Use of an Innovative Pharmaceutical Class Scoring Tool for Prioritized Annual Formulary Review.

Background: Though The Joint Commission requires health systems perform annual formulary review, guidance for how to perform this review is lacking. Published methods include comprehensive review of all pharmaceutical classes; however, this approach may not be the most efficient or effective option for a health system with a large formulary. Objective: To create a prioritization system for annual formulary review through development of a pharmaceutical class scoring tool. Methods: Drug information pharmacists developed the scoring tool, which used external and internal data to score pharmaceutical classes in 4 categories: safety, efficacy, cost, and utilization. The primary outcome, number of formulary changes resulting from pharmaceutical class review, was compared between the highest-scoring and lowest-scoring class to assess the tool's ability to prioritize high-yield class reviews. Results: The tool calculated scores for 91 pharmaceutical classes, altogether containing 962 medications. After review of the highest-scoring class, corticosteroids, 2 formulary changes were made: one dosage form was removed from formulary, and one medication was restricted to outpatient use only. Zero formulary changes resulted from review of the lowest-scoring class, pharmaceutical adjuvants. Conclusions: The tool described in this study prioritized annual formulary review efforts by identifying a pharmaceutical class with meaningful formulary optimization opportunities as the highest-scoring class, while correctly identifying a class with no optimization opportunities as the lowest-scoring class.

Verifying the value of existing frameworks for formulary review at a large academic health system: assessing inter-rater reliability.

BACKGROUND: The value assessment framework (VAF) is one approach to assessing the evidence and value of medications. VAFs are a way to measure and communicate the value of medications and other health care technologies for decision-making purposes. Given the increasing number of high-cost medications, challenging formulary inquiries, and critiques of currently available tools, health systems need to explore a standardized way to incorporate value assessment into formulary decision making. OBJECTIVES: To (a) evaluate existing VAFs by measuring inter-rater reliability among typical clinicians completing formulary reviews and (b) explore general implications of applying these tools to formulary decision making for all medications at a large academic health system. METHODS: This was a retrospective, observational study at a single health system. A list of medications added, denied, and removed from the system formulary from September 1, 2013, through August 31, 2018, was collected. Published VAFs, such as the American Society of Clinical Oncology (ASCO) Value Framework, European Society of Medical Oncology (ESMO) Magnitude of Clinical Benefit Scale, National Comprehensive Cancer Network (NCCN) Evidence Blocks, American College of Cardiology/American Heart Association Value Framework, and the incremental cost-effectiveness ratio (ICER) calculation were applied by 3 different reviewer groups. The primary outcome was inter-rater reliability among the 3 different reviewers for a given framework. Cohen's weighted kappa and the intraclass correlation coefficient (ICC) were used to assess inter-rater reliability. RESULTS: The frameworks were applied to 94 medications. The VAFs with the highest ICCs between all 3 raters were NCCN (0.635; 95% CI = 0.387-0.823) and ASCO (0.634; 95% CI = 0.370-0.832), both indicating moderate inter-rater reliability. The VAFs with the lowest ICCs were ESMO (0.368; 95% CI = 0.126-0.611) and ICER (0.159; 95% = CI -0.018-0.365), with ICCs corresponding to poor reliability. CONCLUSIONS: Because high-cost medications are a challenge to health systems, VAFs may be beneficial to target formulary decision making in this setting. Applying VAFs proactively may improve interrater reliability and usability in formulary decision making. DISCLOSURES: No outside funding supported this study. The authors have nothing to disclose.

Analysis of dosing-button compliance.

PURPOSE: A project was undertaken at an academic medical center to assess use of available dosing buttons within the computerized provider-order-entry (CPOE) system in order to identify opportunities for optimization of medication builds. METHODS: A retrospective observational study was conducted to identify medication records within a CPOE system meeting prespecified inclusion and exclusion criteria. A report capturing all inpatient adult medication orders associated with the identified medication records over a 6-month period was generated. The primary endpoint was percent dosing-button compliance, calculated as the number of orders with doses consistent with existing dosing-button options divided by the total number of orders during the study period. Secondary study objectives included a comparison of high- and low-performing medication record samples and identification of potential reasons for lack of dosing-button use. RESULTS: A total of 2,506 CPOE medication records associated with a total of 694,877 medication orders entered during the study period were analyzed. Median percent dosing-button compliance was 99.92% (interquartile range, 83.33-100%). High-performing records (n = 1243) were more likely to be associated with anti-infective medications (p = 0.041) and medications not on formulary at the study institution (p < 0.001). Medications in the sample of poor-performing CPOE records (n = 614) were more likely to be agents delivered via the i.v. route (p < 0.001). There were 45 records for which poor dosing-button compliance was attributed to lack of a clinically reasonable dosing option. CONCLUSION: A high level of dosing-button compliance was demonstrated despite the lack of routine revalidation of dosing buttons after initial medication builds. Some opportunity for optimization was identified during the project, which established a quality assurance method to facilitate future auditing of medication builds.

Use of economic predictions to make formulary decisions.

PURPOSE: The accuracy of cost savings and reimbursement predictions for medications added to an academic medical center formulary was assessed. METHODS: Formulary changes over a 5-year period were reviewed by the investigators. Medications were included if the medication was added to formulary and the monograph included cost savings or reimbursement data that indicated a positive net margin. The primary endpoints were percent predicted cost savings and net margin per medication based on medication cost only. Secondary endpoints included the percent of medications with at least 100% predicted cost savings or net margin and evaluation of median percent predicted savings or net margin individually. RESULTS: The pharmacy and therapeutics committee reviewed 558 formulary agenda items, 184 of which were selected for further analysis. In total, 19 medications were identified as having a predicted monetary advantage. The endpoints of percent predicted cost savings and net margin yielded a median of 76.5% (range 72.9-188.71%) (n = 3) and 148.2% (IQR 108.9-543.3%) (n = 16), respectively. For 13 (68%) of 19 medications, the percent predicted cost savings or net margin was at least 100%. CONCLUSION: Economic predictions utilized for formulary management at an academic medical center generated net positive monetary value for medications where predicted cost savings or reimbursement factored into the decision to add a medication to the formulary.