Download Prof.Dr. / Abd Elaziz Saleh

USE OF HOSPITAL
FORMULARY TO IMPROVE
MEDICINE USE AT
ALEXANDRIA
OPHTHALMOLOGY HOSPITAL.
EGYPT.
Dr: Hager Abd Elkhalek
Saad Ebrahim Elkazaz
supervisor
Prof.Dr. / Abd Elaziz
Saleh
Faculty of
pharmacy, Alexandria
University
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Abstract:
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Problem Statement: Hospital formularies have been used in several health
institutions to improve medicine use. Hospital pharmacists play important role
in the development of hospital formularies, However, many of the hospitals in
Egypt don’t have medicine formulary and irrational prescribing is commonly
practiced.
Objective: To assess the short term impact of Formulary development at
Alexandria hospital of ophthalmology on improving medication use and
prescribing habits of glaucoma therapy.
method: The formulary developed in this study as collaborative work
between the pharmacy and physicians at Alexandria hospital of
ophthalmology was based on, evaluation of samples of glaucoma patient
prescriptions and development of standard treatment guidelines, cost
effectiveness analysis for glaucoma therapy, and analysis of the available
budget.
Study Population: Ophthalmologists in glaucoma outpatient clinic
Intervention: The Formulary was developed in 9/2010 and its impact was
studied over a period of 6 month, 3month before and 3month after the use of
formulary.
Results: Financial analysis indicated that most of the hospital budget was
directed toward glaucoma therapy, Prostaglandin analogues which is the
costliest among various drug groups. The most frequently prescribed drug for
glaucoma was one of the brand medicines containing latanoprost constituting
38.4% of total prescriptions, followed by another brand medicine containing
dorzolamide & timolol constituting 27.5%, after the use of the formulary the
prescribing was directed toward combination therapy as there is increase in
the brand medicines containing Bimatoprost andTimolol maleate prescribing
by 4% and decrease in prescribing monotherapy by 5.6% in latanoprost.
The prescribing of carbonic anhydrase inhibitors was directed toward brand
medicine containing Brinzolamide (of lower cost) increased by 4.7% and
decreased by 8.9%in dorzolamide & timolol. although the changes that we
demonstrated were small, there are important finding as they provide support
for the theory that the prescribers focus their prescribing on combination
therapy after the introduction of the formulary.
Both the prescription volume of glaucoma drugs and the average cost per
prescription was high due to an ‘add-on’ prescribing effect of the more
expensive carbonic anhydrase inhibitors. Changes in drug costs can result
from changes in prescription volumes. Quantity per prescription changed
from 1.4 to 1.3 and the average cost per prescription decreased from 87 L.E.
to 72 L.E. Saving in cost over 3 month was 1762 L.E. and the cost of the
formulary was500 L.E. so the overall cost saving was1262 L.E.
Prescribing by generic name increased from zero to 12.5%. As the
dispensing policy in the hospital mainly dispense the brand if it is specified.
Prescribing outside formulary decreased by 12.8%and no. of prescription
without instructions decreased by 11.4%.
Conclusions: following the development of a formulary, ophthalmologists
prescribed from narrower range of drugs and the study suggests that
formulary in Alexandria hospital of ophthalmology may favorably improve
prescribing pattern and medication use.
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Background
Formulary and Formulary
System:
• A formulary is a continually
updated list of medications and
related information, representing
the clinical judgment of physicians,
pharmacists, and other experts in
the diagnosis, prophylaxis, or
treatment of disease and promotion
of health.
• As the therapy for the glaucoma is
now in a dynamic phase, evolving
as the underlying disease
pathology becomes more clearly
understood and as new
pharmacological agents and other
treatment modalities become
available; the clinicians find
themselves in dilemma for
choosing an appropriate antiglaucoma medication from the wide
variety of options available.
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Objectives
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what is the evidence that the development of
formularies for Alexandria hospital of
ophthalmology actually alters prescribing
habits and improves medication use?
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Methodology:
Study Design:
Design (intervention, before after study with no
control group )
Study Area: Alexandria hospital of ophthalmology
glaucoma out patient clinic.
1-Prescriptions of glaucoma out-patients from
November 2010 to august 2010 were
collected to evaluate the need of Standard
treatment guidelines for:
• Documentation of IOP in diagnosis of
glaucoma
• Documentation of target IOP
• Maintaining visual stability
• Decision analysis tree;
Glaucoma patient
Persistent
(6 month treatment)
In compliance with
the budget
Non persistent
Withdrawal
Due to side
effect of therapy
2- ABC and VEN analysis for drug dispensed
from July 2009 to July 2010.
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Outcome Measures:
Prescriptions of glaucoma out-patients were
audited and analyzed before and after
insertion of formulary for the following:
Quantity of medications dispensed and cost
of each item, The most expensive drugs, The
most frequently or infrequently used drugs,
Average number of drugs per prescription,
Percentage of drugs prescribed by generic
name, percentage of drugs prescribed from
essential drugs list or formulary, Average
drug cost per prescription and Frequency of
administration (recorded or not).
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Results1: Prescriptions of
glaucoma out-patients evaluation:
60% non-persistent patient due to high cost of the
treatment ( incompliance with the budget ) due to
add on effect of more expensive CAI, also due to
poor patient education.
According to the results, there is great need for the
development of STG that improve the common
existing practice according to the evidence.
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Results 2:
(1)ABC analysis:
Most of the hospital budget was directed toward
glaucoma therapy 51%, followed by topical
antibacterial preparations18% so we have to
analyze the prescribing pattern and the cost of
glaucoma therapy .
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Results2:
(2)cost analysis of glaucoma
therapy:
cost analysis of Ati- glucoma drugs
120
c o s t/ m o n th
100
80
60
40
20
0
ganfort
lumigan
ioprost
travatan
twinzole
azopt
timolol
glucoma therapy
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Prostaglandin analogues were found to be the costliest
among various drug groups followed by carbonic
anhydrase inhibitors and beta blockers were found to be
the cheapest than other anti- glaucoma drugs.
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Results 3: Distribution of anti
glaucoma medication before
and after the insertion of the
formulary:
% o f t o t a l P r e s c r ip t io n
Destribution of Anti-glucoma medications
50
38.5
33
40
30
20
10
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18
22
27.5
18.5
7.8
1.4 0.5
11
2.4 1.5
7.3
12
after
0
ganfort mydrapid ioprost twinzole lumigan travatan
before
azopt
After the formularyThe prescribing was directed toward
combination therapy as there is increase in ganfort prescribing
by 4% and decrease in prescribing monotherapy by 5.6% in
latanoprost and 1%in travatan and mydrapid .
The prescribing of carbonic anhydrase inhibitors was directed
toward azopt (of lower cost) ,increased by 4.7% and decreased
by 8.9%in twinzole due to add on therapy effect of cheaper CAI
which improved by the formulary.
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Results 4 : No. of
interventions made by
pharmacists in last 3 month
before insertion of formulary
for glaucoma therapy
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Observed decrease after insertion of formulary
by 12.8 % that reflect the improvement in
prescribing after the formulary.
p e rc e n ta g e o f
in t e rv e n t io n
40
30
before
20
after
10
0
6,9
7,10
8,11
date in month
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Results 5: prescribing data of
glaucoma therapy before and
after the formulary insertion.
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Average no. of drug per prescription indicates
the absence of poly pharmacy, however after
the insertion of formulary there are
improvement as the value decrease to 1.3.
Average cost of drugs per prescription
improved after the formulary from 87 to 72.8.
Saving in cost over 3 month 1762 L.E. and the
cost of the formulary 50 L.E. so the overall
cost saving 1262 L.E.
No. of drugs prescribed by generic name
increased from zero to 12.5% after the
formulary.
As the dispensing policy in the hospital:
dispense the brand if it is specified.
No. of prescription contain no instruction
decreased after the formulary by 11.4%.
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Implications/Conclusions
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following the development of a formulary for
the hospital, Ophtphalmologists prescribed
from narrower range of drugs and the study
suggests that formulary in Alexandria hospital
of ophthalmology may favorably improve
prescribing pattern and medication use.
Recommendations:
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Any future studies need to be large enough to
have the power to convincingly confirm or
refute the hypotheses being tested.
However, it needs to be recognized that
formulary development is time-consuming
and that practices need to be motivated.
More staff education about the formulary
required to improve the adherence.
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