The truth about hospital formularies:
We've come a long way, or have we?
From the November 18, 2004
What does the term "formulary" mean in a hospital?
If you're a pharmacist, do you consider the formulary a continuously
changing list of preferred drug products that reflects clinically
proven pharmacologic improvements available in the marketplace?
Or is it merely an administrative device for identifying the
drugs that can be ordered through a group purchasing agreement,
or just a subset of the real formulary when you consider the
frequency with which physicians prescribe "nonformulary"
If you're a physician, do you feel the hospital formulary
is a tacit representation of the full universe of pharmaceuticals
in the marketplace, even if it excludes some of the medications
you prescribe on paper? Or do you view the formulary as a
means for hospital administration, pharmacists, and/or the
Pharmacy and Therapeutics Committee to dictate your practice
and control your choice of medications? Do you groan and cringe
at the mere mention of the term because you believe you can
render better care with unfettered access to any medication?
Do you think that the formulary is merely the hospital's means
of cutting costs?
If you're a nurse, do you view the formulary as simply a
list of all drug inventories available in the pharmacy? If
you're the Chief Medical Officer or the Chief Executive Officer,
does the formulary primarily represent a means for restraining
drug costs and utilization to achieve economic goals?
If you're a pharmaceutical manufacturer, do you consider
the hospital formulary an inconvenience that can hamper and
potentially nullify your drug promotion activities?
The term "formulary" can have assorted meanings
and conjure up many different feelings, depending on the person's
point of view. Too often, the term is employed indiscriminately
to suit the convenience of various individuals, organizations,
or companies to describe a particular list of drugs and related
Perhaps these inconsistencies represent an even bigger problem:
Healthcare professionals and industry tend to deny or downplay
the most fundamental and important purpose of a hospital formulary:
To delineate the drugs of choice as determined by clinical
efficacy and relative safety (including adverse drug reactions,
side effects, interactions, as well as error potential and
risk of patient harm). Most of the responses to the term "formulary"
cited above do not allude to drug efficacy, and none reflect
safety as a goal.
Ideally, a carefully selected drug formulary provides a foundation
to guide clinicians in choosing the safest, most effective
agents for treating particular medical problems. But full
realization of this potential has been thwarted by misconceptions,
according to a 1990 article (Rucker TD, Schiff G. Drug formularies:
myths-in-formation. Medical Care 1990; 28:928-942.
Reprinted in Hosp Pharm 1991;26:507-514).
During a 3-year period (1987-89), Rucker and Schiff compiled
statements made by physicians during Pharmacy and Therapeutics
Committee deliberations pertaining directly to the formulary
concept. Sadly, they found that the deliberations centered
less on critical evaluation of scientific data and more on
the purpose, design, and the need for a formulary, per se.
Rather than debating the relative merits of the drug, the
formulary concept itself was often subject to review. In the
end, debates about a particular drug were really disagreements
about fundamental assumptions related to formularies. These
disagreements occurred both within the Committee and with
staff physicians who came to support the addition or deletion
of a particular drug. After contrasting these statements and
other published misconceptions with the basic objectives and
operational requirements of an effective formulary, the authors
classified the comments into frequently occurring myths about
It's been well more than a decade since this article was
first published, so has much changed with hospital formularies
since then? The survey (that appears on page 4 of the PDF
version of the newsletter) describes the formulary myths initially
identified by Rucker and Schiff in 1990. You may be surprised
to find that some of the examples are remarkably similar to
your experiences, even today. Please take our survey and let
us know whether these myths are still in existence in your
facility. We'll report our findings in an early 2005 issue
of the newsletter.
We thank T. Donald Rucker and Gordon Schiff for their
assistance with the preparation of this article and the survey
on formulary myths that appears on page 4.