A primer on formulary structures and strategies.

Formularies are a tool for managing costs, optimizing patient access, and improving overall health outcomes. The general goal of formularies is to provide access to appropriate therapy while promoting effective resource utilization, which allows the managed care pharmacy organization to operate sustainably. Traditional formulary strategies have included open and closed formularies as well as tiered formularies. However, other formulary structures have emerged in support of the focus on product value. The formulary development process is primarily driven by the pharmacy and therapeutics (P&T) committee and value committee within an organization. Key considerations such as member population, regional differences, regulatory/compliance implications, and benefit design strategies may influence payers to create a customized formulary to provide additional value to their members while managing costs. With the rise of high-cost and specialty products, formularies continue to serve as an important tool for managed care pharmacy organizations. Ongoing trends, such as biosimilars, prescription digital therapeutics, and addressing health equity, will shape future strategy and management of formularies.

The role of medicines and therapeutics committees structure in supporting optimal antibacterial use in hospitals in Uganda: A mixed method study.

Although the roles of Medicines and therapeutic committees (MTCs) have been expanding, there is limited information on the role of their structure in optimal antibacterial use in hospitals, especially in low-and-middle-income countries. Our study explored the structure and role of MTC in supporting antibacterial use in regional referral, general hospitals and tertiary private not-for-profit (PNFP) hospitals in Uganda. We conducted an explanatory sequential mixed-method approach with triangulation to explore the structure and functional role of MTCs from August 2019 to February 2020 in hospitals in Uganda. Quantitative data was collected using an interviewer-administered questionnaire among chairpersons or secretaries of MTCs and was analysed using descriptive statistics. We conducted key informant interviews using an interview guide among long-term serving members of MTCs to collect qualitative data which triangulated the quantitative data. The study revealed that sixteen hospitals had successfully established MTCs with an average duration of the MTCs' existence of 5.6 (+2.7) years. The membership of the MTCs varied between 7 and 14, with a median value of 10, and the majority of members in MTCs were pharmacists (15 out of 16) and clinical specialists (13 out of 16). The most frequent subcommittees of the 16 hospitals MTC were supply chain (n = 14), antimicrobial stewardship (n = 13), and infection control (n = 12). Majority (14 out of 16) of the MTCs supported availability and access of antibacterial use by selecting and evaluating antibacterials agents for their formulary lists using established criteria. Additionally, 15 out 16 MTCs conducted antimicrobial stewardship activities to support optimal antimicrobial use. In our study, MTC membership and subcommittees were critical structural components that aided the selection and evaluation antibacterials on hospital formulary lists and they supported optimal antibacterial use through implementing various antimicrobial stewardship activities. There is a need for the Ministry of Health to conduct more training on operationalising MTCs structures in all hospitals.

Establishment of a children's Drugs and Therapeutics Committee to ensure evidence-based and cost-effective medical treatment for children.

The prevalence of undocumented medical treatments among children is a significant issue, as well as many EU countries lack access to newly developed children-friendly medicines. Consequently, there is a pressing need for supplementary resources that can facilitate informed decision-making regarding children's medication. We therefore aim to describe the process of establishing a children's Drug and Therapeutics Committee (cDTC), as well as the preparing and implementation of recommendations for children in the capital region of Denmark. Following the guidelines outlined by the World Health Organization, we established a cDTC, and recommendations for paediatric medication practice were constructed from assessments of medication use patterns among children in the capital region between 2019 and 2021. The recommendations were meticulously crafted based on evaluation of the current marketing authorization landscape and existing best available evidence. In 2019, the capital region established the first cDTC supported by expert councils and an editorial board. A total of 2429 purchase item numbers covering 1 222 846 defined daily doses and 592 088 purchased packages covering 10 200 000 defined daily doses were identified in the secondary and primary sectors, respectively. Three comprehensive lists covering recommendations for newborns and children were published between 2021 and 2020 totaling 331 recommended pharmaceutical products. The recommendations primarily intended for use in the secondary healthcare sector were implemented through the revision of 38 paediatric- and six neonatal product ranges throughout capital region. In conclusion, recommendation lists for children governed by a cDTC provide a rational auxiliary tool that can be immediately implemented in the clinic.

Effectiveness of Acceptance and Commitment Therapy (ACT) for Anxiety, Depression, and Stress during COVID-19 Pandemic: A Narrative Review

The impact of the Covid-19 pandemic on mental health crisis may have a long-lasting effect amidst people who went through loss of lives, self-quarantine, social distancing, job loss, the threat of illness, psychosocial and economic crisis. The dramatic increase of mental health difficulties makes psychotherapeutic assistance a vital need. Recent literature states that Acceptance Commitment Therapy (ACT) is one of the effective methods to moderate psychological distress resulting from the uncertainties of a pandemic. In this study, we aim to identify literature on the effectiveness of ACT in treating anxiety, depression, and stress during the Covid-19 pandemic, and by doing so observe its effectiveness and potential use in pandemic like situations that may arise in the future. The narrative review method is adopted in the study. By focusing on acceptance, mindfulness, and values-based action, acceptance and commitment therapy (ACT) efficiently alleviates anxiety, depression, and stress that are associated to the Covid-19 pandemic. Small sample sizes, inconsistent evidence quality, a shortage of knowledge of long-term impacts, and a lack of attention to the therapeutic process are some of the study gaps, though. Future research should examine ACT protocols, provide manuals tailored to the pandemic, and look into technology-assisted psychotherapy like cyberpsychotherapy (AU)

Knowledge support for environmental information on pharmaceuticals: experiences among Swedish Drug and Therapeutics Committees.

BACKGROUND: Two publicly available Swedish knowledge support systems, "Pharmaceuticals and Environment" on Janusinfo.se and Fass.se, provide environmental information on pharmaceuticals. Janusinfo is provided by the public healthcare system in Stockholm and Fass is provided by the pharmaceutical industry. The objectives of this study were to investigate the experiences among Swedish Drug and Therapeutics Committees (DTCs) with using the databases, retrieve development proposals for these, and investigate the DTCs' challenges with working with pharmaceuticals in the environment. METHODS: A cross-sectional survey with 21 questions, both closed and open-ended, was distributed electronically in March 2022 to Sweden's 21 DTCs. Descriptive statistics and inductive categorization were used for the analysis. RESULTS: A total of 132 respondents from 18 regions filled out the survey. The average regional response rate was 42%. The DTCs used the knowledge supports to consider environmental aspects of pharmaceuticals in their formularies and in education. Respondents were more familiar with Janusinfo compared to Fass but appreciated the availability of both. The DTCs especially valued the concrete proposals for certain active pharmaceutical ingredients on Janusinfo. Respondents requested that all medicinal products have environmental information on Fass. Challenges included lack of data, lack of transparency from the pharmaceutical industry and difficulties considering the environmental aspect of pharmaceuticals in their healthcare practice. Respondents wanted more knowledge, clear messages, and legislation to support their work to reduce the negative environmental impact of pharmaceuticals. CONCLUSIONS: This study demonstrates that knowledge supports for environmental information on pharmaceuticals are valuable for the DTCs in Sweden, but the respondents experienced challenges in their work in this field. The study can provide insights to those in other countries interested in considering environmental aspects in their formulary decision-making.

Política de medicamentos de alto costo en un hospital público pediátrico: Análisis de utilización y costos / High-cost medication policy at a public pediatric hospital: utilization and cost analysis

Objetivos. Analizar el circuito de utilización de los medicamentos de alto costo (MAC) y los resultados clínicos obtenidos en un hospital de pediatría público de alta complejidad de Argentina y presentar una estrategia de selección replicable para otras instituciones de similares características de la región. Métodos: Estudio prospectivo, descriptivo, aleatorizado, conducido en el Hospital de Pediatría Juan P. Garrahan de la Ciudad Autónoma de Buenos Aires en el período entre el 1 de setiembre de 2018 y el 31 de marzo de 2019. Se evaluaron dos unidades de estudio, la unidad paciente y la unidad MAC. Resultados: Los MAC consumen 7.921.200 dólares estadounidenses (USD) anuales y representan el 41% del costo de los medicamentos del hospital de alta complejidad. El 50% del costo de los MAC estuvo representado por la gammaglobulina (medicamento utilizado en diferentes enfermedades). Los pacientes proceden de toda la Argentina y otros países y un 44% tiene cobertura de salud. Los diagnósticos para los que se prescribieron MAC con mayor frecuencia fueron los relacionados con patología oncológica (leucemia linfoide aguda, leucemia mieloblástica aguda). El 54% de los pacientes presentó mejoría atribuible directamente a la administración de los MAC, 39% no presentó cambios y el 7% empeoró. Conclusiones: La efectividad en los resultados clínicos y el análisis de los circuitos de aprobación indican que, además de la aprobación por las entidades nacional e internacionales, la evaluación responsable por parte de las instituciones efectoras, mediante la discusión interdisciplinaria basada en la mejor evidencia, contribuye a optimizar la utilización de los MAC y la seguridad de los pacientes (AU)

Objectives. To analyze the utilization circuit of high-cost medications (HCM) and the clinical results obtained in a tertiarycare public pediatric hospital in Argentina and to present a selection strategy that may be disseminated to other institutions of similar characteristics in the region. Methods: A prospective, descriptive, randomized study was conducted at Hospital de Pediatría Juan P. Garrahan in Buenos Aires between September 1, 2018 and March 31, 2019. Two study units were evaluated, the patient and the HCM. Results: HCMs account for 7,921,200 US dollars (USD) per year and represent 41% of the cost of drugs in this tertiary-care hospital. Gamma globulin (a drug used for different diseases) accounted for 50% of the cost of HCMs. Patients came from Argentina and other countries and 44% had a health insurance. Cancer (acute lymphoid leukemia, acute myeloblastic leukemia) was the diagnosis for which HCMs were most frequently prescribed. Fifty-four percent of patients showed improvement directly attributable to the administration of HCMs, 39% showed no change, and 7% worsened. Conclusions: The effectiveness in clinical outcomes and the analysis of approval circuits show that, in addition to approval by national and international entities, responsible evaluation by the effector institutions through interdisciplinary discussion based on the best evidence contributes to optimizing the use of HCMs and patient safety (AU)

Implementation of a high-impact medication therapy subcommittee within a large academic medical center.

PURPOSE: Healthcare systems are challenged with implementing high-cost, high-impact medication therapies with increasing frequency. Pharmacy & therapeutics (P&T) committees may struggle to integrate requests for these medications into their existing formulary review process. This article describes one large academic medical center's experience with creating a new P&T subcommittee that addresses the clinical, operational, and financial challenges these medications present. SUMMARY: The High-Impact Medication Therapy Subcommittee was established to optimize the institution's process for reviewing formulary requests for medications that are defined as "high impact"-nononcology medications that are extremely expensive and/or have complex operational or clinical challenges. The multidisciplinary subcommittee has 3 chairs-a physician, a nurse, and a pharmacist-and includes representation from all areas of pharmacy practice (clinical pharmacy, operations, supply chain, finance, and informatics), as well as medical and nursing leadership, hospital finance, and patient access services. Additional relevant stakeholders are invited as needed. The first medication to be reviewed at this subcommittee was afamelanotide, a melanocortin receptor agonist indicated for treatment of erythropoietic protoporphyria. The subcommittee addressed cost-efficacy concerns and operational challenges, and the final recommendation was for formulary addition, with clearly defined restriction criteria and the creation of a new workflow to meet the unique operational considerations with this drug. CONCLUSION: As medication costs continue to rise at unprecedented rates and reimbursement requirements continue to increase in complexity, the High-Impact Medication Therapy Subcommittee provides a necessary venue for reviewing high-cost medications with complex clinical or operational considerations and proactively addressing implementation challenges.

Análise das solicitações de medicamentos não padronizados de um hospital universitário terciário / Analysis of requests for non-standard medicines from a tertiary university hospital

Introdução: O uso extensivo de medicamentos não padronizados causa aumento de custos em saúde, além de potencial redução de segurança e uso racional de medicamentos. A Comissão de Farmácia e Terapêutica orienta a prescrição de medicamentos, por meio da avaliação e seleção de medicamentos a serem incluídos no formulário de medicamentos padronizados, com base nas melhores evidências científicas disponíveis e no perfil dos pacientes locais, promovendo o uso racional de medicamentos. O objetivo deste trabalho foi analisar as solicitações de fornecimento de medicamentos não padronizados na instituição. Métodos: Trata-se de um estudo observacional e descritivo onde foram analisadas as solicitações de medicamentos não padronizados realizadas entre fevereiro de 2016 e dezembro de 2021, identificando os medicamentos envolvidos e seus respectivos custos. Resultados: Foram realizadas 203 solicitações no período, sendo 174 incluídas no estudo. Os medicamentos que tiveram mais solicitações foram o rituximabe (41), a imunoglobulina humana (31), o sucralfato (23), a nitazoxanida (12) e o eltrombopague (7). As solicitações com maior custo foram as de imunoglobulina humana (US$ 799,702.38), rituximabe (US$ 717,320.26), eltrombopague (US$ 281,062.50), ruxolitinibe (US$ 167,867.46) e bortezomibe (US$ 149,033.52). As principais clínicas que solicitaram medicamentos não padronizado foram a neurologia (47), a hematologia (30), as moléstias infecciosas e parasitárias (17), e a anestesiologia (12). As solicitações de maior custo foram realizadas pela neurologia (US$ 145,519.08), hematologia (US$ 120,980.25), transplante de medula óssea (US$ 51,635.11) e dermatologia (US$ 44,813.40). Conclusão: O estudo demonstrou que há um fluxo estruturado de solicitação de medicamentos não padronizados na instituição, sendo uma importante ferramenta de gerenciamento dessas solicitações, evitando a aquisição desnecessária de itens que não compõem o elenco terapêutico do hospital.

Introduction: Widespread use of non-formulary drugs (NFD) increases cost and may reduce safety and rational use of medicines. The Pharmacy and Therapeutics Committee provides guidance on drug prescription by evaluating and selecting medications to be included in a hospital's formulary based on best scientific evidence available and local patients' profile, promoting rational use of medicines. The objective of this study was to assess non-formulary drugs prescriptions at a tertiary hospital. Methods: This was a retrospective study. NFD prescribed and its associated costs were assessed through NFD request forms received from February 2016 to December 2021. Results: A total of 203 NFD request forms were received, from which 174 were included in this study. The most frequently prescribed NFD included rituximab (n = 41), immunoglobulin (31), sucralfate (23), nitazoxanide (12), and eltrombopag (7), with the highest costs being with immunoglobulin (US$ 799,702.38), rituximab (US$ 717,320.26), eltrombopag (US$ 281,062.50), ruxolitinib (US$ 167,867.46), and bortezomib (US$ 149,033.52). The most frequent requesting specialties were neurology (n = 47), hematology (30), infectious disease (17) and anesthesiology (12), and highest costs requests were from neurology (US$ 145,519.08), hematology (US$ 120,980.25), bone marrow transplant unit (US$ 51,635.11), and dermatology (US$ 44,813.40). Conclusion: This study showed that a structured request flow for NFD prescription is a critical procedure in order to better manage drug prescription within the hospital, promoting rational use of medicines and preventing unnecessary spending with drugs for which the clinical indication may be covered by a drug already in the hospital's formulary.

Long-Term Care medicines formularies: any reasons for pharmacists' concern?

Abstract This study aimed to characterize and compare medicines formularies (MFs) used in Long-Term Care (LTC) facilities in Portugal, and to identify the prevalence of Potentially Inappropriate Medicines (PIMs). A systematic contact with LTC facilities was undertaken in December 2021. MFs were systematized according to the Anatomical Therapeutical Chemical classification system (ATC), followed by descriptive content analysis. A structured comparison between MFs developed by public organizations and private LTC facilities was performed. After duplicate removal and exclusion of medicines not for systemic use, two explicit criteria - the Algorithm of medication review in frail older people and the EU(7)-PIM list - were employed for PIMs identification. Five MFs were obtained and assessed. The three MFs developed by private institutions covered 23% of the national LTC facilities and approximately 34% of the national total of beds. Heterogeneity was particularly high for the Alimentary tract and metabolism, Blood and blood-forming organs, Musculoskeletal system, and Respiratory system ATC groups. A PIM prevalence of 29,4% was identified. Medicines distribution between the MFs suggests the need to develop national guidelines towards harmonizing medicines usage in LTC. The prevalence of PIMs found highlights the importance of a particular optimized use of this health technology in aged sub-populations

Evaluating the effectiveness of drug and therapeutics committees (DTCs) in controlling irrational drug use: A retrospective analysis.

WHAT IS KNOWN AND OBJECTIVE: This study aimed to explore methods to optimize the function of Drug and Therapeutics Committees (DTCs) in controlling irrational drug use. Clinical pharmacologists contribute their specific knowledge and skills to DTCs and help guide rational therapeutics. The DTC is the highest organization of hospital pharmacy management. METHODS: From January 2016 to August 2021, the DTC promoted the optimization of clinical drug treatment schemes and reduced unreasonable drug use by improving the organizational framework, clarifying the division of functions, regularly monitoring drug use, organizing expert comments, scientific decision-making and functional intervention. During this time, we statistically analysed typical management cases, irrational drug use and drug cost to evaluate the effectiveness of the DTC's management. RESULTS AND DISCUSSION: The DTC's intervention led to a significant reduction in prescribing errors (65.98%, p < 0.05); the intervention acceptance rate increased by 16.37%; and the rate of problem resolution increased by 45.84% (p < 0.05). The level of drug treatment was improved, and the proportion of patients' drug expenses was reduced. WHAT IS NEW AND CONCLUSION: The DTC carried out a series of continuous improvement work that played a significant normative role in clinical drug use. Giving more power to the DTCs can significantly improve the level of drug treatment and reduce unreasonable drug use, which reduces unnecessary drug expenses.

The use of national reimbursement reports to support formulary decisions of the hospital's Drug and Therapeutics Committee: a comparative analysis.

Background New therapies that do not reach patients in need, have not achieved their goal. Drug and Therapeutics Committees in hospitals ensure access to patients by compiling a formulary on rational grounds. An evolving landscape of innovative molecules challenges timely formulary adaptation after national reimbursement. Aim To integrate national reimbursement reports in the hospital's appraisal, thereby promoting access for patients without delay. Method For 2019, the rationale for new molecules at Ghent University Hospital, Belgium, was compared with the public assessment report of the National Institute for Health and Disability Insurance, assessing a medicine in a specific indication following a reimbursement request by the manufacturer. Decision criteria (therapeutic value and cost) between matching medicines in both databases (national & hospital) were retrospectively compared [no (%), mean (SD)]. Results Two-hundred public reports and 30 formulary decisions were analysed (with antineoplastic & immunomodulating as most prevalent class: 41.0% resp. 36.7%). National decision often concerned hospital-only medicines (89; 44.5%) without patient co-payment (101; 50.5%). Of 13 matched medicines (same indication), time delay between national decision and formulary admission was on average 3.1 (SD 2.3) months. Comparative analysis showed that assessment in both committees was mostly based on the efficacy endpoints of Randomised Controlled Trials. Literature used in hospital appraisals was of more recent publication date: + 0.78 (SD 2.2) years. Using public reports as a horizon scan could enable quick identification of new indications. Conclusion To speed up patient access, the scientific evidence of national reimbursement reports can be used for the purpose of hospital formulary decisions.

Incorporation of a mock pharmacy and therapeutics committee as an entrustable professional activity supporting task.

INTRODUCTION: Entrustable professional activities (EPAs) denote activities and tasks students should be able to perform by graduation irrespective of their practice setting. Formulary decision-making includes several core EPA related skills, such as utilization of drug information, written, and verbal skills. The objective of this study was to describe an EPA supporting task aimed at improving utilization of evidence-based medicine skills and its impact on student self-perceived confidence, rating of skills needed, and competence. METHODS: Teams comprised of six to seven students were assigned a drug and instructed to complete the following activities: (1) background literature search, (2) drug monograph, (3) five-min presentation to simulate a live pharmacy and therapeutics (P&T) committee meeting, and (4) vote on a formulary drug in each drug class. Students completed a pre/post five-point Likert scale self-efficacy survey and a perceived importance survey. A scoring rubric assessed monograph and presentation elements (max points 30). Survey items were analyzed using Wilcoxon signed-rank test. Descriptive statistics were used for assignment grades. RESULTS: One hundred ninety students completed the pre/post self-efficacy and perceived importance survey. Confidence showed statistically significant improvement (P < .001) in nine target skill areas. In ranking importance, all 12 assessed skills exhibited a statistically significant increase following the activity. CONCLUSIONS: A mock P&T activity represents an innovative way to evaluate an EPA supporting task that allows students to improve their evidence-based analysis, written, and verbal communication skills.

Engaging community pharmacists in quality improvement (QI): a qualitative case study of a partnership between a Higher Education Institute and Local Pharmaceutical Committees.

BACKGROUND: Quality improvement (QI) involves the use of systematic tools and methods to improve the quality of care and outcomes for patients. However, awareness and application of QI among healthcare professionals is poor and new strategies are needed to engage them in this area. OBJECTIVES: This study describes an innovative collaboration between one Higher Educational Institute (HEI) and Local Pharmaceutical Committees (LPCs) to develop a postgraduate QI module aimed to upskill community pharmacists in QI methods. The study explores pharmacist engagement with the learning and investigates the impact on their practice. METHODS: Details of the HEI-LPCs collaboration and communication with pharmacist were recorded. Focus groups were held with community pharmacists who enrolled onto the module to explore their motivation for undertaking the learning, how their knowledge of QI had changed and how they applied this learning in practice. A constructivist qualitative methodology was used to analyse the data. RESULTS: The study found that a HEI-LPC partnership was feasible in developing and delivering the QI module. Fifteen pharmacists enrolled and following its completion, eight took part in one of two focus groups. Pharmacists reported a desire to extend and acquire new skills. The HEI-LPC partnership signalled a vote of confidence that gave pharmacists reassurance to sign up for the training. Some found returning to academia challenging and reported a lack of time and organisational support. Despite this, pharmacists demonstrated an enhanced understanding of QI, were more analytical in their day-to-day problem-solving and viewed the learning as having a positive impact on their team's organisational culture with potential to improve service quality for patients. CONCLUSIONS: With the increased adoption of new pharmacist's roles and recent changes to governance associated with the COVID-19 pandemic, a HEI-LPC collaborative approach could upskill pharmacists and help them acquire skills to accommodate new working practices.

Barriers to implementing pharmacoeconomics: interview study.

Background: Pharmacoeconomics estimates the value of pharmaceutical products and services and provides healthcare decision-makers with valuable information. Pharmacoeconomic evaluations have not been found to be influential in the Jordanian health care system. Although pharmacoeconomics as a concept is becoming more recognized in the pharmaceutical world, there are still some barriers to its implementation. Objective: To establish the perceived barriers to the implementation of pharmacoeconomics in Jordan. Method: A qualitative study with semi-structured interviews was conducted. Participants were chosen if they might benefit from the application of pharmacoeconomics; such as members of Pharmacy and Therapeutics Committees (PTCs) in public, private, and teaching hospitals; administrative pharmacists on drug pricing committees; those who produce pharmacoeconomic data such as academics; and administrative pharmacists in the Joint Procurement Department (JPD). The interviews were recorded and transcribed. Transcripts were analyzed using a thematic analysis approach. Result: Three main barriers to the implementation of pharmacoeconomics were identified. These were related to the nature of the decision-making process, the lack of pharmacoeconomic data, and inadequate knowledge about pharmacoeconomics. Conclusion: The current use and impact of pharmacoeconomic evaluations in Jordanian healthcare decision-making is restricted, in part, due to the barriers outlined by the respondents.

"There are ways drug companies will get into DTC decisions": How Australian drug and therapeutics committees address pharmaceutical industry influence.

AIMS: One tool for protecting quality use of medicines in hospitals is a drug and therapeutics committee (DTC) that oversees medicines availability. Pharmaceutical industry marketing to prescribers is associated with less appropriate prescribing and increased costs. There is little data on decision-making practices of DTCs so it is unknown whether or how they might be vulnerable to pharmaceutical industry influence. This project explores DTC decision-making with a focus on how pharmaceutical industry influence on access and use of medicines is identified and managed. METHODS: We used a qualitative methodology with individual interviews of 29 participants who were current or recent members of public hospital DTCs across New South Wales, Australia. Participants included medical, pharmacy and nursing staff and 1 citizen. Committees were linked to specific hospitals or regions, and some were affiliated with paediatric, neonatal, rural or mental health services. RESULTS: Drug committee processes for oversight of medicines in public hospitals are vulnerable to pharmaceutical industry influence at several points. Applications for formulary additions are sometimes initiated and completed by company representatives. Conflict of interest disclosures among applicants and committee members may be incomplete. In some institutions, medicines are available from pharmaceutical companies without committee review, including through free samples and industry-supported medicines access programmes. Participants noticed the presence and impact of pharmaceutical company marketing activities to local clinicians, resulting in increased prescriber demand for products. CONCLUSION: Improved DTC practices and review of hospital policies concerning pharmaceutical marketing activities might preserve the independence of evidence-based decision-making for safe, cost-effective prescribing.