Are P&T committees outdated?

September 17, 2007

The author contends that Pharmacy & Therapeutics committees should be replaced by broader Therapeutics committees that review not just drugs but also devices and other treatments.

In my view, the answer is a resounding Yes, and, what's more, pharmacy should lead the way and bring the needed clinical expertise to the hospital.

Why should P&T committees be replaced by a broader structure? We need to be aware of what impact nondrug treatments will have on the overall drug budget and patient care. Will there be cost shifting from other departments, such as from blood banks to pharmacy over the erythropoiesis-stimulating agents (ESAs)? Or consider the shift from coronary artery bypass graft (CABG) to interventional cardiology through the use of stents? The medical literature has documented a 40% shift away from CABG at some hospitals. The development of stent devices allowed this shift in care to even be considered, along with GPIIb/IIIa agents. What is the drug cost for CABG versus percutaneous coronary intervention and the impact on length of stay (LOS) and overall cost per case?

Pharmacy needs to work more closely with materials management/supplier services to become part of the vendor detailing process for devices, to understand the clinical performance (efficacy), safety, labor component, and overall cost of the product, and to determine whether there is a treatment within the pharmacy that could be affected.

Some of the questions that need to be asked by a therapeutics committee and pharmacy are the following: What are all the treatment options for a particular disease/diagnosis? Can we measure clinical/patient outcomes for each treatment option? What is the overall cost to the hospital/patient for each treatment option? What do we get reimbursed by each payer for a particular disease or each treatment in the outpatient setting (e.g., ESA versus packed red blood cell infusion)? Is there an impact on LOS, or can we move an inpatient admission to the outpatient setting? Other questions: Should a value analysis committee, nutrition support committee, or blood/transfusion committee become reporting committees to the therapeutics committee? If you have an Institutional Review Board (IRB) committee, do you look at the devices being used in research within your facility and how they may impact patient care and other treatments in the future?

More than five years ago, while I was an administrator of pharmacy services, then chairman of the therapeutics committee at a 650-bed community teaching facility, I began addressing this transition. I also recognized that using a pharmacoeconomic model was not the answer. I started developing a "thereconomic" model to address the quality and financials of all treatments. As care began to transition from the inpatient to outpatient setting, as drugs were being developed to replace/conserve blood products, as devices such as the AngioJet were discussed at our IRB to treat peripheral arterial occlusion instead of using a lytic agent in interventional radiology, it became more important to incorporate more than drugs when looking at treatment options for pharmacy.

Some of the treatments would go through supplier services and pharmacy would have no idea of hospital spend, whether the clinical information being presented was correct, and so on. The need to look at all treatments-drug, device, surgical-to ensure optimal patient outcomes for each treatment and to measure the cost of each treatment is more important today. It is not an individual department budget issue, but rather a hospital budget issue. Who evaluates the efficacy and cost of each treatment option? We need to move out of department silos and address patient care from a broad facilitywide perspective. Pharmacy can be the leader in this initiative. We have the clinical expertise to bring to the table!

THE AUTHOR is senior director of pharmacy affairs at Premier Inc., a group purchasing organization based in San Diego. The views expressed in this article are his own and do not reflect the policy and practice of Premier.