Formularies in integrated health systems: Fallon Healthcare System.

Formulary management implications in a Massachusetts integrated health system consisting of a physician group practice clinic, an HMO, a hospital, a long-term care facility, a physician-hospital organization, a home care agency, and a clinical laboratory are described. Two formularies govern drug therapy for most patients in the system. The formulary of the group practice (Fallon Clinic) is used for 180,000 patients covered by the HMO. The formulary of Saint Vincent Hospital influences drug use in the hospital and the system's long-term care facility. Both formularies require formal review before a drug is added and have structured processes for nonformulary requests. Entities in the health system are still being integrated at the operational level. The system does not have a formal position on integration of the formularies, but information exchange and collaboration occur because of overlap in the membership of the committees that approve the two formularies. Formulary decision-making has been coordinated to account for systemwide needs (for example, enoxaparin was not added to the hospital's formulary because of concerns about continuity of drug therapy after discharge, and the hospital's formulary includes the oral agents on the clinic's formulary). The systems uses one group-purchasing organization and one wholesaler; one person negotiates separate contracts for the hospital and the clinic. System coordination of formulary management has had little effect on daily activities of the pharmacy staff. Drug use among ambulatory patients in this integrated health system is influenced by the clinic's formulary, and drug use among patients in the hospital and subacute care beds is influenced by the hospital's formulary.

Formulary evaluation of third-generation cephalosporins using decision analysis.

A structured, objective approach to formulary review of third-generation cephalosporins using the decision-analysis model is described. The pharmacy and therapeutics (P&T) committee approved the evaluation criteria for this drug class and assigned priority weights (as percentages of 100) to those drug characteristics deemed most important. Clinical data (spectrum of activity, pharmacokinetics, adverse effects, and stability) and financial data (cost of acquisition and cost of therapy per day) were used to determine ranking scores for each drug. Total scores were determined by multiplying ranking scores by the assigned priority weights for the criteria. The two highest-scoring drugs were selected for inclusion in the formulary. By this decision-analysis process, the P&T committee recommended that all current third-generation cephalosporins (cefotaxime, cefoperazone, and moxalactam) be removed from the institutions's formulary and be replaced with ceftazidime and ceftriaxone. P&T committees at other institutions may structure their criteria differently, and different recommendations may result. Using decision analysis for formulary review may promote rational drug therapy and achieve cost savings.

Evaluation of amitriptyline use for depression when prescribed by internists and psychiatrists.

The efforts involved in structuring and implementing a drug utilization review (DUR) program that was designed to assess the use of amitriptyline for depression when prescribed by internists and psychiatrists is described. In-depth audit criteria were used to identify deviations from the criteria for each group. An immediate goal of this amitriptyline DUR program is to apply the results of the study toward the implementation of a targeted, multifaceted educational program. The design of the DUR program should emphasize the individual needs of each of the two study groups.