Hospital Formulary Development and Selection
Hospital formularies are primarily based on cost-effectiveness, clinical efficacy, safety, and institutional needs, with decisions made by multidisciplinary Pharmacy and Therapeutics committees that balance clinical outcomes with financial considerations.
Key Factors in Hospital Formulary Development
Hospital formularies are developed through a structured process that considers multiple factors:
1. Clinical Considerations
- Efficacy and safety profiles of medications based on current evidence
- Access to medications necessary for treating common conditions in the patient population served 1
- Usual and customary medications needed to treat specific conditions (e.g., diabetes requires access to short-, medium-, and long-acting insulins) 1
- Treatment goals and protocols that require specific medication classes 1
2. Economic Factors
- Cost considerations are a major determinant in formulary decisions 1
- Negotiated pricing between hospitals/health systems and pharmaceutical companies 1
- Budget constraints within the hospital's financial framework 1
- Cost-effectiveness analysis comparing clinical benefits against acquisition costs 1
3. Institutional Structure
- Local patterns of antibiotic resistance for antimicrobial formularies 1
- Hospital size and type (academic, community, specialty) influences formulary needs
- Patient population characteristics served by the institution
- Existing hospital budget and reimbursement systems 1
The Decision-Making Process
Pharmacy and Therapeutics (P&T) Committee
The P&T committee typically:
- Consists of physicians, pharmacists, nurses, administrators, and other healthcare professionals
- Reviews clinical evidence for medication efficacy and safety
- Evaluates cost implications of adding medications to formulary
- Makes final decisions on formulary inclusion/exclusion
- Develops protocols for medication use within the institution 1
Evidence Evaluation
When selecting medications for formulary inclusion, committees prioritize:
- Clinical practice guidelines from professional societies
- High-quality clinical trials demonstrating efficacy and safety
- Comparative effectiveness data between therapeutic alternatives
- Local resistance patterns for antimicrobials 1
Special Considerations
Antimicrobial Stewardship
- Antimicrobial formularies require special attention to:
- Local resistance patterns
- Appropriate use protocols
- De-escalation strategies
- Cost-effectiveness of therapy 1
High-Cost Medications
For expensive medications (e.g., novel antibiotics, specialty drugs):
- Special approval processes may be implemented
- Restricted use criteria based on specific indications
- Alternative reimbursement models may be considered 1
- Insurance coverage and prior authorization requirements influence decisions 1
Pitfalls and Challenges
- Administrative burden of managing formulary restrictions and prior authorizations 1
- Balancing cost containment with clinical needs of diverse patient populations
- Keeping formularies updated with rapidly evolving evidence and new medications
- Ensuring adequate access to necessary medications while controlling costs 1
Emerging Trends
- Value-based purchasing models that consider total cost of care
- Novel reimbursement approaches for high-cost medications (e.g., England's fixed annual price model for antibiotics) 1
- Integration of pharmacoeconomic analyses in formulary decisions
- Collaborative purchasing agreements between hospital systems to increase negotiating power
By understanding these factors, healthcare systems can develop formularies that balance clinical efficacy, safety, and cost-effectiveness while meeting the needs of their specific patient populations.