment FC, as staff have been able to process more FC requests and spend more time addressing patients' financial concerns. It has also allowed patients to compare costs of different treatment regimens. Conclusion The implementation of ChemoCalc was successful with 100% adoption rate and significantly improved efficiency and accuracy. ChemoCalc's algorithm can easily be adjusted to accommodate country- or institution-specific reimbursements for implementation elsewhere. Further studies are required to investigate if pre-treatment FC addresses financial toxicity or influences healthcare costs.

Evaluating Trainees' Experiences with Intravenous Iron Use

Background: Iron deficiency (ID) and iron deficiency anemia (IDA) cause significant morbidity. Despite being a disease of high prevalence, affecting people with heart failure, chronic kidney disease, heavy menstrual bleeding, irritable bowel disease, hereditary hemorrhagic telangiectasia (HHT), and bariatric surgery, it has low healthcare priority. The World Health Organization (WHO) estimates 37% of people who are pregnant, and 30% of women 15-49 years of age worldwide are anemic. Fibroids, which are the leading cause of abnormal uterine bleeding, disproportionately impact people of color. ID and IDA cause fatigue, impaired cognitive function, and poor mental health, eroding quality of life and personal productivity. In addition, IDA has been associated with an increase in all-cause mortality is associated with an increased risk of arterial and venous thrombosis. Under-treatment of IDA results in avoidable hospitalizations, emergency room visits, blood transfusions, decreased HRQoL, and loss of personal productivity. Despite the significant impact ID and IDA can have on morbidity, mortality, and quality of life, intravenous iron remains underutilized. No study has been performed to date to assess provider practices, knowledge, and perceptions of intravenous iron use. This qualitative study aims to understand trainees' experiences with intravenous iron use in patients with ID and IDA. Methods: We conducted an inductive reflective thematic analysis of semi-structured qualitative interviews from five focus groups to understand trainees' experiences with and barriers to prescribing intravenous iron in patients with ID and IDA. Internal medicine residents from academic institutions across the country were recruited via snowball sampling. Chief residents from six internal medicine programs were contacted to disseminate sign up links to their residents; programs were chosen for geographic diversity. Results: Twenty-eight internal medicine residents responded and nineteen residents across five institutions participated (PGY levels 1-3). Thematic analysis of trainees' experiences of caring for patients with conditions characterized by iron deficiency resulted in three main themes: education, systemic factors, and practice pattern. Participants identified a wide range of conditions for which they consider administration of oral or intravenous iron. However, they generally expressed uncertainty as to whether evidence-based guidelines exist to guide their decision-making with the exception of intravenous iron administration in heart failure patients. In addition, systemic factors, such as setting, support staff, hospital formularies, order sets, and insurance status often impacted their decision to use intravenous iron. Conclusions: There is a wide variation among residents' practice patterns in regard to their comfort with prescribing intravenous iron. The ease or hesitancy with which they do so is greatly influenced by educational and systemic factors. By gaining a deeper understanding of the experiences of trainees we can lay the foundation to develop evidence-based guidelines and educational initiatives for conditions characterized by ID and IDA. Additionally, by identifying both institutional facilitators and barriers, we can cultivate system-based initiatives to improve access to intravenous iron. To assess this need on a larger scale, our next step involves developing a survey that will be widely distributed via national societies. While cost, insurance status, and need for specialty referral were identified as barriers for intravenous iron use, there was no explicit discussion of how these barriers may contribute to healthcare inequity for underserved populations.

Improving hospital formulary drug decision making with multi-criteria decision analysis (MCDA): case study from a national government hospital in Indonesia

This study aimed to look at the applicability of the multi-criteria decision analysis (MCDA) framework to improve hospital formulary drug decision-making. The case study method was used to investigate MCDA implementation in the National Brain Center Hospital Jakarta, Indonesia. A two stage-workshop was held on October 29th, 2019 and 5 February 5th, 2020, where participants conducted a hands-on experience in applying MCDA for selecting off-patent pharmaceuticals (OPPs) for the hospital formulary. The results of the workshop created awareness of MCDA that can be beneficial in transparently selecting OPP, which is not based only on price while involving multiple stakeholders. As a follow-up, MCDA was used during the drug selection process for the National Brain Center Hospital formulary in 2021 with criteria in accordance with the workshops, namely: 1) equivalence with the reference (originator) product; 2) real-world clinical or economic outcomes; 3) quality assurance; 4) reliability of drug supply; 5) stability and drug formulation; 6) pharmacovigilance, and 7) price advantages. In conclusion, the MCDA method can be implemented with customized criteria and weighting based on hospital needs to help with drug selection for the hospital formularies.