Praxis makes perfect

If you like theory, you'll love the current debate about health care reform, in which theories and projections abound. But if you want to put your money on a proven winner, you'll have to look beyond the klieg lights that illuminate the deliberations of health policy analysts. Perhaps to your surprise, you'll have to return to the workings of most American hospitals. Tucked away in the hospital bureaucracy, out of sight of health policymakers, committees that regulate the purchase and use of drugs have learned to weave larger policy objectives into the web of clinical practice. With the support and active participation of clinicians, these hospital formulary committees have controlled costs, regulated physician practice patterns, and improved patient care. Policy planners would do well to test their theories against the practical model provided by the formulary committee. These committees have learned how to translate data collected in the aggregate into savings at the patient's bedside without alienating practitioners or distorting the healing enterprise. As we evaluate proposals to reform and perhaps restructure the health care system, formulary committees provide a working model for thoughtfully balancing the needs of patients, practitioners, and institutions. If indeed "God is in the details," we would be well advised to understand this equitable, creditable, and scientifically sound strategy. A Formulary Primer Formulary committees control drug expenditures by selectively purchasing pharmaceutical products and by regulating their use once they are on the formulary. Employing a hybrid blend of cost-effectiveness analysis, peer review, and continuing medical education, these committees use an interdisciplinary method to evaluate drug purchases and to ensure that practitioners use drugs thoughtfully. Drugs that are not approved by the formulary committee are available initially only on an emergency basis and thereafter only through a special appeals process. Drugs are considered for inclusion on a hospital's formulary after rigorous peer review by a committee composed of individuals with expertise in a range of medical and surgical specialties as well as pharmacology, epidemiology, infectious disease, microbiology, and hospital administration. Drugs can be proposed for inclusion by hospital pharmacologists or clinicians who believe that an addition to the formulary is indicated. Committees assess the clinical merit of prospective additions by reviewing the published literature and considering what additional benefits new drugs might bring to the existing formulary. Drug choices may vary from one institution to another, and formulary committees can select drugs based on the needs of their institutions and the patients they serve. For example, a specialized cancer center treating immunocompromised patients may need a wider assortment of antibiotics than a community hospital treating an unselected population. Formulary committees can choose agents based on these local demographic data and tailor their selection of antibiotics to best meet the drug resistance patterns of the bacteria within the institution. All selections are made by considering the benefits new agents will bring to the existing formulary. Like the college admissions officer who selects a freshman class based on its balance and diversity, the formulary committee evaluates drugs based on their individual merit and what an agent adds to the range and scope of the entire formulary. This strategy minimizes the purchase of new drugs that duplicate the indications of drugs already available. It also identifies when new agents confer a significant benefit over older drugs and when older, less effective drugs need no longer be maintained in stock. Because formulary committees purchase all drugs used within hospitals, they provide an important buffer between the practitioner and the marketplace. …