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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" drugs?

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 medical products.

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 formularies.

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.

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