Author, Editor, Clinical Pharmacist, Santa Rosa, California, USA *Corresponding Author: Diana Rangaves, Author, Editor, Clinical Pharmacist, Santa Rosa, California, USA.
The anatomy of a formulary process is precarious and longwinded. Keeping the ‘Rational’ at the front and center takes effort, energy, intellect, and integrity. Many times alternative agendas, values, and ethics play a dramatic part in processes and decisions. Oblivious, unaware or unwitting players are duped by personal bias, money, greed, power, reaction, or targeted marketing.
Allowing these elements to infiltrate a system will corrupt processes, and those desirous of power will replace excellence. In the decision-making process, all must be rejected. Excellence, integrity, and quality must be at the forefront of any system.
A model for drug decision making for a formulary purpose is described by the System of Objectified Judgment Analysis (SOJA) . In the SOJA method, medication selection parameters are specified for each therapeutic drug classification. The settings applied are effectiveness, frequency, and gravity of adverse effects, dosage frequency, drug interactions, and cost of purchase, credentials, pharmaceutical and pharmacokinetic features.
The additional significance is given to the development of resistance to antimicrobial agents. The consequence of the SOJA method is that non-rational selection criteria are left out, and those drug selection decisions are solely based on rational principles . The use of computer software creates a transparent, realistic, and specific metrics. Impact When healthcare resources are limited, decisions will have significant after-effects with individual magnitudes more significant than first thought .
Decision-makers may not be conscious of the influence that power has on these multiple factors. Supported evidence-based medicine applies the use of fair and sensible health outcomes information. The SOJA method, based on decision-making processes in economics, ensures that health outcomes information is given appropriate weight. Such approaches are valuable tools in discussions about product selection for formularies . In the United States, prescription drug spending increased at a rate of >10% per year and currently represents 11% of all healthcare expenditure.
In the United Kingdom, the Health Care Financing Administration estimated that drug prescription costs would continue to increase by approximately 11% annually . This imbalance will continue to trend worldwide. A SOJA approach will: (i) allow drug selection within a therapeutic classification across a range of indications, (ii) confer clinical effectiveness primacy over cost, and (iii) be suitable for the development of formularies that would create cost-effective and safer drug recommendations and administration across healthcare .
The SOJA Approach The true order of the decision-making process is safety, effectiveness, system tolerance, ease of use, administration, and cost. Each medication is compared to the imaginary ‘perfect’ agent within the therapeutic classification. The medication will be administered once per day, have optimal clinical effects with no side effects in 100% of all patients. This is the benchmark of excellence.
Efficacy is the actualization of positive outcomes and treatment goals. Safety is the avoidance of negative outcomes, such as hazardous side effects that prolong the length of stay and outpatient co-ordination of care. Tolerance is the interruption of the care process due to less hazardous, generally brief, but disturbing, side effects. Ease of use is ease for the healthcare team and the patient; for example, dosing frequency with a user-friendly administration form.
Applicability is the scope of the treatment freedom from interactions and the ease for the caregiver. Costs price per year . Collaborative Approach There is an uneven approach in the study, examination, and comparison to formulary selection protocols. The most reliable predictor of implementation success is adherence to medically appropriate and cost-effective therapies for our patients. Senior leadership, hospitalists, physicians, nurses, pharmacists, pharmacy technicians, and support personnel proactively review opportunities. Educational efforts are focusing on the creation of a medication monograph summary based on current information.
A representative of the Pharmacy Department presents the findings to the Pharmacy and Therapeutics Committee for determination of formulary status. This service and SOJA strategies will simplify the selection of appropriate formulary medications for our patients. An organization must be dedicated to the dissemination of evidence-based, non-commercial information to physicians and healthcare providers with the goal of securing optimal outcomes for all. A team of physicians, nurses, pharmacists, pharmacy technicians and health care professionals are working together to offer a unique form of one-on-one education called Academic Detailing.
Academic Detailing Academic detailing is based on free thought, critical thinking and reaching out for the sole purpose of education and growth . The practice involves the peer-to-peer teaching of prescribers by trained health care professionals, including nurses, pharmacists, physician assistants or physicians. The objective of academic detailing is to transform prescribing of medications to be consistent with evidence-based medicine, validate patient safety, and be cost-effective.
A critical component of non-commercial or university-based academic detailing programs is that academic detailers, management, staff, program developers, etc., refrain from monetary connections to players in the pharmaceutical industry. Researched over 25 years  and has shown to improve the prescribing of targeted medications about 5% from baseline . Academic detailing (AD) is an educational method for disseminating information to enhance physician medication selection and delivery. Multifaceted AD interventions have a positive effect on the measured outcomes of changes in prescribing behavior, drug utilization, improvements in clinical outcomes and costs .
Interactive continuing education is the most effective in stimulating change in physician care patterns and patient outcomes . AD programs are currently delivered by CME providers in 5 Canadian provinces: British Columbia, Alberta, Saskatchewan, Manitoba, and Nova Scotia. These groups form the Canadian Academic Detailing Collaboration (CADC). The goal of the CADC is to prepare AD topics accurately, efficiently and to disseminate evidence-based information correctly .
This method has proved successful as educational ‘props’ by pharmaceutical companies and representatives–drug ‘reps’ to improve drug prescribing practices of their ‘special interest’ products. An equally valid manner of operation, about achieving ownership by prescribers, senior leadership, pharmacy and nursing departments, may be made in the area of Pharmacy and Therapeutics Formulary. In a groundbreaking discovery, academic detailing improves identification and reporting of adverse drug events . This lays the foundational support for safe practice recommendations. Each facility is unique; therefore, critical evaluation and application must be managed in practice.
Role of Pharmacy Technician It is projected that from 2008 to 2018 the demand for pharmacy personally will rise by 25 percent, which is much faster than the average for all occupations. As the population ages, there will be an increasing sector of older people-who by system standards take more prescription drugs than younger people-this will create an upsurge of a need for pharmacy personnel. Also, as biologic and novel pharmaceutical medications are brought to market and more people will have drug coverage, pharmacy and clinic staffing will grow.
To maintain or reduce costs, payers and insurers have begun to use pharmacies as clinics where pharmacists are actively in patient care; pharmacy technicians will continue to see growth in their responsibilities. Also, they will increasingly adopt patient care and administrative duties .Advancement opportunities in large pharmacies and health systems pharmacy technicians will be promoted to management positions. An upward career ladder toward positions in medication reconciliation, chemotherapy, palliative care and nuclear pharmacy technician will offer a robust professional track.
Others may move into Formulary Management. The Pharmacy Technician job descriptions are ever evolving including but not limited to:
- Pharmacy Service Health Associates Formulary Research • Formulary Administration • Organizational Review and Audits • Pharmacy Recovery • Prior Authorization • Medicare Drug Procedures Using established organizational guidelines and competencies, the Pharmacy Technician may reviews requests made by physicians, medical groups, pharmacies and members for the use of prescription drugs and pharmacy benefits. The pharmacy technician will research, and resolve questions, problems or issues and present findings at committee meetings. They will consult with Clinical Pharmacists or Regional Medical Director on related matters. Essential Duties and Responsibilities include and are not limited to: Formulary Management • Reviews and processes formulary requests from P and T Committee. • Submits and maintains formulary requests. • Conducts quality assurance (QA) reviews to ensure the accuracy of formulary set up. • Supports the development, maintenance, and submission of the formulary. • Monitors the formulary for quality and to ensure accuracy. • Performs periodic audits to ensure accuracy and compliance with formulary administration requirements. • Assists with formulary database maintenance and accuracy. • Supports formulary revisions and document updates. • Maintains expert knowledge of the formulary. • Educates the healthcare providers on new medications and presents research to P and T Committee. • Reviews requests made by physicians for the use of prescription drugs that are non-formulary, • Researches using the appropriate reference material and documents findings. • Responsible for knowing and interpreting pharmacy policy and procedure. • Performs audits and quality checks.
• Assists with identifying and correcting formulary oversights. • Maintains expert knowledge of pharmaceutical therapeutic classifications. • Liaison to internal and external departments for pharmacy. • Preparation and review of various operational reports and audits. • Formulary management functions, including quarterly formulary updates to the website, database and benefit maintenance as necessary. • Assist with formulary clinical projects. Pharmacy Technician Formulary Management Competencies Performance Evaluation Scale 1. Exposed to the task 2. Accomplished task with help 3. Accomplished task to criteria 4. Able to teach task Formulary and Business Operations State and define the process and primary goals of a Pharmacy Formulary, Pharmacy and Therapeutics Committee, SOJA, Academic Detailing and Quality Assurance programs. Pharmaceuticals Identify and describe the following: • Define a drug. • Identify therapeutic drug classifications. • Differentiate between over-the-counter drugs and prescription drugs. • Distinguish between generic drugs and brand-name drugs. • List the various dosage routes for drugs. • Explain the importance of dosing time intervals. • Differentiate between dosage forms and their advantages and disadvantages. • Identify terms related to patient response to drugs. • List the main dangers of drug-drug interactions. • Describe therapeutic drug level monitoring. • Identify and use abbreviations correctly. • Calculate safe dosages for infants and children. • Calculate dosages for individual patients given the patient’s weight and/or height and the recommended dosage. • Perform calculations necessary for the infusion of IV medications. • Utilize various medical research references via books, Internet, etc. Conclusion The results of the present research show that the SOJA and Academic Detailing tools can make a significant contribution to containing costs, improving the quality of drug selection, and patient outcomes. The system has been used for statins, proton pump inhibitors, selective serotonin reuptake inhibitors, wound dressings, and medical and surgical devices . The process provides better continuity of care across the primary-and secondary-care interface; decreased inventory within the hospital and actual reduction of drug costs after full implementation .
Glossary of Terms Academic Detailing: is an educational method for disseminating information to enhance physician medication selection and delivery Formulary: a list is developed and maintained through a formal evaluation process to assure efficacy and safety and is reviewed at least annually against emerging safety and efficacy information.
Rational: balance, cogent, sensible, reasonable, logical, realistic, sound, wise, judicious and based on reason. SOJA: System of Objectified Judgment Analysis is a structured approach to the selection of drugs for formulary inclusion.
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