Pharmacy and Therapeutic Committees

1
Pharmacy and Therapeutic Committees

• January 2002

2
Drug and Therapeutic or Pharmacy and Therapeutic
Committees

• Around for a long time, various functions in
  developed countries
• Hardly exist or function effectively in
  developing countries
• NDPs support PTCs but in practice often meetings
  become drug shortage confrontations

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Why interest in PTCs

• Almost complete absence of data on improving drug
  use in hospitals in developing countries
• Cost and quality conflicts increasing everywhere
• Australian models seem useful
• Recognition that quality of care determines
  willingness to pay

4
Justification for PTCs

• Cost control
• As technology develops, populations transform
  AIDS affects health services, pressures mount to
  control costs while maintaining services
• Quality of Care
• Quality is determined by more than structures and
  resources. Need processes and people to produce
  outputs
• Efficiency
• As health systems become more complex, efficiency
  requires effective communication and collaboration

5
Essential Function of PTCs

• Meeting ground between clinicians, pharmacists
  and financial managers to negotiate the balance
  between cost and quality.
• The pharmacist often has to play the role of an
  expert referee!

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Membership

• Staff from medicine, surgery, pharmacy, nursing,
  quality management, hospital administration,
  information systems, and infection control. In
  Australia community members!
• The number of members range from eight to twelve
  in the United States, with Australia averaging
  nine members.
• The chairperson is chosen usually from clinical
  members while secretary a pharmacist.

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Meetings Frequency and Duration

• Most committees meet monthly,
• usually for 60 to 90 minutes

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Terms of Reference

• Includes
• Selection
• Standard Treatment Guidelines
• Drug Utilization Review
• Production of Drug bulletin

• Providing objective information including DICs
• Adverse Drug Reactions
• Medication errors
• Control of Drug Reps
• ????

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Functioning in Practice

• Selection
• Hospital Formulary or Hospital drug lists e.g.
  Emergency, Surgical, Medical, Pediatrics etc
• Review of Applications for additions, deletions,
  buying out, special requests, ABC Analysis
• Defining drug priority VEN analysis
• Producing and Reviewing STGs
• Disease or Drug based Examples Cerebral Malaria,
  OP hypertension OR blood, ciprofloxacin or
  ceftriaxone
• Defining levels of use
• Specialist only, counter signatures,
• Distribution controls

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Functioning in Practice (2)

• Educational Activities
• Printed Materials
• Large Group teaching
• Small group teaching
• Individual detailing
• Teaching Nurses, medical students, new appointees
• Opinion leaders

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Drug Utilization Review / Evaluation

• Effective but not that frequently done
• Steps
• Problem Identification (Condition or drug)
• Define criteria
• Measure performance
• Compare performance with criteria
• Feedback results

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Other Functions

• ADR Monitoring
• Medication Errors

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Adverse Drug Reaction Reporting
14
Adverse Drug Reaction Assessment
15
Adverse Drug Reaction Assessment
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Other functions (2)

• Controlling drug reps (Achieving the impossible!)
• Appointments
• Prior review of materials
• Equal time for presentations
• Patients have priority!

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Evaluation of Interventions

• Structural and Process evaluation needed annually
• Outcome evaluation of interventions
• Best method is time series ideally with a control
  hospital. Need at least 6 points before and at
  least 6 points after intervention. Better to have
  8 or 12 pre and post time points

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Data Sources for Monitoring Evaluation

• Drug Stock records
• Prescribing records
• Dispensing records
• Case notes
• Registers of Expensive drugs
• Financial Records

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Budgeting for PTC Activities

• Consider
• Staff time costs
• Meeting costs (Food, parking, duplication)
• DUR data collection costs
• Intervention costs
• Reporting costs

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Difficult PTC Issues

• Conflict of Interest
• Lack of adherence to PTC decisions
• Role of Pharmaco-economics in decision making
• Lack of evidence based assessment in selecting
  drugs for formulary
• Appeal mechanisms and transparency

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What makes a successful PTC?

• Chairman
• Members
• Quality and responsiveness of technical support
• Attendance and involvement at meetings
• Members carry decisions back to their departments

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Why is it so difficult to get these committees to
function effectively?

• Personal View
• Clinicians, pharmacists and financial managers
  have different world views.
• For progress each group need to understand and
  respect the others world view

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Importance of PTCs

• With technology development, changing patterns of
  disease and financial limits, critical that these
  committees function effectively
• Each committee will need to determine their own
  priorities, work plans and systems
• Without these committees decisions will be taken
  without regard for quality of care or cost
  efficacy of treatment

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Boston Area PT Survey

• Determine the positive and negative
  characteristics of PT Committees
• What makes a PT Committee successful?
• Application in developing countries

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Methods

• Created Survey Instrument to gain qualitative and
  quantitative data
• Piloted Instrument Internally. Gave interviewers
  practice to be sure they understood questions.
  Also practiced responding to some answers and
  styles (reluctance to share, time constraints,
  etc)

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Methods

• AHA code chart to identify hospitals
• Inclusion Criteria 40 mile radius Boston
• Exclusion Criteria

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Methods

• 47 hospitals randomly selected using Metastat
  2.01
• 2 hospitals merged
• 8 hospitals too far away to visit
• 37 hospitals sent invitation letter (BU SPH
  letterhead, Richard and Brenda authors)
• 27 hospitals telephone follow-up by Brenda

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Methods

• Of 27 hospitals phone follow-up
• 4 refused to participate
• (assumed that refusal to participate more likely
  with lower performing PT C)
• 5 hospitals could not find mutual meeting times
• Final sample size14 hospitals

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Methods

• Directors of Pharmacy interviewed
• (usually serve as secretary of PT)
• Occurred over 6 weeks in early 1998
• Predetermined questions/survey
• 2 Interviewers per site (1 asks, 1 records)
• 60-90 minute interviews

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Results Structure Organization, Evaluation

• 9 of 14 Mission Statement
• plan
• 9 of 14 evaluated by JCAHO (every 3 years)
• 3 of 14 have inhouse evaluation

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Results Meetings

• All meet regularly
• 9 of 14 meet monthly
• most have fixed meeting times (first Thursday,
  etc)
• 1-1.5 hour meetings
• early morning (730am) -convenience or midday
  (lunch providedincreases attendance)the 1
  hospital that did not serve lunch had lowest
  attendance rate

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Results Membership

• Common Medicine, Surgery, Nursing, Pharmacy,
  Hospital Administration, Quality Assurance /
  Infection Control
• Others Nutrition, Lab staff
• None had IT..but available for consult
• None had ethicist or community representation and
  not available for consult

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Results Attendance

• Range 50-100
• MDs and Surgeons lowest attendance
• Medicine 67, Surgery 58, Pharmacy 96, Nursing
  90, QA 89, Administration 78, Infection
  Control 87
• Nutrition 82, Laboratory 80
• Other Not open to all staffrequire invitation
  to attend
• No Drug Reps

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Results Incentives

• 13 of 14 offer food
• Power and Prestige
• None pay extra money

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Results Minutes

• All record minutes
• 1/2 send minutes to medical executive committee
• none distribute to med/surg staff or nursing
  staffhave access of they ask
• some send to pharmacy

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Results Budget and HR

• 1 of 14 has money allocated to PT
• 3 of 14 give staff time to prepare for meeting

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Functioning

• All review ADRs..some use subcommittees
• 13 of 14 review medical errors
• All provide educational materials to
  staff..memos, newsletters, computers
• 11 of 14 endorse objective detailing-providing
  information proactively (rounds) or reactively
  (phone after order written)

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Functioning

• All conduct DUR/DUE (JCAHO requirement)
• Results not effectively distributed to staff
• 10 of 14 have presentations to MDs on improving
  drug use, usually in a specific area

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Functioning

• Adding Medications to Formulary Not added 0-60
  time (usually 10-25)..usually handled
  informally and never make it to meetings
• 2-30 drugs per year added
• 0-24 drugs removed from formulary
• 12 of 14 more added than removed

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Functioning

• Therapeutic Guidelines never denied- generated
  by pharmacy
• seen as lower priority
• Drug-Use Guidelinesnever denied
• 1-30 per year (3-6)

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Functioning

• All base decision to add on clinical safety and
  efficacy
• 13 of 14 use economic analysis..teaching
  hospitals more inclined to use p-economics
• 3 of 14 look only at cost of drug

42
Functioning

• 10 of 14 had guidelines on how to submit request
  to add
• Any attending MD can make request
• Some allow pharmacy and nursing to request, some
  require chief signature,
• Drug reps go through MDs to get their drugs added

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Functioning

• 1/2 Peer review
• Not formal or outlined
• Pharmacy does lit search and grunt work
• 11 of 14 oversee nonformulary drug use
• 5 issue a report of use by MD

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Drug Promotion

• Problem in all pharmacies
• 9 of 14 have policies on drug promotion
• Policies deal with access, involvement with
  MDs, samples
• Enforced by director of pharmacy (sign in and out)

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Effectiveness

• Characteristics associated with highly
  functioning committees
• personality of chairman integrity, respected,
  focus on efficacy and cost
• commitment of members willing to attend,
  energetic, forward thinking

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Effectiveness

• Characteristics associated with low-functioning
  PT Committees
• Promotional Activities of Drug Industry no
  medical education, marketing data-not clinical
  data
• Poor Attendance
• Interpersonal Dynamics of Members hidden
  agendas, proprietary interests, turf

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Discussion

• All had mission statements, but FEW were able to
  provide it
• Few have strategic plans-function routinely
  instead of filling hospitals needs
• No real evaluation process
• Minutes recorded but not distributed
• Workload not spread out

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Discussion

• DUE/DUR not a priorityconflict with published
  data on importance of DUR
• More drugs added than removed
• P-economics not applied, cost comparison and
  cost-utilization used
• Many lack peer review
• Many do not report nonform use

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Discussion

• Some have no drug promotion policy
• Policies are inadequate

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Not reported to Increase Effectiveness

• Lack of training in p-epi, p-economics, lit
  review, negotiation skills

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recommendations

• Require a written mission statement that is
  dynamic
• Require strategic plan that is reviewed by
  medical executive committee
• Create an appeal process
• Provide incentives meeting time and food
• Record AND DISTRIBUTE minutes

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recommendations

• 0.5 FTE including 1 RPH and director of pharmacy
  dedicated to PT activity
• Active DUR/DUE
• Make decisions to add on therapeutic guidelines
  and remove drugs regularly
• Peer review
• Report NF use

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recommendations

• Explicit policy on drug promotion enforcement,
  WHO ethical guidelines on drug promotion
• Find the right chairman