Part II: Managing Medication Use

Chapter
4
Medication Management
Kathy A. Chase

n  n n Key Terms and Definitions

Learning Objectives ■■ Closed formulary: A list of medica-
After completing this chapter, readers tions (formulary) which limits access
should be able to: of a practitioner to some medications.
1. Describe the purpose of a formulary A closed formulary may limit drugs to
system in managing medication use in specific physicians, patient care areas, or
institutions. disease states via formulary restrictions.
2. Discuss the organization and role of the ■■ Drug formulary: A formulary is a
pharmacy and therapeutics committee. continually updated list of medications
3. Explain how formulary management and related information, representing
works. the clinical judgment of pharmacists,
4. List the principles of a sound formulary physicians, and other experts in the
system. diagnosis and/or treatment of disease
5. Define key terms in formulary manage- and promotion of health.
ment. ■■ Drug monograph: A written, unbi-
ased evaluation of a specific medica-
tion. This document includes the drug
name, therapeutic class, pharmacology,
indications for use, summary of clinical
trials, pharmacokinetics/dynamics, ad-
verse effects, drug interactions, dosage
regimens, and cost.
■■ Drug therapy guidelines: A document
describing the indications, dosage regi-
mens, duration of therapy, mode(s) of
administration, monitoring parameters
and special considerations for use of a
specific medication or medication class.
■■ Drug use evaluation (DUE): A
process used to assess the appropriate-
ness of drug therapy by engaging in
the evaluation of data on drug use in a
given health care environment against
predetermined criteria and standards.
◆◆ Diagnosis-related DUE: A drug
use evaluation completed on pa-

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 tients with a specific disease state or for activities related to self governance
diagnosis. An example is the use of and for performance improvement of
antibiotics in patients with commu- the professional services provided by all
nity acquired pneumonia. practitioners privileged through medi-
◆◆ Prescriber-related DUE: A drug cal staff process.
use evaluation completed on ■■ Medication use review: A perfor-
patients managed by a specific mance-improvement method that
physician or physician group. For focuses on evaluating and improving
example, selected antibiotics may be medication-use processes with the goal
limited to infectious disease spe- of optimal patient outcomes.
cialists or drotrecogin alfa may be ■■ Nonformulary agent: A medication
limited to critical care specialists. that is not a part of the drug formulary.
◆◆ Drug-specific DUE: A drug use This may be due to the medication not
evaluation completed on a drug being considered for formulary addi-
(medication). tion or the medication being consid-
■■ FOCUS-PDSA: A performance ered but the P&T committee choosing
improvement model used by hospitals not to add it.
and health-systems. It includes the ■■ Open formulary: A list of medications
performance improvement elements (formulary) which has no limitation to
of measuring the output of the process access to a medication by a practitioner.
and modifying the process to improve ■■ Order entry rules: Logic established
the outcome. within the hospital information system
■■ Formulary restriction: The act of order entry module to notify prescrib-
limiting the use of specific formulary ers of adverse effects, drug interactions,
medications to specific physicians monitoring required or other actions
based on areas of expertise (e.g., cardi- required.
ology), patient disease state (e.g., acute ■■ Outcome assessment: A systematic
myocardial infarction), or location process of evaluating the appropriate-
(e.g., operating room). ness, safety and efficacy of a medica-
■■ Formulary system: An ongoing tion. The process involves review of
process whereby a health care organi- patient medical records to evaluate the
zation, through its physicians, phar- drug use against predetermined criteria
macists, and other health care profes- and standards.
sionals, establishes policies on the use ■■ Pop-ups: Information that appears
of drug products and therapies and on a computer monitor when specific
identifies drug products and therapies actions are taken. Hospital information
that are the most medically appropri- systems often use rules to determine
ate and cost-effective to best serve when pop-ups will occur. These pop-ups
the health interests of a given patient may contain clinical information about
population. medication use, potential drug interac-
■■ Health-system board: A committee tions, recommended monitoring, etc.
of hospital and community members ■■ Stop orders: Physician orders that are
chosen to govern the affairs of hospital automatically terminated. The P&T
or health-system. committee may establish stop orders
■■ Medical executive committee: A for medications that require additional
committee of the hospital medical evaluation after a specific time. Ex-
staff that has the primary authority amples of stop orders are antibiotic

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 therapy stopped after 7 days and nesir- but of the same pharmacologic or ther-
itide therapy stopped after 24 hours. apeutic class and usually having similar
■■ Therapeutic class review: An evalu- therapeutic effects and adverse-reaction
ation of a group of medications with profiles when administered to patients
an established therapeutic class (e.g., in therapeutically equivalent doses.
first-generation cephalosporins). The ■■ Therapeutic interchange: Authorized
review evaluates the indications for use, exchange of therapeutic alternatives in
pharmacokinetics/dynamics, adverse accordance with previously established
effects, drug interactions, dosage regi- and approved written guidelines or
mens, and cost to determine similarities protocols within a formulary system.
and differences.
■■ Therapeutic equivalent: Drug prod-
ucts with different chemical structures

n  n n
Introduction
Medication use management describes the process used to assure the safe and effective
use of drugs in a cost conscious manner. Key to medication management in the health-
system environment is the formulary system. The formulary system is a mechanism for
ongoing assessment of medications that are available for use. The system is managed by a
committee of experts, which includes pharmacists and physicians.
This chapter will discuss the medication management system with focus on the fol-
lowing:
■■ Formulary system
■■ Pharmacy and therapeutics committee
■■ Formulary management
■■ Drug use evaluation
■■ Medication use policies
■■ Published formulary

The Formulary System

A drug formulary is a continually updated list of medications and related information,
representing the clinical judgment of pharmacists, physicians, and other experts in the
diagnosis and/or treatment of disease and promotion of health. It is often described as a
list of medications routinely stocked by the health care system. The formulary was devel-
oped by hospitals in the 1950s as a management tool. It was initially used to assure that
physicians had an adequate and consistent supply of medications for their day-to-day
needs. A key purpose of the formulary was to discourage the use of marginally effective
drugs and treatments.
Over time, the formulary has evolved beyond a simple list of medications. It is
now one element of a system that includes medication use policies, a pharmacy and thera-
peutics committee, medication use evaluation, and formulary management. The formu-
lary, today, can be more accurately defined as a continually updated list of medications
and related information, representing the clinical judgment of pharmacists, physicians,
and other experts in the diagnosis and/or treatment of disease and promotion of health.
I n t r o d u c t i o n t o H o s p i ta l a n d H e a lt h - S y s t e m p h a r m a c y p r a c t i c e    61
 Formularies are fundamental to the
formulary system—defined as an ongo- n  n n
ing process which methodically evaluates
Key Point . . .
medications on an ongoing basis for inclu-
sion or exclusion, establishes guidelines The formulary has evolved beyond a list of
for optimal medication use, and develops medications to a system that manages the
policies and procedures for prescribing, drug use process.
dispensing, and administering medica-
tions. The formulary system is managed by . . . So what?
the pharmacy and therapeutics committee Standard definitions of formularies refer
or equivalent group—made up of an orga- to them as static compilations of recom-
nized team of medication system experts.
mended medications in a pharmacy. In
There are advantages and disadvan-
tages to a formulary system. The primary truth, they are really dynamic entities
advantage is that it provides a systematic that consist of a constantly changing
method to review scientific evidence on medication list, policies and procedures
clinical effectiveness and cost effectiveness
for managing that list, and tools used to
in drug selection decision, thus potentially
improving health outcomes while reducing encourage appropriate use of medications
costs. A major disadvantage, however, is on that list—e.g., therapeutic substitution,
that an overly restrictive formulary system drug utilization review).
may potentially reduce the quality of care
by limiting access to clinically indicated
medications.

The Pharmacy and Therapeutics Committee

The pharmacy and therapeutics committee (P&T committee) has oversight for medica-
tion management in the health-system. Specific regulatory or accrediting bodies may
confirm this accountability. To be effective, the committee must have the support of the
individual members as well as the health-system and medical staff as a whole.
Organization
The committee is generally a policy recommending body to the medical staff through
the medical executive committee—a group of the hospital medical staff in charge of
institutional governance and performance. The committee is responsible to the medical
staff as a whole, and its recommendations are subject to approval by the organized medi-
cal staff as well as the routine administrative approval process. More recently, in some
organizations, the P&T committee has reported directly to a non-medical staff advisory
committee of hospital and community members called a health-system board rather
than a local medical executive committee.
Because drug products and medical literature are continually changing, meetings
should occur at least four to six times per year. Generally, monthly meetings are needed
to keep the meeting time to 60–90 minutes.
Subcommittees or task forces have been established to facilitate meeting efficiency.
Examples of subcommittees include medication safety, drug review panels, and medica-
tion use review. The medication safety task force may be charged with review of adverse
drug events and medication errors, their trending, and development of plans for preven-

62   c h a p t e r 4 : M e d i c at i o n M a n a g e m e n t
tion of future events. Drug review panels may be focused on a particular specialty such
as cardiology or infectious disease and review drug products and guidelines in their area
of specialty. The medication use review task force may monitor one or more medica-
tions use reviews, evaluate the data and development plans to optimize specific drug use.
Figure 4-1 illustrates how these subcommittees relate to the organizational structure of
the P&T committee.
It is important to establish rules for a quorum to make certain that key stakeholders are
represented at meetings. Such rules may
establish a minimum number of members
that must be present to conduct a meeting
n  n n
or a minimum number of member types Key Point . . .
that must be present to conduct a meeting. Medication management is a multidisci-
For example, a committee with 15 mem-
plinary process.
bers might be required to have at least five
members present of which two must be . . . So what?
physicians and one must be a pharmacist Even though it is called the Pharmacy and
before a quorum has been established.
Therapeutics committee, representation
Committee Membership on the committee often includes physi-
P&T committee membership should in- cians, nurses, and respiratory therapists
clude pharmacists, nurses, physicians, ad-
given their roles within the medication use
ministrators, risk or quality improvement
managers, and others as appropriate. These process. The collective efforts of all of the
members are selected with the guidance of disciplines is needed to achieve optimal
the medical staff. Medication management health outcomes.
is a multidisciplinary process. Committee

Figure 4-1. Formulary management process.

Pharmacy Staff Medical Staff Professional Staff

Medication Use
Management Initiatives
Drug Review Panel
Evaluates drugs for consid-
eration and makes recom-
mendations

Pharmacy & Therapeutics Committee

* Review and Act on Recommendations Safety Committee
* Formulate Implementation Plan Evaluates medication safety
and makes recommen-
Medication Use Review
dations to reduce
Review the success of
implementation and ongoing
medication use

Medical and Hospital Staff Notification

* Newsletters
* Department Meetings
* Alliance with Pharmaceutical
Representatives

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membership should include nonphysician members such as nurses, respiratory therapists,
and other health care professionals. While the voting members of the P&T committee in
many hospitals remains the physician members only, this is changing as the committee
membership is evolving.
Responsibilities
The committee performs the following functions:
■■ Establishes and maintains the formulary system.
■■ Selects medications for formulary inclusion by considering the relative clinical, quality
of life, safety, and pharmacoeconomic outcomes. Decisions should be balanced to all
of the above. Decisions should include consideration of continuity of care (e.g., local
health plan formularies).
■■ Evaluates medication use and related outcomes.
■■ Prevents and monitors adverse drug reactions and medications errors.
■■ Evaluates or develops and promotes use of drug therapy guidelines.
■■ Develops policies and procedures for handling medications to include their procure-
ment prescribing, distribution, and administration.
■■ Educates health professionals to the optimal use of medications.
Formulary System Maintenance
The committee develops a list of medications for use in the organization. They may
also develop guidelines for the optimal use of the medications and/or for specific disease
management. They review the medication list and guidelines on a regular basis to assure
that it is current and meets the needs of the medical staff and patients.
Medication Selection and Review
The committee should have established methods for medication selection and review. A
written medication review is prepared from available literature. The review should be un-
biased, as should the discussion of the review. Meeting participants (committee members
and guests) should be required to discuss any conflict of interests prior to discussion of
the drug or drug class. Medication selection criteria should include medication efficacy,
safety, and cost.
■■ Is it a duplication of an existing formulary agent? If so, is it more effective? Safer?
Less costly?
■■ How should it be used?
■■ When should it be used?
■■ Who should use it?
■■ Are there any other special concerns?

Barriers to optimal formulary decisions may include physician experience with the
drug under consideration, physician preference for other agents, detailing by pharmaceu-
tical company representatives, and unpublished or anecdotal studies and reports. Selec-
tion criteria should be such to minimize the effect of the aforementioned barriers.
Medication Use Evaluation
Medication use evaluation (MUE) is the method for evaluating and improving medi-
cation-use processes with the goal of optimal patient outcomes. The P&T committee
should establish a regular process for reviewing how medications are used in the health-
system (i.e., medication use evaluation). Medications may be considered for review based

64   c h a p t e r 4 : M e d i c at i o n M a n a g e m e n t
on their use, safety, cost or a combination of factors. For example, antibiotics represent a
high use item; overuse of a particular antibiotic may place patients at risk for the devel-
opment of resistant infections; and some antibiotics may also be costly. Establishment of
specific criteria for use, review for compliance to the criteria, and routine review of the
data is the foundation of the medication use process. Key to the process is timely data to
review, action plan development, and follow-up.
Medication Safety Evaluation
Medication safety is evaluated through adverse drug reaction reports and medication
error reports. Such reports may be local (i.e., from the health-system) or global (i.e.,
literature, press releases). The impact of such reports should be considered relative to the
health-system population, resources, and alternatives. A report of increased bleeding in
patients over the age of 65 may not be critical in a pediatric hospital. However, reports
of infusion rate reactions may require changes in nursing procedures in drug administra-
tion. Such reports should be used in considering whether a drug should be added to the
formulary, retained on the formulary, or deleted from the formulary.
Drug Therapy Guidelines
Drug therapy guidelines are a listing of the indications, dosage regimens, duration of
therapy, mode(s) of administration, monitoring parameters and special considerations
for use of a specific medication or medication class. In a hospital or health-system, these
guidelines are developed with the oversight of practitioners with expertise in the use of a
specific medication or management of a disease state. The guidelines are often put into
practice via a pre-printed physician order sheet placed in the patient chart or computer-
ized order set.
The development of drug therapy guidelines is often the result of a medication use
review or medication safety evaluation. A review of this data may indicate that the drug
is not being used in an optimal manner with regard to patient selection, dosage, frequen-
cy, route, length of therapy, or a combination. The development and implementation of
drug therapy guidelines may foster the safe, efficacious and cost effective use of selected drug
products. Education of the professional and medical staff to these guidelines is critical to
their success. Just as important is a method for routine review of the guidelines to assure
they are current.
Policy and Procedure Development
The P&T committee is responsible for medication use in the hospital. This includes the
development of guidelines on historically pharmacy related topics of medication procure-
ment, selection, and distribution. In addition, they are responsible for the medication
administration process. This may include determining what medications are administered
in specific locations for the hospital (i.e., intensive care unit) or under specific conditions
(i.e., by chemotherapy certified nurse). Finally, they define the formulary management
process, specifically, guidelines for the evaluation of medications by the P&T committee,
frequency of such review, maintenance of the medication list, et cetera.
Education
The P&T committee must communicate its actions to health-system staff and physi-
cians. A newsletter is often employed to communicate these decisions. The newsletter
may also include clinical information on drugs added to the formulary, drug therapy
guidelines developed, and medication safety information available. The success of a newslet-
ter may be limited by the format and content. The newsletter should be visually pleas-
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ing, easy to follow, and succinct. Optimally, it should be limited to two to four pages
in length. The audience for the newsletter is generally broad and includes physicians,
nurses, pharmacists, and other health care professionals. Other methods to communicate
and educate others to P&T committee actions are presentation at medical staff depart-
ment meetings, nursing unit staff meetings, and pharmacy staff meetings and electronic
messaging through email or the health-system website. The P&T committee may also
assist in the development of programs to educate health care professionals or patients
regarding medications.
Regulatory and Accrediting Bodies
Regulatory and accrediting bodies may require a P&T committee and define its mem-
bership and responsibilities. Regulatory bodies requiring such activity include the State
Department of Health or Board of Pharmacy; this varies by state. Accrediting bodies re-
quiring this activity include The Joint Commission, the American Osteopathic Associa-
tion (AOA), and Commission on Accreditation of Rehabilitation Facilities (CARF). The
facility type will define the accrediting body; each has a slightly different interpretation
of the term formulary. Regulations and accreditation standards are dynamic and require
vigilance by the pharmacy to assure compliance.
Pharmacist Role
Pharmacists are essential to the formulary management process. Often pharmacists will
guide the P&T committee activities to assure optimal medication management. The
pharmacist responsibilities may include the following:
■■ Establish P&T committee meeting agenda.
■■ Analyze and disseminate scientific, clinical, and health economic information regard-
ing a medication or therapeutic class for review by the P&T committee.
■■ Conduct drug use evaluation and analyze data.
■■ Record and archive P&T committee actions.
■■ Follow-up with research when necessary.
■■ Communicate P&T committee decisions to other health care professionals such as
pharmacy staff, medical staff, and patient care staff.

Formulary Management
The formulary is the foundation of the formulary system. In its simplest form, the
formulary is a list of medications available for use at a hospital or health-system. This list
includes the dosage forms, strengths and package sizes of each of the medications on it.
Diligent management of this list has both patient care and financial implications. Patient
care considerations include medication efficacy and safety. Financial considerations are
the cost of the drug as well as the costs associated with stocking the medication such as
shelf space, drug outdates, and handling.
Formularies can be categorized by their access to medications as open or closed. An
open formulary has no limitation to access to a medication. Open formularies are
generally large. A closed formulary is a limited list of medications. A closed formulary
may limit drugs to specific physicians, patient care areas, or disease states via formulary
restrictions.
Formulary restrictions (i.e., limits on institutional drug use) do not necessarily
translate to optimal medication management. For example, limitation of an antibiotic to

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a restricted status may result in shifting to a
different antibiotic. While sometimes this n  n n
change is desirable, that may not always
Key Point . . .
be the case. The new agent of choice may
be more expensive or less safe than the re- Formulary restrictions do not necessarily
stricted agent. Careful consideration of the translate to optimal medication manage-
impact of the formulary product selection ment.
and/or restriction is critical to the process.
Some authors have suggested that restrict- . . . So what?
ing formularies has resulted in increased Formulary restrictions often have unin-
health care costs by increasing utilization tended consequences. For example, strict
1,2
of physician visits and hospitalizations.
limitations on the number of antibiotics
While this data has been criticized, it is
important to note the impact of formulary used within a hospital may allow microbes
3
decisions in total health care costs. The a better chance of adapting to these few
Institute of Medicine (IOM) evaluated the medications and developing antibiotic
Veterans Administration (VA) National
resistance in comparison to an institution
Formulary impact on health care costs in
4
six closed or preferred class of drugs. The with no restrictions on antibiotic use. The
IOM concluded that the VA National For- key is to carefully consider the potential
mulary was cost saving, probably generat- impact of formulary restrictions prior to
ing savings of $100 million over 2 years
implementation and to monitor the actual
and did not appear to have any effect on
hospital admissions for selected heart or impact after implementation.
ulcer related conditions.
Drug product selection should be
based on individual chemical entities. The Food and Drug Administration (FDA) de-
fines the equivalence of individual chemical entities or generic equivalents. A list of such
equivalents can be found in the Approved Drug Products with Therapeutic Equivalence
Evaluation commonly known as the Orange Book. Policies for the use and dispensing of
generically equivalent products should be set forth in the formulary system policy.
Many health systems have also established therapeutic equivalents and therapeutic
interchange programs. Therapeutic equivalents are drug products with different chemi-
cal structure but are of the same pharmacologic and/or therapeutic class and are expected
to have similar therapeutic effects and adverse effects. Examples of therapeutic equiva-
lents include first generation cephalosporins and histamine-2 blockers. Therapeutic
interchange is the authorized exchange of therapeutic alternatives in accordance with
previously established and approved written guidelines. Establishment of therapeutic
equivalents extends beyond the chemical entity. It must include the dosage strength,
dose frequency, and route of administration for the interchange. Examples of therapeutic
interchanges are listed in Table 4-1.
The P&T committee should establish guidelines for generic substitution and thera-
peutic interchange. Such guidelines should include the following:
■■ The pharmacist is responsible for selecting generically equivalent products in
concert with FDA regulations.
■■ Prescribers may specify a specific brand if clinically justified. The decision should be
based on pharmacologic and/or therapeutic considerations relative to the patient.
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Table 4-1.
Therapeutic Interchange Equivalence by Therapeutic Class
Therapeutic Class Generic Name Dosage Dosage Frequency Route
First generation Cefazolin 1 g Every 8 hr IV
Cephalosporins Cephalothin 1 g Every 6 hr IV
Cephapirin 1 g Every 6 hr IV
H2 blockers Cimetidine 300 mg Every 6 hr IV
Ranitidine 50 mg Every 8 hr IV
Famotidine 20 mg Every 12 hr IV

■■ The P&T committee determines therapeutic equivalents and how they are processed.
The pharmacist is responsible for the quality, quantity, and source of all medications,
chemical, biologicals, and pharmaceutical preparations used in the diagnosis and treat-
ment of patients. Such products should meet the standards of the United States Pharma-
copeia and the Food and Drug Administration.
Formulary maintenance is the ongoing process of assuring relative safety and efficacy
of agents available for use in the health-system. Processes used in formulary maintenance
include the following:
■■ New product evaluation
■■ Therapeutic class review
■■ Formulary changes (rationale for retaining or deleting an agent from the formulary)
■■ Nonformulary drug use review

New Product Evaluation

Pharmacists have the opportunity to assume a leadership role in the selection of agents to
the formulary. The evaluation of an agent should consider the indications for use, phar-
macokinetics, safety, and cost. Considerations to drug storage, mode of administration,
special considerations, and drug-dispensing issues should also be included in the evaluation.
Development of a standard format for new drug evaluations is useful in facilitating P&T
committee discussions. Standard elements include the following:
■■ generic name—List officially approved name of all chemical entities in the drug
product.
■■ trade name—List common trade name(s) of the drug product.
■■ therapeutic or pharmacologic class—State the pharmaceutical or therapeutic class to
which the agent belongs. Similar agents within the class may be listed.
■■ pharmacology—Describe the mechanism of action and related pharmacologic effects
of the drug. If the mechanism is unknown, state this.
■■ pharmacokinetics—Describe how the drug is handled by the body. Include onset of
effect, serum half-life, metabolic considerations, and route of excretion as appropriate.
■■ indications for use—State the indications approved for use by the Food and Drug
Administration. Include any additional uses under investigation.
■■ clinical studies—Briefly describe clinical study data supporting the indications for use.
This review should be an unbiased, comparative review of studies, which identifies

68   c h a p t e r 4 : M e d i c at i o n M a n a g e m e n t
 strengths and weaknesses as appropriate. Study description should include informa-
tion about the patient populations, inclusion and exclusion criteria, study design and
protocol, statistical analysis, outcomes, and conclusions.
■■ adverse effects/warnings—List adverse effects associated with the drug and the frequen-
cy of occurrence. Describe methods to reduce or treat adverse effects. Discuss the risks
and benefits of this drug therapy. Also, list any special precautions such as drug use in
pregnancy and excretion of the drug into breast milk.
■■ drug interactions—List drug-drug and drug-food interactions associated with this
agent, significance of these interactions, and methods for prevention.
■■ dosage range—List a dosage range for different routes of administration and indica-
tions for the drug. Include special dosing considerations for renal disease, age, and
hepatic function.
■■ dosage form and cost—List the dosage form and strengths proposed for formulary ad-
dition. Include the cost of each dosage form and strength. A table listing comparable
agents may be useful in determining the value of a formulary addition or modification.
■■ summary—Summarize the information provided in a single paragraph.
■■ recommendation—State the recommendation and rationale for the recommendation.
Recommended actions may include formulary addition, formulary restriction, formu-
lary deletion, or do not add to formulary.
■■ references—List references used. Reference materials useful in preparation of the for-
mulary monograph should be unbiased
and current. Peer-reviewed primary
literature is optimal whenever possible. n  n n
Other resources include textbooks such Key Point . . .
as American Hospital Formulary Service
Conditional approval allows the P&T
Drug Information and Drug Facts and
Comparisons. Electronic databases such committee to further assess the use and
as DrugDex (www.micromedex.com), safety of the product before final formulary
Medline (www.ncbi.nlm.nih.gov/ addition.
entrez/query.fcgi?), and National
. . . So what?
Guideline Clearinghouse (www.
guideline.gov) are often useful. A “wait and see” attitude often serves a

In preparing the drug monograph, P&T committee well when deciding to add
it is important to understand the P&T a new drug. Many new drugs on the mar-
committee needs. Some committees desire ket can have insufficient evidence of safety
a detailed analysis of the points listed above,
because they only need to be tested on a
whereas others prefer an abbreviated
monograph. Critical elements to both are limited number of patients prior to FDA ap-
efficacy, safety, and cost. To assist the P&T proval. In addition, utilization patterns for
committee membership, use of tables and the new drugs by physicians will also be
comparative data within a therapeutic class
unclear. Unexpected widespread adoption
or indication is useful. Knowing the cost
of an agent is meaningless if the cost of of a very expensive medication can bust
comparator agents is unknown. The rec- the pharmacy drug budget. Conditional
ommendation put forth by the pharmacist approval can help things from getting out
should be concise, include the rationale for
of hand.
the decision, any possible formulary dele-
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tions that might result by adding this agent, guidelines for use when appropriate, and
consideration for future review. Some health systems add new agents to the formulary
for a limited or trial period such as 3 or 6 months. This conditional approval allows the
P&T committee to further assess the use and safety of the product before final formulary
addition.
Therapeutic Class Review
The regular review of drug classes by the P&T committee is useful in assuring that
optimal drug therapeutic options are available. Therapeutic class reviews should not be
so broad or all inclusive so as to not be meaningful. The review of antimicrobials may
be too broad whereas the review of quinolone antibiotics may prove to be more useful.
The committee may set forth criteria for these reviews. Such criteria might include new
medical information, adverse event profiles, purchase or use data and cost. Some P&T
committees conduct a therapeutic class review with each consideration for formulary
addition. The objective is to have the optimal agents within a therapeutic class in terms
of efficacy, safety, and cost. The end result of a therapeutic class review may be formulary
modifications (i.e., additions or deletions), implementation of a drug use review or the
development of therapeutic guidelines.
Formulary Changes
A process to continually update the formulary must be established. Such a process should
include a method for making additions and deletions to the formulary. This process
typically involves the submission of a request for formulary addition or deletion from the
pharmacy or medical staff. This request may be written or verbal. Requests generally require
specific information.
■■ Agent to be considered for addition or deletion.
■■ Rationale for request. This should include the impact on the cost and quality of
patient care.
■■ Alternative agents currently on the formulary.

Some organizations require or permit the requesting individual to attend the P&T
committee to support their request.
Nonformulary Drug Review
The objective of a formulary is to have the most efficacious, safe, and cost effective
agents available for routine use in the health-system. On occasion, unique patient needs
may require the use of a nonformulary agent. To prevent the erosion of the formulary
system by overuse of nonformulary agents, a process for the management of nonfor-
mulary agents should be in place. Such a process should include a policy for the use of
nonformulary drugs, procedure for procurement of nonformulary drugs, and regular
review of nonformulary drug use by the P&T committee. The policy for use of nonfor-
mulary drugs should include pharmacist contact with the prescribing physician to offer
alternatives. It may also include the completion of a nonformulary request form by the
prescribing physician or authorization by the P&T committee chair prior to dispensing.
The procedure for drug procurement should be well-defined and communicated to the
pharmacy, medical, and nursing staff so that expectations are appropriately understood.
Such a procedure may indicate up to a 24-hour delivery time for nonformulary medica-
tions. It may also permit the use of a patient’s own medications in concert with other

70   c h a p t e r 4 : M e d i c at i o n M a n a g e m e n t
hospital policies. The ongoing assessment of nonformulary drug use by the P&T commit-
tee is an important part in managing the medication process. Critical information for the
committee to consider includes the agent used, formulary alternatives, number of times
used in previous 6–12 months, patient safety, and cost impact. Understanding this infor-
mation will allow the committee to determine an action plan. Such actions may include
reconsideration of an agent for formulary addition, development of guidelines for use of
a drug within a therapeutic class or disease state, or individual physician intervention.
A national survey of hospital pharmacy practice was conducted in 2007.9 The
authors described the various formulary techniques used in their hospitals (those afore-
mentioned in this chapter). They noted the decline of all but two of these techniques:
therapeutic interchange and nonformulary medication management. The use of clinical
practice or drug therapy guidelines has become a key tool in managing drug use in the
health-system.
A new and evolving method of formulary management has resulted from automating
the medication prescribing process. Computerized prescriber order entry facilitates the
implementation and compliance with drug therapy guidelines. Formulary management
oversight includes the establishment and/or review of order entry rules. Such rules may
include weight based dosing, required laboratory tests, and allergy checks. In addition, the
responses (pop-ups) to the rules may be determined by the P&T committee through the
formulary management process. Review of
this information will be a key element in n  n n
managing and monitoring medication use
Key Point . . .
throughout the health-system.
Medication use evaluation (MUE) encom-
Drug Use Evaluation passes the goals and objectives of DUE in
Drug use evaluation (DUE) is a systematic its broadest application, with an emphasis
process used to assess the appropriateness on improving patient outcomes.
of drug therapy by engaging in the evalu-
ation of data on drug use in a given health . . . So what?
care environment against predetermined In some respects, the differences between
criteria and standards. Medication use MUE, DUE, and outcomes assessment are
evaluation (MUE) encompasses the goals
arbitrary. Nevertheless, these definitions
and objectives of DUE in its broadest
application, with an emphasis on improv- have evolved in response to a tendency for
ing patient outcomes. Use of MUE rather some pharmacists to only see medication
than DUE emphasizes the need for a more use as it relates to the world of pharmacy.
multifaceted approach to improving medi-
Therefore, compliance with formulary
cation use.
Medication use or drug use evalu- restrictions, pharmacy policies and proce-
ation programs were first established in dures, and other processes are sometimes
the 1980s. They provide an ongoing, emphasized over the actual outcomes
structured, organized approach to ensure
achieved by patients. Redefining terminol-
that drugs are used appropriately. More
recently, the term outcome assessment has ogy can refocus efforts of medication use
been used to describe such programs. The evaluation toward achieving the goal of
desired endpoint is the same—safe, effica- positive patient outcomes.
cious drug therapy.
I n t r o d u c t i o n t o H o s p i ta l a n d H e a lt h - S y s t e m p h a r m a c y p r a c t i c e    71
 Medication use evaluation programs should be incorporated into the overall hospital
performance improvement process. They should employ the performance improvement
model used by the health-system. There are multiple performance improvement models.
A common model used in health-systems is FOCUS-PDCA or (PDSA). The acronym is
described below:
Find process to improve
Organize a team that knows the process
Clarify current knowledge of the process
Understand causes of process variation
Select process improvement
Plan
Do
Check (or Study)
Act
Figure 4-2 illustrates a drug use evaluation using the PDCA model for antibiotic
prophylaxis for surgery.
Pharmacists can take a leadership role in designing the drug use evaluation pro-
grams. The program should measure and compare the outcomes of patients who received
drug therapy in concert with approved criteria versus those that did not. Selection of
agents for drug use evaluation programs should be based on whether a drug is high-
use, high-cost, or high-risk. Many drugs fall into more than one category: thrombolytic
agents are high-cost and high-risk; select antibiotics may be high-use. Medication use
criteria may be diagnosis-related, prescriber-related, or drug-specific.
Diagnosis-related DUE criteria identify indications for which select drug(s) may be
appropriate for a given disease state. For example, the use of selected antibiotics for com-
munity acquired pneumonia. Use of other antibiotics would fall outside the approved list
and require follow-up.
Prescriber-related DUE criteria identify specific physicians whom the P&T committee
has determined may use certain drugs. For example, selected antibiotics may be limited to
infectious disease specialists or drotrecogin alfa may be limited to critical care specialists.
Drug-specific DUE criteria focus on specific aspects of a select drug such as the
dose or dosing frequency. For example, the dosage regimen of a low molecular weight hepa-
rin might be reviewed. Dosage regimens outside the criteria would require action.
Pharmacists, working with key physicians, develop criteria for drug use evaluation.
The criteria should be focused and limited. Select three to five criteria to evaluate that are
meaningful and simple to collect. If possible, data should be collected during the patient
visit (concurrent) rather than retrospectively (chart review). Concurrent review often is
more complete. It allows the pharmacist to obtain information from the prescriber that
may not have been clear in the medical record. It also provides timely information to
act on. Because medical information is dynamic, the most meaningful drug use evalua-
tions should reflect current practice patterns rather than those of 6–18 months ago. The
criteria should also include a number of patients to be reviewed and the time period. For
example, “20 patients each month” receiving the drug are reviewed. The drug use evalu-
72   c h a p t e r 4 : M e d i c at i o n M a n a g e m e n t
 ation criteria are presented to
the P&T committee for their
review and endorsement prior
to commencing data collec-

Analyze Cause
tion.

Plan for the Future

Negative Results

Positive Results

Maintain Gains
Technology may be used
to collect or screen data. Use

ACT
of information systems to
identify patients for review
and collate the data will
facilitate the process. Hand-
held computers or personal

and bar graphs

data assistants (PDAs) may be
Evaluate Results

2. Correlate data

control charts
findings with

with medical
metrics for

4. Share data
useful in the data collection
guidelines
CHECK

3 months
1. Evaluate

3. Publish

process.
staff
Once the data has
been collected, it should be
compiled for review. The use
of trend graphs or control
measure metrics
Propose Solutions

of improvement
with physicians

charts are helpful in iden-

pharmacists to
impact metrics
3. Explore areas
methods to

impact and

tifying opportunities for

2. Determine

positively
1. Establish
DO

metrics

improvement. The result of

4. Utilize

a drug use evaluation may

be validation that drug use is
appropriate and safe. How-
ever, it may also indicate an
2. Identify areas
Analyze Cause

3. Validate data

opportunity for improving

1. Chart review

4. Determine if
focus areas
Figure 4-2. PDCA Model: Antibiotic prophylaxis for surgery patients.

impacted
for focus

the way a drug is used. Once

can be

the data is collated, it may be

beneficial to form a task force
to develop an action plan.
This task force should in-
clude key physicians, nurses,
prophylaxis is not in concert

compliance resulting in high

Determine Present Situation

pharmacists, and other health

steps that lead to guideline
Objective: Identify action

care professional appropriate

Hypothesis: Antibiotic

effective drug therapy

quality, safe, and cost
with CMS guidelines

to the drug therapy under

PLAN

review. The task force should

develop an action plan and
criteria for ongoing monitor-
ing. The action plan may
include development of drug
use guidelines, preprinted or-
ders, medication order entry
Define Project

prophylaxis
for surgery

rules, professional staff educa-

Antibiotic

tion, formulary changes, or a

combination of these actions.
The drug use evaluation results

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and action plan are presented to the P&T committee for consideration. The committee
will review and endorse and/or modify the plan for implementation and follow-up. A
single drug use evaluation should not continue indefinitely. Once the desired endpoint
has been achieved, an ongoing review may be discontinued or conducted less frequently
(e.g., once or twice a year).

Medication Use Policies

Medication use policies are critical in the management of medications in the health care
settings. Such policies should include the following:
■■ Formulary management
■■ P&T Committee
■■ Medication prescribing, dispensing, and administration

Formulary Management
Formulary policies should include information on who may use a specific agent (for-
mulary restrictions), how a drug is added or deleted from the formulary, how a drug is
stocked, and which drugs are stocked. The formulary restriction policy should specifical-
ly define how items are selected for formulary restriction, rationale for selecting approved
prescribers, and a method for managing the process. A formulary policy should describe
the method for drug addition and deletion as well as nonformulary drug use. A policy
should describe how an agent is added to the pharmacy stock once it is added to the for-
mulary and who gets to decide. For example, the P&T committee approves the addition
of a chemical entity added and the pharmacy manager selects dosage forms, strengths, et
cetera, or the P&T committee determines the chemical entity and dosage form(s) and
the pharmacy manager selects the strengths or sizes to be stocked. The basic policies and
procedures governing the formulary system should be incorporated in the medical staff
bylaws or in the medical staff rules and regulations.
Pharmacy and Therapeutics Committee
The policy should address the committee membership, operation, and responsibilities.

Medication Prescribing, Dispensing, and Administration

Organizational policies on the prescribing, dispensing, and administration of pharma-
ceuticals are required and necessary to ensure safe medication use. Such policies should
address all aspects of the medication process.
■■ writing medication orders or prescriptions—Defines practitioners that may write
medication orders or prescriptions in concert with state and federal regulations.
This or related policies may also include the format for order writing and unac-
ceptable abbreviations.
■■ verbal orders—Defines who may accept a verbal order and the transcription process of
such an order. This policy should address the reading back of the order to confirm its
accuracy.
■■ stop orders—Defines the orders that are automatically terminated, how the prescriber
is notified, if appropriate, and the method for their reinstatement. Stop orders are
often established for medications that require additional evaluation after a specific
time. Examples of stop orders are antibiotic therapy stopped after 7 days and nesirit-
ide therapy stopped after 24 hours.

74   c h a p t e r 4 : M e d i c at i o n M a n a g e m e n t
■■ investigational drug orders—Defines how investigational drugs are managed in the
health care system. This policy should include the review process as well as the meth-
od for prescribing, dispensing, administering, and monitoring investigational agents.
■■ controlled substances—Defines the flow of controlled substances through the health
care system. This policy should include approved prescribers, the ordering process
from the pharmacy and the vendor, the distribution and tracking of use, discrepancy
tracking and follow-up, and management of diversion.
■■ generic and therapeutic substitution—Defines how a drug is selected for generic
substitution and therapeutic equivalents approved by the P&T committee. It should
describe how an alternative agent may be prescribed if deemed medically necessary.
■■ self-administration of medications—Defines the conditions and process for the admin-
istration of medication by the patient in the hospital setting.
■■ medication samples—Defines the condi-
tions and process for the use of medica-
tion samples in the hospital or clinic n  n n
setting. Key Point . . .
■■ floor stock—Defines the criteria for
Organizational policies on the prescribing,
selecting agents for floor stock, process
for modifying the stock, and the regular dispensing, and administration of phar-
review of the stock by the P&T com- maceuticals are required and necessary to
mittee. ensure safe medication use.
■■ definition of order interpretation—
. . . So what?
Defines the meaning of specific types
of orders including sliding scale orders, Policies are developed for common, well
range orders, as needed orders, tapering understood problems seen in the media-
orders, and titrating orders. tion use process. They are designed to
■■ medication administration times—De-
ensure that the produces and services
fines specific medication administration
times and rules for interpretation. This provided by a pharmacy are of consistent
may include the definition of stat and high quality. Rather than re-inventing the
related terminology. wheel each time a problem occurs, clear
■■ adverse drug reactions—Defines an
directions are given delineating responsi-
adverse drug reaction, the reporting
process, and monitoring methods. bilities and actions. Policies are not meant
■■ medication errors—Defines a medica- to replace professional judgment of phar-
tion error, the reporting process, and macists (e.g., I know it is a bad idea. I am
monitoring methods.
just following our policy). They are meant
■■ others—Other topics for policy consid-
eration include pharmaceutical repre- to supplement and guide pharmacist deci-
sentatives, pharmacy hours of service, sion making.
emergency medications, and medica-
tion delivery devices.

Published Formulary
The published formulary should provide information on the medications approved for use,
basic therapeutic information about each item, information on medication use policies and
procedures, and special information about medications such as dosing guidelines, etc.
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Medication List
The key element of the published formulary is the list of medications approved for use.
This section includes both entries for each medication and indexes to facilitate use.
Medication entries may be arranged alphabetically by generic name and trade
(synonym) name, therapeutic class, or a combination. At a minimum, each drug entry
should include the following:
■■ generic name of primary active ingredient—Combination products may be listed by
generic ingredients or trade name.
■■ trade or synonym name that is commonly used—A disclaimer in the introduction to the
formulary should explain that the presence or absence of a trade name does not imply
that it is or is not the agent stocked by the pharmacy.
■■ dosage form, strength, and size stocked by the pharmacy
■■ active ingredients (formulation) for combination products

Additional information that may be added:

■■ DEA schedule (C-II through C-V)
■■ special precautions—Such as for im use only and protect from light.
■■ pediatric or adult dosage ranges
■■ cost information—Some health-systems have chosen not to publish actual purchase
prices for confidentiality reasons but rather to list a cost scale to allow for price com-
parisons. Cost information is most useful when drugs are arranged within a therapeu-
tic group or class to allow for easy comparison.
The medication list should include one or more indexes. The index should assist the
user in locating the medication entry by generic name. The index should include both
generic and trade name entries. The trade name entry may state “see generic name, page
123.” Such an index may be incorporated into the formulary itself. If that is done, then
the formulary listing should be alphabetical and include both generic and trade names.
A second index type is the therapeutic index. This index arranges drugs generically by
therapeutic or pharmacologic class. It is particularly useful for the prescriber that is not
familiar with the formulary of a health-system and desires to prescribe a certain type of
drug (i.e., ACE inhibitor).
Medication Use Policy and Procedures
Inclusion of information on the prescribing, dispensing, and administration of medica-
tions in the published formulary provides a quick reference for health care providers.
Either selected policies may be published or key information summarized in an abbrevi-
ated format. Policies for inclusion are the formulary policy, P&T committee policy, and
organizational regulations regarding medication use. Information on pharmacy operat-
ing procedures may be beneficial. These would include hours of services, prescription
policies, medication distribution procedures, contact information and other pharmacy
services such as anticoagulation monitoring or pharmacy newsletters.
Medication Use Guidelines
This section should detail guidelines for medication use, which are approved or endorsed
by the P&T committee. Such guidelines may include preprinted orders and clinical
pathways that have been developed. Examples of medication use guidelines are provided
below.

76   c h a p t e r 4 : M e d i c at i o n M a n a g e m e n t
■■ Antibiotic use guidelines
■■ Antibiotic use in surgical prophylaxis
■■ Community acquired pneumonia clinical pathway
■■ Weight-based heparin orders
■■ Potassium replacement orders
■■ ICU sedation guidelines
■■ Thrombolytic therapy guidelines for stroke
■■ Alcohol detoxification orders

Special Information
The information in this section is health-system specific. It should be tailored to the
needs of the professional and medical staff based on the services provided by the health-
system and the pharmacy. Examples of topics to include are below.
■■ Nutritional products approved for use
■■ Equivalent dosage tables (e.g., pain medications, corticosteroids)
■■ Parenteral nutrition formulas
■■ Pediatric dosages
■■ Potassium content of drugs or foods
■■ Antidote list
■■ Advanced Cardiac Life Support (ACLS) or emergency medication list and dosages
■■ Metric conversion table
■■ Serum drug levels
■■ Standard concentrations of drugs in IV solutions
■■ Common equations used (e.g., ideal body weight, estimated creatinine clearance, anion
gap)
■■ Antibiograms
■■ Drug dosing in renal or hepatic dysfunction
■■ Examples of forms that are routinely used such as nonformulary drug requests, ad-
verse drug reaction reports

Publishing the Formulary

The formulary must be published regularly. The medication list should be readily avail-
able to all personnel involved in the medication process. Electronic versions of the formu-
lary may be preferable. Copies of the formulary should be made available where medications are
prescribed, administered, and dispensed. Printed formularies are often revised and printed
annually. A method should be established for updating the formulary between editions.

Summary
The pharmacist plays a critical role in the management of medication use in the health-
system. As the drug expert, the pharmacist can assure safe, efficacious, and cost effective
drug use through the formulary system. Ongoing formulary maintenance and routine
drug use evaluations are key elements in this process. Focused consideration of medication
safety in all medication related discussions optimizes formulary system management.

References
1. Foulke GE, Siepler J. Antiulcer Therapy: An Exercise in Formulary Management. J Clin Gastroenterol.
1990;12(suppl 2):S64-8.

I n t r o d u c t i o n t o H o s p i ta l a n d H e a lt h - S y s t e m p h a r m a c y p r a c t i c e    77
 2. Kozma CM, Reeder CE, Lingle EW. Expanding Medicaid drug formulary coverage. Effects on utilization
of related services. Med Care. 1990 Oct;28(10):963-977.
3. Posey LM. Formularies and quality of care: Pharmacoeconomics drives revisionist thinking. The Consul-
tant Pharmacist.1996 May;11(5).
4. Blumenthal D, Herdman R, eds. Description and Analysis of the VA National Formulary. VA Pharmacy
Formulary Analysis Committee, Division of Health Care Services, Institute of Medicine; 2000.
5. Formulary Management. The Academy of Managed Care Pharmacy’s concepts in managed care pharma-
cy. Academy of Managed Care Pharmacy. Available at: http://www.amcp.org/amcp.ark?p=AAAC630C.
Accessed June 20, 2010.
6. Tanielian T, Harris K, Suárez A, et al. Impact of a Uniform Formulary on Military Health-system Prescrib-
ers: Baseline Survey Results. National Defense Research Institute and Rand Health; 2003.
7. White paper: formulary development at express scripts. Available at: http://www.express-scripts.org/re-
search/formularyinformation/development/formularyDevelopment.pdf. Accessed June 20,2010.
8. American Society of Health-System Pharmacists. ASHP Statement on Medication Use Policy Development.
Bethesda, MD: American Society of Health-System Pharmacists; draft.
9. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital
settings: prescribing and transcribing 2007. Am J Health-Syst Pharm. 2008. 65: 827-843.
10. American Society of Health-System Pharmacists. ASHP guidelines on the pharmacy and therapeu-
tics committee and the formulary system. Am J Health-Syst Pharm. 2008; 65:1272-1283.
11. American Society of Health-System Pharmacists. Principles of a sound formulary system. Bethesda,
MD: American Society of Health-System Pharmacists; 2000, 2006.
12. American Society of Health-System Pharmacists. ASHP statement on the pharmacy and therapeutics
committee and the formulary system. Bethesda, MD: American Society of Health-System Pharmacists;
2008.

Chapter Review Questions

1. The following elements of the formulary system are used to manage drug costs
(select all applicable).
a. Therapeutic interchange
b. Nonformulary drug use
c. Generic substitution
d. Drug Therapy guidelines
Answer: a, c, d. Nonformulary drug use often drives up drug costs in a health-system.
2. Once the formulary has been established, no further action is required except
to add new pharmaceutical entities as they become available.
a. True
b. False
Answer: b. False. The formulary must continually be evaluated for additions and
deletions.
3. P&T committees may have subcommittees to facilitate specific objectives. Ex-
amples of subcommittees include (select all applicable)
a. Medication Safety
b. Antibiotic/Infectious Disease
c. Laboratory Testing
Answer: a, b. Laboratory testing is not under the purview of the P&T committee;
but rather the pathology committee of the medical staff or health-system.

78   c h a p t e r 4 : M e d i c at i o n M a n a g e m e n t
4. When selecting a drug for formulary addition, which of the following should
be considered? (select applicable)
a. Does it come in unit dose packaging?
b. Is it a duplication of an existing formulary agent?
c. How should it be used?
d. Is it safer than similar agents already on formulary?
e. Will the vendor give the health-system free samples?
Answer: b, c, d.

5. The _______________________ is responsible for oversight of all medication

use in the hospital.
Answer: Pharmacy and therapeutics (P&T) committee.

6. Therapeutic interchange is the

a. Interchange of generic equivalents
b. Interchange of chemically different drugs within the same pharmacologic or
therapeutic class
c. Interchange of chemically different drugs within the same pharmacologic or
therapeutic class in accordance with approved written guidelines
Answer: c. Therapeutic interchange must be approved prior to implementation.

7. Medication use evaluation is a systematic approach to monitoring drug

therapy and associated outcomes. The optimal data collection period is
_____________________
Answer: Concurrent or during the patient visit.

8. The Pharmacy and Therapeutics Committee is a multi-disciplinary committee

including physicians, pharmacists, and nurses.
a. True
b. False
Answer: a. True. While pharmacists and nurses may not be permitted to vote, they
are important members of the committee.

9. The rationale for completing a drug use evaluation is to

a. Validate drug use is safe and appropriate.
b. Determine the most common prescribers of a specific drug.
c. Educate the nursing staff on appropriate medication administration.
Answer: a. DUE monitoring criteria often include indication for use and adverse
events as well as other criteria such as dose, frequency, route of administration, etc.

10. The pharmacist is not responsible for assuring the following

a. Quality, quantity and source of all medications in the health-system.
b. All medications in the health-system meet FDA and USP standards.
c. All brands of formulary agents are available for use in the health-system.
Answer: c. Formulary systems seek to reduce the number of brands of medication
because offering all brands is inefficient and costly.

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Chapter Discussion Questions
1. How do formularies influence medication use within institutions?
2. How can pharmacists take a leadership role in the formulary management?
3. What are key elements in successful and efficient operation of a Pharmacy and
Therapeutics Committee?
4. How are Drug Use Guidelines incorporated into the formulary management pro-
cess?

80   c h a p t e r 4 : M e d i c at i o n M a n a g e m e n t