Volume 24 No. 1 January 2000
xxC O S T XC O N T A I N M E N T XR E P O R T
costs are an obvious but sensitive target
Since Nov. 3, physicians at Stanford Hospital have been using a drug formulary that is designed to help channel medication selections in a safe, effective and efficient drug manner.
Sara J. White, director of pharmacy, who also serves as secretary to the physician-led Stanford Hospital and Clinics Pharmacy and Therapeutics [P&T] Committee, observed that probably nowhere in the hospital setting does safe, effective cost savings involve physicians more closely than in drug selection and prescribing.
"You didn't pay attention to drug costs a few years ago; it wasn't worth the time," said White. "It was rare five years ago to have a drug costing $100 a dose. Now, medications costing several hundred to several thousand dollars per dose are not uncommon. It's obvious that the need to reduce costs must be the goal of both physicians and pharmacists working together."
Cost is only one of many factors influencing prescription habits, obviously.
"For one thing, we've had significant therapeutic advances in drugs in the last few years. There is far greater specificity, and writing of prescription orders is reflecting this," said White.
Peter Gregory, SHC chief medical officer, chairs the Cost Containment Steering Committee, which each month brings together key clinical chairs and other physician leaders to find ways to improve care while cutting $9 million from the SHC 1999-2000 fiscal year budget. Gregory has said the institution cannot make significant further cuts without the help of doctors, because to do so could compromise clinical care.
In the prescription arena, Gregory and Larry Shuer, chief of staff, have direct responsibility for helping physicians make necessary cuts: They have to sign off on exceptions to the new formulary rules, which were based on recommendations made in October by the P & T Committee.
According to the hospital formulary - which is based on principles first published in 1983 by the American Society of Healthcare Pharmacists - no non-formulary drugs are stocked in the pharmacy or available in patient care areas. A policy for exceptions, which had been sent to the medical staff in September, reads in part:
"In those unique clinical situations where a non-formulary drug is judged to be the only medically effective drug, the Chief Medical Officer [Gregory] or Chief of Staff [Shuer] must be contacted for approval before it will be ordered [with a 24-48 hour lead time]. This eventuality is expected to be infrequent."
"I've been impressed that physicians here are willing to use a more cost effective product as long as it doesn't decrease the quality of care," White said.
Gregory and Shuer told the Medical Board in January that the number of requests for exceptions has been small. Gregory cited two examples: He approved one request for a nonformulary anticoagulant after a physician provided convincing, albeit anecdotal, information that a non-formulary drug was more effective for his patients. He asked the attending physician to review a request for a nonformulary drug for a terminal patient; the request for the exception was not pursued by the physician, he said.
Representing what White calls a paradigm shift in health care tradition, patients may bring in their own drugs if they are not on the formulary, particularly if they need to continue medications for conditions unrelated to their admission.
"This can be a convenience for, say, a patient who is here for two days and is accustomed to a branded ulcer drug, arthritis pain medication, or cholesterol-lowering drug for which we stock only an equivalent," said White. A physician or pharmacist identifies the carried-in medications and writes a "patient to take own medications" order, she said.
Sometimes external forces, including the mass media, can influence drug choices. Edward D. Harris, professor of medicine and the chair of the P&T committee, said consumer advertising can affect prescription writing practices when patients demand, often inappropriately, a drug that they've heard advertised.
"The key to proper medication use - cost concerns or not - is information," said White. "Our pharmacy staff members are always available for consultations, and our pharmacy staff is never shy about asking questions, for example, 'Can your patient on IVs be converted to an oral medication?'
"When we implement physician order entry, providing information useful to prescribing physicians will become even easier. We'll have prompts offering warnings about such issues as possible drug interactions or suggestions about potentially more efficacious drug choices," White said.
Meanwhile, physicians are being told about cost effective and/or more effective alternatives through newsletters. For example, the policy governing the use of quinupristin/dalfopristin (Synercid) was explained to physicians by SHC clinical pharmacist Lana Witt in the Sept.-Nov. Drug Information Service newsletter. The drug is useful for treating vancomycin-resistant Enterococcus faeclum (VREF), but White noted it costs 26 times as much as vancomycin.
"We need to reserve Synercid for those infections where it is uniquely effective. There is a lot more than economics driving this. The last thing we want is to overuse Synercid and run the risk of creating new VREF's," White said.
One of the primary ways money is saved is through consolidated bulk purchases when chemically or clinically identical products are ordered through a single vendor. In the cancer area, for example, physicians have agreed to pool their use of antiemetic drugs, White noted. Overall, consolidation is expected to save several hundred thousand dollars of the $4 million target, White said.