Getting organized about therapeutic class reviews
March 1, 1997 4 minutes read
Getting organized about therapeutic class reviews
One pharmacy’s 10-step answer
Few projects undertaken by a pharmacy have more potential to get botched than a therapeutic class review. Everything from hurt feelings to patient complaints to actual medical problems can result from a sloppy review process. And that’s to say nothing about the physicians affected by a change.
One pharmacist looked to good organization to avoid many of these pitfalls, and Joanne Raymond, assistant director of pharmacy at the Hennepin County Medical Center in Minneapolis, came up with the following 10-step process almost guaranteed to cut out the complaints: Call them "Raymond’s Rules" for drug class reviews.
Step one: Get MDs to buy in to the program
1. Identify a drug class to review.
Search the literature, of course. Look for classes of drugs with similar members. But make sure you include doctors right from the start. "How much buy-in you get from physicians will determine the success or failure of the project," Raymond says. So ask doctors early and ask often: What drugs do you use? Which seem to work better?
Once you’ve identified a potential target, decide whether choosing one over another would truly give a cost benefit. For example, Raymond says the anti-emetic odansetron is more economical to use in many cases, but granisetron has a place at Hennepin as well. In other words, sometimes it’s not worth it to make a change.
2. Do an intensive literature search.
Find out everything you can about a product’s safety profile and side effects. At Hennepin, Raymond says, this is the point at which the H-2 blocker cimetidine was cut from consideration — even though it was cheaper than the others.
3. Find out who is using the drugs in the hospital and how much they’re using.
Identify the big writers. This will give you a good idea of the impact a change will make. Also, look at other formularies from other area hospitals. Remember, patients get discharged, and you may never see them again. How will a change affect the hospital community? What are other hospitals using? How difficult will it be for the patient to get a prescription of your formulary product once they’ve been released?
At this point, you should have a pretty good idea of what you, the pharmacist, would like to do with the drugs in question. But you still need a panel of experts to bolster (or kill) your case.
4. Form a task force.
Raymond says it should consist of practitioners who specialize in body systems affected by the drugs. For example, when Hennepin was reviewing "statin" cholesterol drugs, the task force consisted of an endocrinologist, a nephrologist, a cardiologist and, of course, a clinical pharmacist.
Yes, you should call call your drug rep
5. Do something crazy.
Notify your local drug rep that you’re considering making a change. You might get bombarded with visits, literature, and pepperoni pizzas — but Raymond says it’s important to include the reps in the buy-in. Let them make the case for their product in a free and open forum. "They’re going to find out anyway," she says, "and it could cause more conflict if they find out later."
6. Have the task force review all the literature and prepare recommendations for the pharmacy and therapeutics committee.
7. Have one member of the task force deliver those recommendations to the pharmacy and therapeutics committee.
8. If the committee agrees to the recommendations, have them delivered to the big guys on the medical executive committee.
Once the big guys say "yes" to the change, you’re ready for step 9.
9. Find out which physicians use the drugs in question — if you haven’t done so already — and notify each about the change.
10. Send letters to physicians notifying them of the change.
This step is somewhat of a reiteration of step 9, and Raymond admits it can feel like an exercise in futility. You’d get more mileage out of a step 10a: attaching an informational sheet to the charts of patients who come in for clinic visits, who previously were taking drugs removed from the formulary.
"Then, poof, it’s magic!" Raymond says.
She’s kidding, of course. No therapeutic review gives everyone what they want, and Raymond says you have to expect some dissent. But, she adds, if most doctors and patients adhere to the change, the hospital will ultimately save money and provide the best care possible.
Some reviews you might consider
Raymond identified eight other therapeutic classes either undergoing or having under- gone review at Hennepin besides cholesterol- lowering agents:
• H-2 blockers. Ranitidine’s out, famotidine’s in, but a final decision won’t come until the FDA decides whether generic ranitidine will enter the market this year.
• Proton pump inhibitors. Omeprazole beat lansoprazole. Raymond says long-term safety data with the former were better than with the latter.
• Calcium channel blockers "We’re going to upgrade’ [to use a Pfizer term] all of the patients on Procardia XL to Norvasc," Raymond says.
• Selective serotonin reuptake inhibitors. Sertraline's the choice.
• ACE inhibitors (no decision yet).
• Non-steroidal anti-inflammatories (no rush to make a decision, given that a few just went generic).
• Alpha-blockers. Raymond says doxazosin (Cardura) is just as effective and costs less than terazosin (Hytrin) for both benign prostatic hypertrophy and hypertension.
• Oral antibiotics.
Therapeutic class reviews do more than save money: They educate. For example, Raymond says pharmacists learned through literature searches that the calcium channel blocking agent Dilacor (diltiazem) is a "very inferior" product that provides incomplete coverage over 24 hours. She says one doctor even complained his patients were getting chest pain while on the drug, 20 hours after they’d taken it. Now they know why.
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