Drug formulary decision-making: Ethnographic study of 3 pharmacy and therapeutics committees.

PURPOSE: An ethnographic study of 3 pharmacy and therapeutics (P&T) committees was conducted to characterize the process by which evidence is weighted and decisions are made. METHODS: We recorded discussions and conducted an analysis of the transcripts from the 3 P&T committees for a 1-year period. We examined the content and ideas expressed during deliberations and synthesized themes to give a broader picture of the issues arising. Committee discussions were transcribed and the segments of each meeting that addressed any new formulary additions were then analyzed. Using constant comparison method, we generated a series of topic codes to characterize and classify that portion of the discussion. RESULTS: At 26 meetings across the 3 sites, 24 new drug formulary additions were discussed. A total of 1,093 discussion segments were identified and mapped to 7 broad categories related to discussion of evidence of need, efficacy/indications, safety, misuse potential, cost issues, committee decision-making issues, and discussion related to operationalizing use and implementation at the local institution. Overall, the leading category of discussion was efficacy/indications followed by evidence of need, operational issues, and cost issues, with some variation by site. The committees devoted substantially greater portions of their discussion to the logistics of using the drugs in their institutions than they did safety issues. We identified wide variations in specific drugs being considered and the relative amount of time devoted to various issues related to these drugs being discussed. We found discussions generally did not follow a systematic, standardized, rigorous, and reproducible approach. Discussions tended to be more idiosyncratic, individualized, varying from drug to drug, and at times devoted to a variety of tangential issues raised by committee members. CONCLUSION: P&T committee discussions at all 3 sites tended to be idiosyncratic and individualized, varying from drug to drug, and at times devoted to a variety of issues more tangentially raised by committee members. All spent less time talking about drug safety, in each case roughly half the time that they devoted to discussions of efficacy.

Development and implementation of a piperacillin-tazobactam extended infusion guideline.

Administration of ß-lactam antibiotics by extended infusion optimizes the pharmacodynamic properties and bactericidal activity of these agents resulting in a potential improvement in patient outcomes and reduction in drug expenditure. Consequently, a pharmacist-led piperacillin-tazobactam extended 4-hour infusion guideline was implemented hospital-wide at a 500-bed academic medical center. Each piperacillin-tazobactam infusion was prospectively monitored for 5 weeks to ensure accurate administration and identify barriers to guideline adherence. Overall, a total of 103 patients received 1215 doses of piperacillin-tazobactam by extended infusions. In all, 98% of the doses were administered at the correct extended infusion rate and 94% of the doses were given at the scheduled time. There were a total of 20 missed doses and 53 delayed doses, accounting for 2% and 4% of the total administered doses, respectively. The primary barrier to adherence was the patient not being on the unit at the time of the scheduled dose followed by the piperacillin-tazobactam dose not being available on the floor. While insufficient power prevented meaningful evaluation of clinical outcomes, we anticipate a conservative annual estimated cost savings of $108,529. Key elements contributing to our success included consistent pharmacy leadership, multidisciplinary involvement, thorough inservicing to health care professionals, hospital-wide implementation, and extensive quality assurance monitoring.