Exploring Opportunities for Collaboration Across the Spectrum of

Formulary Decision-Making: The Nova Scotia Experience

Anne Hiltz, Director Pharmacy and Renal Program

Nova Scotia Health Authority

Speaker Disclosure

Speaker has no real or potential conflicts to disclose in relation to this presentation

Background - Nova Scotia Health Authority

Established April 1, 2015 as an amalgamation of nine previous health districts with over 23,000 employees and 2500 physicians Includes all health care organizations (acute, tertiary, quaternary, community, mental health, addictions, forensics) with the exception of the IWK Health Centre Comprised of four zones $94 million dollars in drug expenditures

Speaker Perspective

Current state of transition with district drug formulary decision-making still in place Majority of presentation will focus on existing state within previous Capital District Health Authority, now Central Zone of Nova Scotia Health Authority

Collaboration with Nova Scotia Department of Health and Wellness

No mandate to align hospital formulary with provincial drug plan Good working relationship with Pharmacy Services, Department of Health and Wellness Commitment to focus on alignment

Formulary Overview

All formulary and drug policy decisions across the district (nine sites and roughly 50% of provincial population) approved at the District Drugs and Therapeutics Committee (DD&T), with the exception of newer oncology drugs approved by the province

Decision-Making ProcessGeneral Principles

On admission, patients kept on current medication even if non-formulary in hospital mainly for safety reasons and issues with medication reconciliation Drug reviews only initiated upon request of prescribers (e.g. levetiracetam)

Decision-Making Process Three types of reviews:

Drugs on provincial formulary Drugs not on provincial formulary and hospital-only drugs High-cost non-formulary drugs

Drugs on Provincial Formulary

Budget impact analysis only completed and reviewed at DD&T If above a set dollar limit, request for funding goes to Executive

Drugs not on Provincial Formulary and Hospital-only Drugs

Complete review prepared by a subcommittee of DD&T in consultation with stakeholders Safety, efficacy and all elements of cost considered (e.g. IV irons) Both pharmacoeconomic and ethics expertise on DD&T Recommendations are taken to DD&T with the committee voting on the recommendations Excellent collaboration between different departments within hospital (e.g. NOAC’s)

High-Cost Non-Formulary Drugs

Drug requested usually by a specialist to VP, Medicine Pharmacy reviews evidence (often limited) and makes recommendation to VP VP informs requestor of decision

What’s Working Well?

Knowledge of committee members increased Willingness of most clinicians throughout organization to wait on provincial decision before submitting request (i.e. NOACs) Increased engagement in process Enabled by co-leadership model across organization

Challenges Eagerness to use all new drug entities in a tertiary care organization Perception that decisions made by both CADTH and the province are related mainly to cost and not efficacy Lack of depth of knowledge re: evidence informed decision-making by some individuals

Moving Forward Structure of DD&T in a provincial health authority? Will there will one single formulary for the province? How will all parts of the province be represented? Challenge of developing a single provincial hospital formulary with many smaller community hospitals while aligning it with the province, especially if not mandated