EVALUATION OF TYPE C HOSPITAL FORMULARY IN YOGYAKARTA Anggriani Y, Pudjaningsih D, Suryawati S Department of Clinical Pharmacology, Faculty of Medicine, Gadjah Mada University, Yogyakarta

Abstract Problem Statement: Many pharmaceutical products on the market are new and nonessential drugs. Appropriate selection is needed to support rational use of drugs. Establishing and maintaining a good hospital formulary is one way to increase drug selection efficiency. Objectives: To evaluate and compare the quality of 7 hospital formularies in Yogyakarta, and to determine the processes used to maintain the formulary in each hospital. Indicators: number of brand-name products, % of essential drugs, % generic drugs on the list, % drugs supported by the primary literature, % drugs with a single ingredient, and % generic drugs kept in stock. Design: Descriptive-analytical, explorative case study. Setting and Population: 5 public hospitals and 2 private hospitals in Yogyakarta. Method: Seven Hospital Formulary Lists were evaluated. Quantitative data included the numbers of each the followings: total number of drugs on the list, number of drugs in brand name, number of drugs in generic name,, the number of essential drugs, and number of drugs supported by primary literature. At the time of inspection, following data were collected, ie, number generic drugs available, and the number of non-formulary drug. A Chi-square test was applied to see if there was any difference between public and private hospitals. Information on the process of maintaining a formulary was obtained from qualitative data, including in-depth interviews with Drug and Therapeutic Committee (DTC) members and representative doctors from 4 wards (Obstetrics and Gynecology, Pediatrics, Surgery, and Internal Medicine). Qualitative data were analyzed by content analysis. Outcome Measures: The quality of a formulary was measured by the number of brand-name products, % of essential drugs, % generic drugs on the list, % drugs supported by the primary literature, % drugs with a single ingredient, and % generic drugs kept in stock. The process of maintaining a formulary was measured by frequency of revision, % of nonformulary drugs, and observation of DTC meetings. Results: Although no hospital showed an ideal formulary list, the quality of public hospital formularies was relatively better than that of private hospital formularies. The comparison of public vs private hospitals, as shown by the indicators, were respectively as follows: the number of brand-name drugs (296–532 vs. 513–1575); percentage of essential drugs (41–71% vs. 20–28%); percentage of generic drugs on the list (26–50% vs 17–18%); percentage of drugs supported by the primary literature (73–90% vs. 67-73%); percentage of drugs with a single ingredient (41–71% vs. 20–28%); and percentage of generic drugs kept in stock (26–48% vs 13–16%).The consistent differences between the two types of hospitals were significant (P= 0,00). The percentage of nonformulary-drug procured and the nonformulary drug kept in stock were lower in hospitals that had frequent formulary revisions and established policy on formulary revision. Regular meetings for formulary management was not yet established. In both public and private hospitals, the DTC tended to accommodate the doctors’ requests. Conclusions: The quality of public hospital formularies was better than that of private hospitals, but both of them were found not yet satisfactory. The process for maintaining a hospital formulary has not yet been established at the hospitals studied.

Background Many pharmaceutical products on the market are new and nonessential drugs. Increasing number of new drugs being introduced to medical doctors need a strong hospital drug policy and instruments to manage the hospital formulary list. Hospital formulary list is often developed without adequate process Even if there is a guide, the decision is oftenly based on individual interest. Appropiate selection is needed to support rational use of drugs. Quality of hospital formulary?

Objectives To evaluate and compare the quality of 7 hospital formularies. To determine the processes used to maintain the formulary in each hospital

Methods Descriptive-analytical, explorative case study 5 Public and 2 Private Hospitals The quality of hospital formularies were observed by looking at some indicators, i.e.,: Number of brand-name products Percentages of generic drugs on the list Percentages of essential drugs (drug from NEDL) Percentages of drugs supported with the primary literature Percentages of drugs with a single ingridient Percentages of generic drugs kept in stock

Outcome Measures The quality of a formulary was measured by the number of brand-name products, % of essential drugs, % generic drugs on the list, % drugs supported by the primary literature, % drugs with a single ingredient, and % generic drugs kept in stock. The process of maintaining a formulary was measured by the frequency of revision, % of nonformulary drugs, and observation on minutes on DTC meetings.

Results 1: The values of each indicator in 7 hospitals Indicators Public Hospitals Private Hospitals A B C D E F G  Active ingredients 525 441 382 532 296 513 1575  Brandname products 619 570 388 686 308 1002 2153 % Generic drugs on the list 37 35 26 34 50 17 18 % Drugs from NEDL 61 41 49 71 28 20 % Drugs with primary literature % Drugs with single ingredient 90 77 73 80 67 %Generic drugs kept in stock 31 29 27 48 16 13 Hospital E shows relatively better perfomance compared to the other hospitals Hospital G shows the worst perfomance among 7 hospitals

Results 2: Number of non-formulary drugs vs frequency of revision Indicators Public Hospitals Private Hospitals A B C D E F G % Non-formulary drugs procured 31 34 24 7 1 65 3 % Non-formulary drugs in stock 41 27 36 28 64 9 Frequency of revision 4 Year of the newest edition 1995 2000 1999 2001 1996 Hospital E, which perfomed better on result 1, its formulary is among the most frequently revised

Results 3: Criteria for drug selection HOSPITALS A B C D E F G Certificate of GMP Price Continuous delivery Track record of the industry Lag time of delivery

Results 4: Step in developing hospital formulary list Listing all drugs available in stock Distributing the existing drug list and drug request forms to medical doctors Establishing criteria for drug selection and revise formulary in DTC meeting. Parties involved : DTC members and Doctors Request is discussed only if attended by doctors who request the new drug Discussing the requests Official announcement of the new formulary by the hospital director.

Results 5: Mechanisms of new drug additions into formulary Hospital B, C, D and E Fill in the drug request form Submit to pharmacy department Discuss drug requests in DTC meeting Distribute supplementary formulary Procured by the pharmacy department Hospital A, F, G Fill in the drug request form Submit to pharmacy department Procured by the pharmacy department

Other findings DTCs in private hospitals tend to accommodate the doctors’ request Doctors perceived that generic and essential drugs were not sufficient to clinical needs Formulary development and management were not well established due to inadequate financial support. DTCs do not have regular meetings to manage formulary list Request form to deletion is unfortunately is not available at all hospitals

Conclusions Tendency of DTC in private hospitals to accommodate the doctors request Although no hospital showed ideal formulary list, the quality of public hospital formularies was relatively better than that of private hospitals formulary, due to: Doctors’ general perception that essential and generic drugs are not sufficient to clinical needs The mechanism to manage hospital formulary is not well established, mostly because: Financial support is inadequate Regular meetings for formulary revision in not yet established