Formulary compliance and pharmacy labor costs associated with systematic formulary management strategy

Purpose. The impact of a comprehensive hospital formulary management system on formulary compliance and pharmacy labor costs was evaluated. Methods. The formulary management system consisted of monitoring nonformulary medication use, reviewing formulary medication use annually, and providing periodic feedback. Workflow scenarios for nonformulary medication requests were identified. Pharmacy personnel were interviewed to obtain the probability of occurrence of each scenario and the time involved. Labor costs were determined by multiplying the average total minutes spent on each activity by the corresponding average salaries per minute. Formulary compliance was compared before the implementation of the formulary management system (January to June 2008) with six consecutive six-month periods after implementation. Results. Nonformulary medication use decreased from 17.8 to 5.9 nonformulary medication initiations per 100 admissions over a three-year period (p <0.001). Time and labor costs associated with managing nonformulary medication requests varied from 4 to 69 minutes and from $3.68 to$27.28, respectively, depending on the scenario used. Automatically converting to a formulary alternative was the least labor-intensive option ($4.40 per request), followed by changing to a formulary alternative after consulting the prescriber ($9.92). Conclusion. A comprehensive formulary management system resulted in increased compliance to a formulary that matched the needs of the institution and minimized the number of nonformulary medication requests. Expanding pharmacists' therapeutic interchange authorities was the least labor-intensive way of managing nonformulary medication requests, and adding the most frequently used nonformulary medications to the formulary was the second least costly option

Decision support at the point of prescribing to increase formulary adherence

Purpose. Study results demonstrating the effectiveness of order-entry clinical decision support (CDS) alerts as a tool for enforcing therapeutic interchange are presented. Methods. A retrospective observational study was conducted at an academic medical center to evaluate formulary nonadherence before and after implementation of a fully electronic medical record with computerized prescriber order-entry (CPOE) technology configured to display therapeutic interchange alerts immediately on entry of orders for nonformulary agents. Formulary nonadherence (defined as the proportion of pharmacist-verified nonformulary orders to total verified orders) within eight medication classes was assessed during a six-month baseline period and two consecutive six-month periods after implementation. Results. In the 12 months after implementation of the therapeutic interchange alerts, the overall rate of formulary nonadherence decreased by 65%, from 3.5% at baseline to 1.2% during the second 6-month postintervention period (p <0.001). The total number of verified nonformulary orders decreased from 300 at baseline to 102 during the second postintervention period. The largest decreases in formulary nonadherence were observed in the intranasal steroid drug class (the rate of nonadherent orders declined by a total of 12 percentage points) and the nonbarbiturate sedatives and hypnotics class (a 5-point decline), with significant 6- and 12-month declines also documented in four of the remaining six drug classes. Conclusion. The incorporation of hard-stop CDS alerts into the CPOE system improved the overall rate of prescriber adherence to institutional therapeutic interchange protocols

Drug-drug interaction checking assisted by clinical decision support:a return on investment analysis

Background Drug-drug interactions (DDIs) are very prevalent in hospitalized patients. Objectives To determine the number of DDI alerts, time saved, and time invested after suppressing clinically irrelevant alerts and adding clinical-decision support to relevant alerts. Materials and methods The most frequently occurring DDIs were evaluated for clinical relevance by a multidisciplinary expert panel. Pharmacist evaluation of relevant DDIs was facilitated using computerized decision support systems (CDSS). During Phase 1, only CDSS-assisted DDI checking was implemented. During Phase 2, CDSS-assisted DDI checking remained in place, and clinically irrelevant DDIs were suppressed. In each phase, the number of alerts and duration of pharmacist DDI checking were compared to conventional DDI checking. In addition, the time invested to implement and configure the CDSS was compared to the time saved using CDSS-assisted DDI checking. Results CDSS-assisted DDI checking resulted in a daily decrease of DDI checking alerts from 65 to 47 alerts in Phase 1 (P=.03) and from 73 to 33 alerts in Phase 2 (P=.003). DDI checking duration decreased from 15 to 11 minutes (P=.044) and from 15 1/2 to 8 1/2 minutes (P=.001) in Phases 1 and 2, respectively. Almost 298 of the 392 hours required for implementation were invested by pharmacists. An annual timesaving of 30 hours yielded a return on investment of 9.8 years. Conclusion CDSS-assisted DDI checking resulted in a 55% reduction of the number of alerts and a 45% reduction in time spent on DDI checking, yielding a return on investment of almost 10 years. Our approach can be used to refine other drug safety checking modules, increasing the efficiency of checking for drug safety without the need to add more staff pharmacists

Doing the right things and doing things right:inpatient drug surveillance assisted by clinical decision support

Increased budget constraints and a continuous focus on improved quality require an efficient inpatient drug surveillance process. We describe a hospital-wide drug surveillance strategy consisting of a multidisciplinary evaluation of drug surveillance activities and using clinical decision support to augment drug surveillance practices. Key characteristics of the decision support system are the integration of the Dutch national knowledge base (G-Standard), the ability to monitor the effects of drug therapy over time and prevent irrelevant alerting by adding essential patient data to the conventional medication safety checking algorithm. Integration of existing national medication safety knowledge bases into decision support systems assures the availability of up-to-date information, minimises maintenance and prevents irrelevant alerts. Developing decision algorithms based on the desired intervention decreases the burden of validation and maintenance, as duplication of multiple similar decision algorithms is prevented