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HOSPITAL FORMULARY

HFF1M I ION :

The hospital formulary is a continuously revised compilation of pharmaceutical dosage

agent and their forms etc. which reflects the current clinical judgment of the medical
staff.

HOSPITAL FORMULARY SYSTEM:

The hospital formulary system is a method where by the medical staff of a hospital with the
,

help of pharmacy and therapeutic committee , selects and evaluates medicinal agents and
their dosage forms which are considered to be most useful in Ihe patient care.

Hospital formulary provides information for

• Procuring .
• Prescribing.
• Dispensing.
• Administration of drugs

ORIGIN OF HOSPITAL FORMULARY:

The first hospital formulary in India was published in 1968 by the Department of
Pharmacy , C MC, Vellore.

• The first hospital formulary for the development of government hospital teachings was
published in 1997 at Government Medical College, I rivendrem , Kerala

ADVANTAGES OF HOSPITAL FORMULARY:

* Most effective methods for ensuring rational drug therapy and controlling drug cost.
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They can offer simple and cost effective solutions for many medicines.
Formulary is a continually revised compilation of pharmaceuticals and some important
ancillary information that reflects the current clinical judgement of medical staff .

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* Set standards for best practice, promoting high quality,evidence based prescribing
» Reduces the variation in ( he level of treatment provided to the patients and controlling
drug cost .
* Hospital formulary is the vehicle by which the medical , pharmacy and nursing starts
make use of the system .
* It is complete , concise, updated and easy to use .

* The implementation of the formulary will have significant impact on clinical practice
of health care professionals.
* it helps physicians to know about the available drugs in the hospital pharmacy and
also helps in better inventory control
* This review gives the complete information about the importance, preparation and
benefits of the formulary.
Quality of care will be further improved if medicine selection is based on evidence
based treatment guidelines ..
* It is made so precise that it is very handy for use by the physician and nursing staff.

I )1 HA DV AN TAGVS OK HOSPITAL FORM l LAKY:

* The hospital formulary system deprives the physician of his night and
prerogative to prescribing and obtained the brand of his choice.
* The hospital formulary system in many instances, permit he pharmacist to act
as the sole judge of which brands of drugs are to purchased and dispensed .

* The system allow for the purchase of inferior quality of drugs particularly in
institutions where there is no staff pharmacist.
* The system does not reduce Ihe cost of drug to Che patient or the third party payer
because most institution purchase large volume of drug at reduce rate do not pass on
the patient any reduction in their cost .

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TYPES OF IIOISPI rAL FORMULARY

I here are three basic types of formularies :

I, Open formulary.
? Closed or restricted formulary .
3. Incentive based formulary.

OPEN FORMILARY ;

An open formulary serves merely as a guide; a physician may prescribe any drug , but is
encouraged to use the formulary list in prescribing decisions.

CLOSER OK RESTRICTED FORMl LARY :

ID contrast, a dosed or restricted formulary' lists the drugs that will be reimbursed by the
health care provider; non-formulary drugs will be reimbursed only if they are authorized
prior to prescribing .

INCENTIVE BASED FORMULARY:

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An incentive based formulary represents a hybrid between the open and closed formularies;
patients pay a higher price for non formulary drugs.

MEMBERS INVOLVED IN THE PREPARATION Ol HOSPITAL FORMULARY;

• The most important function of Drugs and Therapeutics Committee (DTC) is to

prepare and implement a formulary for the hospital .
• The committee should have sufficient members to represent all stakeholders, including
the major clinical departments* the administration and the pharmacy.
• Members should be selected with reference to their positions and responsibilities.

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In must hospitals, the membership includes:

* A representative clinician from each major specially, including surgery „

obstetrics and gynecology, internal medicine, pediatrics, infectious diseases, and
,

general practice ( to repressnl the community) .

* A clinical pharmacologist , if available .
* A nurse, usually the senior infection control nurse or sometimes the matron.
,

* A pharmacist (usually the chief or deputy chief pharmacist ),or a pharmacy

technician where there is no pharmacist ,
* An administrator, representing the hospital administration and finance
department.
* A clinical microbiologist or a laboratory technician where there is no
microbiologist .
* A member of the hospital records department , .

CRITERIA IN MEDICINE SELECTION

Selection of drugs depends on many factors, such as the

* Pattern of prevalent diseases.
* Treatment facilities.
IVyinmg and experience o 1 avai 1abte personnela
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* Financial resources.
* Genetic.
* Demographic and environmental factors.

W HO ( 1999 ) has developed the following selection criteria *

• Only those medicines should be selected for which sound and adequate data on
efficacy and safety are available from clinical studies , and for which evidence of
performance in general use in a variety of medical settings has been obtained .

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Each selected medicine must be available in a form in which adequate quality,
including bioavailability, can be assured: its stability under the anticipated
conditions of storage and use must be established .
• When two or more medicines appear to be simi lar in the above respects, the choice
between them should be made on the basis of a careful evaluation of their relative
efficacy, safety, quality , price and availability .
• In cost comparison between medicines the cost of the total treatment and not only
,

the unit cost of the medicine, must he considered . Where drugs are not entirely
similar selection should be made on the basis of a cost effectiveness analysis.
,

• In some cases, the choice may also be influenced by other factors , such as
pharmacokinetic properties, or by local considerations such as the availability of
facilities for storage or manufacturers .
Most essential medicines should be formulated as single compounds , Fixed ratio -
combination products arc acceptable only when the dosage of each ingredient
meets the requirements of a defined population and when the combination has a
proven advantage over single compounds administered separately in therapeutic
effect , safely or compliance.

GUIDELINE KOK HOSPITAL FORM I LAKY:

• The governing body of the hospital shall appoint a pharmacy and therapeutic
committee composed of physician and pharmacist which will prepare the hospital
formulary system ,
The medical staff in the governing body shall sponsor and outline the purpose,
organization function and scope of ( he hospital formulary system . It should adopt the
principle as per the need of particular hospital .
* The pharmacy and therapeutic committee shall develop policy and procedure
governing the hospital formulary and the medical staff shall adopt these policies and
procedures subject to administrative approval

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* The policy and procedure shall afford guidance in the appraisal, selection
^
procurement , storage, distribution , use, safety procedures and other matter relating to
drug in the hospital and shall be published in the hospital’s formulary
* To ensure the maintenance of the responsibility and procreative of the physician in the
exercise of his professional judgment .
* The medical staff shall adopt the policy formula, and procedure for including drugs in
the formulary by the non proprietary name even though proprietary names continue to
being use in the hospital physicians
* In Lhe absence of written policies approved by the medical staJT related to the ,

operation
* the hospital shall make it certain that the nursing personnel are in formed in writing
though its system of news of communication that there exits the formulary system in
the hospital and the procedure governing its operations

In the formulation of policies and procedure the term substitute or substitution should
be avoid since these term have been used to imply the unauthorized dispensing of
entire different drug , neither of which tabes place under a properly operated hospital
formulary system .
* It shall be made known to the medical staff about the changes in tire working in die
hospital formulary system or in the content of the hospital system .
* Provision shall be made Ibr the appraisal of the member of the medical staff for the
use of the drug not include in the formulary or the investigational drugs,
* The pharmacist with the advice and guidance of the pharmacy and therapeutic
committee shall ascertain the quantity and source of supply of all drugs, chemical ,

biological and pharmaceutical preparation used for diagnosis and treatment of patient,
* The labeling of drug and medicine container with non proprietary name of the content
always should be proper.

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STEPS INVOLVED IN THE PREPARATION OF HOSPITAL
FORMULARY:

Identify ihe most common diseases being treated in the hospital hy consulting all medical
departments, For each disease, an appropriate first choice of treatment should be identified
using standard treatment guidelines.

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An expert committee can be brought together to identify the appropriate treatment tor each
of the common health problems. The alternative method is reviewing the WHO model list of
essential medicines may also be used as a starting point.

I
The capability of the hospital and its staff lo handle specific drugs should not be forgotten
during the selection process.

I
A draft of the lisL must be prepared and must be given lo each department to comment on the
list .

i
The Drugs and Therapeutics Committee must deliberate oil their comments and provide
feedback .

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All information should be discussed with evidence based reviews where possible .

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After the preparation of final list, monographs for each drug should he prepared and it should
contain unbiased information.

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CONTENTS OF I1 RUG MONOGRAPH ;

The drug monograph consists of following subheadings such as ;

* Non-proprietary name of drug .
* Synonyms
* Available brands.
* Cost
* Reconstitution.
* Administration
* Dosage forms ,

* Indications ,
» Con traindi cal ions.
* Precautions.
* Dose.
* Pregnancy risk factors.
* Adverse effects.
* Interactions,

MANAGING A FORMULARY LIST ( Adding and deleting diuf >s):

* For a new medicine to be added into the hospital formulary the committee should
,

consider the therapeutical equivalency to existing drugs in terms of efficacy, safety, or

convenience of dosing/ administration*
For the addition and deletion of drugs the total cost for u course of treatment with new
medicine should be compared with the already listed medicines.
• If a new medicine is added to the list for reasons of improved efficacy, safety or lower
price, serious consideration should be given to delete the medicine which was
previously on the formulary list for the same indication, for two reasons:
—> If the 'new medicine is better, why continue to hove a less good 'old'
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medicine on the list '?

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—> If no effort is made to consider deleting medicines none will be deleted
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and the list will grow irn size ,

Formulary Management Process

Pharmacy Medical Staff Professional

i i

*
Medical Executive Committee
Health System Board

*
*
*
PlfcT Committee
Meets 6 times / yr
Review and act on
Drug Review
Panel I

0 recommendations
- Formulate Implementation

Safety
Cornnnittee >
Medical and Hospital Staff ilMotrf k ation

MAINTAINING A FORMULARY ;

* Formulary may become a col lection of older, less effective drugs

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* The entire formulary should be reviewed every 2 3 years.
* t his can be done by evaluating all the formulary medicines within each therapeutic
class in a systematic way on a regular basis and comparing them to other new non
formulary medicines within that class
* Requests for the addition of new medicines and deletion of old medicines.
* Systematic review of a therapeutic class of medicines.

* Review of programmes to identify and resolve medicine use problems.

* All decisions of the DTC should be dtxrunnenled ( minuted ) .

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IMPROVING ADHERENCE TO A FORMULARY

The existence of a well-maintained formulary does not mean that prescribes will adhere to
it . Methods to promote formulary adherence include the following:
* Reviewing and taking action on all non-formulary medicine use ; action may include
adding the medicine to the formulary, educating the prescribe! about the non formulary
,

status of the medicines or banning use of the medicine within the hospital.
* Prohibiting she use of non -formulary drug samples in the hospital .
* Establishing procedures and approved drug product lists for therapeutic interchange or
substitution.
* Providing easy access to the formulary list , with copies at each drug ordering location
and in pocket manuals for staff
Involving medical staff in all formulary decisions .
* Advertising and promoting all formulary changes.
* Establishing agreed procedures for clinical trials with non-formulary medicines.

Examples of Formulary:

* WHO Formulary; British National Formulary; Indian National Formulary are some of
the formularies used as standard references in many hospitals .
* Many hospitals in India have developed their own I lospital Formularies like Kasnirba
Hospital at Mzimpaf Christian Medical College Hospital at Vellore and KLE Hospital
at Belgaum etc .

ROLE OF PHARMACIST IN HOSPITAL FORMULARY ;

* Pharmacist in the DTC has a key role in developing policies and procedures
governing the hospital formulary .
The chief pharmacist has the primary responsibility for the preparation of hospital
formulary;

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Pharmacist with the advice and guidance of DTC shall as certain the quantity and
source of supply of all drugs, chemicals, biological and pharmaceutical
preparations used for the diagnosis, and treatment of patients .
• Pharmacist should ensure that quality of drugs is not compromised by economic
considerations.

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