E-drug: Re: Drug and Therapeutics Committees (contd)
----------------------------------------------------------
Based on my experience from approx. 15 years as secretary to university
hospital committees and three years to the national committee in Botswana, I
should like to make the following comment on what in my opinion is essential
for the acceptance of a committee and for it to exert some power. I will
also comment on possible indicators.
When reactivating a dormant committee in Trondheim in 1990 the chairman (a
clinical pharmacologist and anaestesiologist) and myself worked hard on the
mandate. This was to ensure that the recommendations/decisions of the
committee could not be easily overruled by the hospital director. Thus the
mandate looked as follows:
-------------------------
1. The D&T committee is the highest professional body of the hospital in
drug related issues and shall exert genuine influence on the drug use in the
hospital. A drug is to be understood as an item being used to diagnose,
treat or alleviate illness. It comprises therefore intravenous fluids,
irrigation fluids and dialyses fluids as well as diagnostics. The goal of
the committee is quality assurance by contributing to optimal drug use in
the individual patient and to balance professional and economical
considerations in drug-related issues. This is to be secured by
interdisciplinary cooperation and by utilising the hospital's professional
and economical expertise. The committee shall stimulate and participate in
drug committee work in the region.
2. The members are to be appointed by the hospital director for 4 years:
- Chief medical officer and an economist will represent the management
-The board of doctors will appoint 6 doctors from anaesthesiology,
infectious disease, surgery, oncology, internal medicine and paediatrics
respectively
- Chief nurse appoints two nurses
- The pharmacy appoints two pharmacists
- The department of clinical pharmacology appoints one member
The clinical pharmacologist is to be the chairman and a pharmacist the
secretary. A group consisting of chairman, secretary, one doctor and one
nurse will constitute a working group.
3. The committee is to meet 4 times a year, the working group approx. 1/month.
4. The Committe will make a plan of action every year. The tasks of the
committee will comprise use of drugs (treatment regimens, administration to
patients, documentation of drug treatment) rationalisation (drug lists,
procurement, drug consumption monitoring), information on drug use,
registration of clinical trials, adverse drug reaction monitoring and
development of regional tasks/cooperation.
5. The decisions of the committee are advisory to the departments and the
Director. However, if the advice is not followed, the reason for this has to
be justified to the committee.
6. The committee will appoint consultants and/or establish working groups
for handling particular issues where considered appropriate. The head of
department/unit in departments/units which will be particularly affected by
the committee's recommendation, shall be consulted during this process if
they are not represented on the committee.
7. Minutes and other information are to be distributed to heads of
departments, Director and Board of doctors.
-----------------------------
This committee was very successful and achieved containment of drug costs
and good compliance with recommendations. One factor essential for the
successful performance of a committee is the commitment of the chairman and
secretary who will allways carry the heavy burden. Without their commitment
and enthusiasm little is to be achieved.
Being member of a D&T committee requires a lot of time which most people in
hospital do not have. And doing the work on non-paid overtime is getting
less and less popular. The issue of economic compensation for being member
of a D&T committee is often being raised, but in Norway it is not yet
solved. However, in Sweden the valuable work is recognised, committees are
now mandatory in hospital and primary health care and members are paid (0.5%
of drug cost set aside for committee work).
Another important aspect concerning hospital D&T's is to feel responsible
also for primary health care. The use of drugs in hospital greatly
influences GP prescribing. It is therefore recommended to include GPs in the
committee or in working groups.
One main focus for us was to reduce or stabilise cost as during the 80's
drug costs increased with up to 20% per year. We used drug consumption
statistics which will give both cost and DDDs to focuse on the most
expensive drugs and look at the use of those drugs. Here is where most of
the savings will be achieved. Only 20 drugs in this hospital would be
responsible for 50% of the drug budget. Of these 20, 35% would be for
antiinfectives, 26% for X-ray diagnostics. (Anti-infectives would constitute
27% of the total)
So, during the four years (1991-95) we amongst other things focused on
antibiotic use, surgical prophylaxis with heparin, antiemetic treatment
postoperatively and in oncology and treatment of GI-ulcers.
We spent a lot of time on these four issues. One goal was to secure
adherence, e.g. by ensuring broad participation when developing guidelines,
another to make simple guidelines (one sheet if possible). For antibiotic
prophylaxis in surgery, each discipline was consulted individually,
presented our proposal and if they disagreed had to provide documentation
for why they wanted another regimen. For prophylaxis against venous
thromboembolism, representatives of all surgical disciplines were called
together with specialists from internal medicine. The goal was one regimen
for all. Not easy, but we succeeded. The recommendation included
continuation treatment with low-molecular heparin after discharge which
meant patients had to be trained to set subcutaneous injections or be
visited by a community nurse.
We also found it important to be one of the presenters at the weekly
meetings for doctors (all doctors of the hospital meet once a week and each
department is responsible for the programme once in 6 months. At two
meetings a year the committtee would present a topic, normally consumption
figures would be one topic. I should also add that the pharmacy would issue
consumption figures in cost and DDDs per ATC-group per department 3 times a
year in a format which was easy to read and with % changes from last period.
The departments were to comment to the D&T committee any changes larger than
8% for the group or a certain amount for an individual drug. One thing we
would have liked to see, was some incentive to the departments/wards that
reduced their drug costs. As it was, any saving would end up in the big pot.
In addition to lack of commitment from the management, one problem with this
is that some departments might have been good for a long time and thus
potential savings would be small, whilst for others which might have been
very wrong, savings would be much larger. Now, would it be fair to only
credit the previous big spenders?
Now for indicators:
- One indicator is of course changes in drug consumption. Cost/bed-day or
per admitted patient, DDDs/bed-day or admitted patient.
In Sweden they have developed a new method of assessing quality of drug
prescribing in hospitals and nursing homes, DU90%:
Bergman U et al. Drug utilization 90% - a simple method for assessing the
quality of drug prescribing. Eur J Clin Pharmacol 1998;54(2):113-8 (Medline)
- Comparison between hospitals e.g. in consumption per bed-day is possible
when denominators are relatively comparable (same set of
activities(specialties etc).
- When we started our work on antibiotics, we did a point-prevalence study
to get more data than what you get from consumption figures alone. On one
day we noted all patients receiving antibiotics. The prescribing was so bad
that we had few problems in convincing clinicians that things had to change.
We even convinced the management that it would be cost-effective to engage
an adviser - which we did. Then after a couple of years with guidelines and
adviser a new point-prevalence study was done and changes measured (data is
available as this was my MPH thesis).
- For heparin prophylaxis in surgery an indicator could be no. of
readmittances from venous thromboses. Problem: patients undergo surgery in
surgical or gynecological departments, will be readmitted to internal
medicine, may be even to another hospital. Lack of communication causes no
feedback from internal medicine to e.g. the orthopaedic surgeon (at least in
Norway).
- Our orthopaedics felt that the new guidelines on treatment of infections
had reduced length of stay/complication rate. This could be developed into
an indicator.
- One indicator could be prescribing on discharge. Is the doctor prescribing
the same drugs as is used in the hospital or is s/he using expensive
brandname products.
- Another indicator could be whether habitforming drugs such as hypnotics
and tranquillizers are prescribed automatically on discharge as a
continuation of what was done in hospital (several studies not least from UK
has shown that a large number of patients started their habit in hospital).
- Postoperative infection rate could probably be used to measure impact of
guidelines on antibiotic prophylaxis in surgery.
- Ratio between iv and oral antibiotics is one indicator.
Concerning Richard's proposals I would comment that I find frequency of
meetings not to be a good indicator. A lot of work can be done without the
committee meeting too often. Some committees, such as ours, will also
organise for most of the work to be done in working groups etc.
Finally, remember that continuous intervention, review and feedback is ital!
It is not sufficient to make formularies, guidelines etc, distribute them
and then sit back and relax. Even if you have succeeded in changing habits,
the effect will not last indefinitely.
Two references which are useful:
Feely J et al. Hospital formularies: need for continuous intervention. BMJ
1990;300:28-30
Baker JA et al. Seventeen years' experience of a voluntarily based drug
rationalisation programme in hospital. BMJ 1988;297:465-9
Kirsten
Kirsten Myhr, MScPharm, MPH
Bygdoy alle 58B
0265 Oslo, Norway
Fax +22 24 90 17
myhr@online.no
--
Send mail for the `E-Drug' conference to `e-drug@usa.healthnet.org'.
Mail administrative requests to `majordomo@usa.healthnet.org'.
For additional assistance, send mail to: `owner-e-drug@usa.healthnet.org'.