# E-DRUG: Re: Drug and Therapeutics Committees (contd) **URL:** \ **Category:** e-drug\ **Created:** [September 28, 1998, 8:10pm UTC](https://talk.edrugplus.org/t/e-drug-re-drug-and-therapeutics-committees-contd/3556 "1998-09-28T20:10:58Z")\ **Posts on this page:** 1\ **Page:** 1
**Author:** ![myhr](https://avatars.discourse-cdn.com/v4/letter/m/f07891/32.png) [@myhr](https://talk.edrugplus.org/u/myhr)\ **Post date:** [September 28, 1998, 8:10pm UTC](https://talk.edrugplus.org/t/e-drug-re-drug-and-therapeutics-committees-contd/3556/1 "1998-09-28T20:10:58Z")
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'.