A Needs Assessment of Drug Formulary Review Processes Across a Local Health Integration Network (LHIN) in Ontario Natasha Burke 1,2, Anne Holbrook 1,2, James M Bowen 1,2, Sue Troyan 1,2, Jathishinie Jegathisawaran 1,2, Carolyn Gosse 2, Marita Tonkin 3, Sandra Kagoma 4, Sue Alderson 3, Ron Goeree 1,2 1 McMaster University; 2 St. Joseph s Healthcare Hamilton; 3 Hamilton Health Sciences; 4 Brant Community Healthcare System 2013 CADTH Symposium, May 7, 2013
Disclosure and Acknowledgement Supported by: Academic Health Science Centres (AHSC) AFP Innovation Fund (PI: Dr. Anne Holbrook) 2
Background Drugs approximately 16% of total health care spending in Canada Hospital drug expenditures estimated at $2.4B in 2009 1 Pharmacy and therapeutics (P&T) mandated committee Evaluation of new drugs and current drug therapies for inclusion or deletion from hospital formulary Drug use policies and procedures Variable use of evidence-based methods to assist in decision-making regarding drugs 3 1 CIHI, Drivers of Prescription Drug Spending in Canada, 2012
Local Health Integration Network (LHIN) In 2006, MOHLTC divided Ontario into 14 LHINs Intended to plan, integrate and fund local health services including hospitals, community care, longterm care and mental health services 4
Project Objective To examine current formulary review processes and preferences related to a potential collaborative drug review process across P&T committees within the LHIN 5
Methods: Institutional Profile Survey (Part 1) To gather information regarding the structure of current drug review processes at each hospital Profile of institutions Formulary characteristics P&T committee characteristics Formulary review submission process Evidence submitted for review Formulary review decision-making Directors of Pharmacy asked to complete (n=10) Response rate 100% 6
Methods: P&T Committee Member Survey (Part 2) To gather feedback from individual committee members on process for new drug formulary requests and preferences related to centralization 5-point Likert scale; open-ended questions Each Director of Pharmacy asked to distribute to 4-5 committee members Anonymous survey responses returned Response received from 28 members 7
PART 1: Institutional Profile Survey 8
LHIN 4 - Hamilton-Niagara-Haldimand- Brant (HNHB) Total Population: 1.3 million 9
Profile of Institutions within HNHB LHIN 10 Hospitals/Institutions 23 sites 15 community; 8 academic Setting: 17 inpatient/outpatient; 2 inpatient only; 4 outpatient only 3566 beds Pharmacy Staff: 137 FTE pharmacists 201 FTE pharmacy technicians 10 FTE administrative support for pharmacy 10
P&T Committee & Drug Formulary (n=10) Characteristic N (%) P&T Committee: P&T committee provides service for more than 1 site 4 (40%) Frequency of committee meetings <6 times per year 4 (40%) >10 committee members 7 (70%) Subcommittees (medication safety, nursing/pharmacy, antimicrobial, accreditation medical management) Committee representation (mean) Drug Formulary: 11 5 (50%) 35% medicine 29% nursing 25% pharmacy 0-7% other Major review of formulary within past 10 years 6 (60%) On-line access to drug formulary 6 (60%) P&T newsletter used to communicate changes to formulary 7 (70%)
Hospitals Number of New Drug Formulary Requests Reviewed Per Year 7 6 5 4 3 2 1 0 1-5 6-10 11-15 No. Requests Per Year 12
P&T Resources Across the LHIN Time commitment for new formulary drug submissions/reviews: Hours per month Pharmacists 96 Physicians 15 Administrative 9 Nursing 9 Technicians/assistants 4 Clerical 4 Total Hours Per Month 137 Total hours per year = 1,644 Equivalent to 0.84 FTE 13
Other Economic Clinical Formulary Submission: Evidence Requested Disease description Pharmacology & pharmacokinetics Product & administration Efficacy Efficacy - detailed Safety Safety - detailed Critical appraisal-clinical evidence Economic evaluation Hospital BIA Budget impact calculations Critical appraisal-economic evidence Institutional impact assessment Drug plan coverage (ODB) Ethical/social implications Education/communication plan 0% 25% 50% 75% 100% 14
Formulary Submission: Evidence Synthesis and Evaluation Primary literature searches are conducted to identify clinical efficacy & safety information Systematic review methods or meta-analytic techniques are used to summarize the evidence Economic evaluations are conducted internally Budget impact analyses are conducted internally N Never, R arely or NA Sometimes Often or Always 10 10% 50% 40% 9 44% 22% 33% 10 60% 20% 20% 10 30% 30% 40% 15
PART 2: P&T Committee Member Survey 16
P&T Member Survey (n=28) Committee Member Characteristics (those reporting) n (%) Profession: Pharmacist 15 (54%) Medicine 5 (18%) Nursing 4 (14%) Other 4 (14%) Number of years of practice, median (range) 19 (2-40) Number of years experience on a drug review committee, 5 (1-25) median (range) Any formal/structured training: Clinical pharmacology or therapeutics 22 (79%) Evidenced-based medicine 14 (50%) Systematic review 13 (46%) Health economics 6 (21%) Health technology assessment 5 (18%) 17
Formulary Review Submission Process (n=28) Statement Considering the current submission process for a new drug formulary request, the process captures all of the information needed for the review Statement How comfortable are you in evaluating the quality of the submission or the evidence provided? Statement Overall, how satisfied are you with your institution s drug formulary submission process? Disagree or Strongly Disagree Neither Agree or Disagree Agree or Strongly Agree 9 (32%) 3 (11%) 16 (57%) Uncomfortable or Slightly Comfortable Moderately Comfortable Very/ Extremely Comfortable 5 (18%) 13 (46%) 10 (36%) Unsatisfied or Slightly Satisfied Moderately Satisfied Very/ Extremely Satisfied 7 (25%) 13 (46%) 8 (29%) 18
Quality of Information Submitted (n=28) In general, the evidence provided in the submission is sufficiently comprehensive and detailed for decision making: 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 46% 29% 25% 36% 21% 39% 43% 25% 36% Agree or Strongly Agree Neither Agree or Disagree Disagree or Strongly Disagree Clinical Evidence Economic Evidence Organizational Impact Analysis 19
Formulary Review Decision Making Statement N (%) Your committee currently has amongst its participating members, sufficient clinical and economic expertise to make a fully informed decision for all formulary requests (n=28) If no, what expertise is currently lacking (n = 19): 20 9 (32%) Health economics/ impact expertise 14 (74%) Physician participation 5 (26%) Evidence/critical appraisal expertise 3 (16%) Other issues that impede the quality of formulary review at your institution (n = 13): Limited resources/ staff/ administrative support 6 (46%) Limited / lack of information 5 (38%) Incomplete/ brief submissions 2 (15%) Time constraints 2 (15%)
Coordinated Review Process: Interest Statement A standardized drug formulary submission process across institutions in the LHIN would be beneficial. A common drug formulary across the institutions in the LHIN would be beneficial. The institutional formularies should be synchronized with ODB drug formulary listings. The OPDP should expand its formulary process to evaluate and decide on reimbursement for hospital-only drugs. National and provincial formulary reviews should be used to inform institutional formulary decisions. Expansion of group purchasing contracts (e.g. MedBuy) to negotiate discounts on all new drugs added to the formulary would be beneficial. Disagree or Strongly Disagree Neither Agree or Disagree Agree or Strongly Agree 2 (7%) 1 (4%) 25 (89%) 6 (21%) 4 (14%) 18 (64%) 7 (25%) 5 (18%) 16 (57%) 0 (0%) 7 (25%) 21 (75%) 1 (4%) 1 (4%) 26 (93%) 0 (0%) 3 (11%) 24 (89%) 21
What benefits would be obtained by harmonizing or centralizing formulary review processes within the LHIN? Most common themes (n=25 responses) Frequency Efficiency/ sharing of workload 15 More standardization/ reduce variation 11 Efficiency/ sharing of cost 9 Improve quality/ expertise in review 7 22
What drawbacks would there be to harmonizing or centralizing formulary review processes within the LHIN? Most common themes (n=24 responses) Frequency Institution-specific population/ needs/ priorities 13 Equity across large and small sites 7 Physician autonomy/ buy-in 6 Time/cost of implementation 3 Institution-specific budget impact 3 23
What do committee members need/want from a centralized formulary review process within the LHIN? Most common theme (n=21 responses) Frequency Shared review of clinical and/or economic evidence 8 Representation of members from across all sites 5 Standardized procedures 5 Individual decision-making/ local consideration 5 24
Summary Review of formulary submissions across LHIN represents 1 FTE annually Resources still an issue across institutions Gap in health economic and HTA expertise Interest in centralized/coordinated process Concerns about adequate resources, equity across institutions and specific needs of institutions (i.e. special populations) Use of national and provincial reviews supported 25
Questions? Natasha Burke, MSc Program Manager, Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph s Healthcare Hamilton Research Associate, Department of Clinical Epidemiology & Biostatistics, McMaster University Telephone: (905) 523-7284 Fax: (905) 522-0568 Email: nburke@mcmaster.ca Website: http://www.path-hta.ca PATH Research Institute 25 Main Street West, Suite 2000 Hamilton, ON, Canada L8P 1H1 26