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Myths Still Exist About Hospital Formularies

HUNTINGDON VALLEY, Pa. February 23, 2005 -- Fifteen years ago, an article in Medical Care documented common myths about hospital drug formularies. Recently-released results from a survey conducted late last year by the Institute for Safe Medication Practices (ISMP) show that many of the same myths still exist. The survey reveals that formulary deliberations today may still be centered less on the critical evaluation of scientific data and more on misconceptions about formularies.

The survey’s 265 respondents were asked to report on the frequency with which specific comments illustrative of those myths had been made during 2004 formulary deliberations at their Pharmacy and Therapeutics (P&T) Committee meetings. All eleven of the myths presented in the survey were encountered by at least 19% of respondents during 2004. Some of the most frequently encountered include the following:

Myth: “The specialist knows best.” This was the most common myth encountered during P&T committee meetings. Almost three-quarters (74%) of respondents reported they’d received comments suggesting that it was presumptuous for non-subspecialists to play a role in formulary decisions for specialty drugs. Seventy-three percent of respondents who encountered this myth reported that the comments impacted formulary decisions. While specialists must be represented and consulted regarding formulary drugs within their specialty, nothing should preclude the P&T committee from pursuing a thorough evaluation of each formulary request.

Myth: “Causal empiricism.” Three-quarters (75%) of respondents reported assertions from physicians that favorable experiences, including personal cases or anecdotal observations, justify the addition of a new drug to the formulary, at least for a “trial” period for the medical staff to “evaluate” the drug. Almost three-quarters (70%) of respondents reported that the comments impacted formulary decisions.

Myth: “Sicker patients need more drugs.” This myth was heard by again almost three-quarters (74%) of respondents. Two thirds (67%) of all respondents who encountered this myth reported that the comments impacted the formulary decision. While most formularies include second-line alternatives for specific classes of medications, the assumption that sicker patients need more intensive pharmacotherapy, or more choices among available products, is only warranted if there is evidence of benefit.

Myth: “The formulary interferes with clinical freedom.” Two thirds (67%) of respondents cited this as a problem, with more than half (53%) of all respondents who encountered it citing the comments as impacting formulary decisions. The basic underlying tenets of effective formularies include acknowledgement that each clinician prescribes a very limited subset of available products, recognition that a formulary prepared by a group of experts with adequate resources is likely more optimal than a clinician’s personal formulary, and preservation of clinical freedom by providing broad therapeutic decision-making guidance, not interference with prescribing.

Myth: “Widespread use equals drug of choice.” Almost three-quarters of respondents (72%) encountered this myth during formulary deliberations, and almost 65% of those individuals reported that it impacted formulary decisions. Widespread use may be more of a measure of marketing success than comparative benefits of the product, especially in light of the rapid acceptance of new drugs that ultimately proved to be potentially harmful, and inappropriate prescribing of some high volume medications.

Perpetuation of these formulary myths can be attributed to many factors, including lack of didactic training. Holding frank discussions about myths and misperceptions could prove to be one giant step on the journey toward optimal care for patients. Focused attention on the theoretical foundation and operational parameters of formularies by health professional schools, the research community, and funding agencies could also help identify the most appropriate role of drug formularies in today’s healthcare organizations.

Source: Institute for Safe Medication Practices

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