INTRODUCTION

Drug and therapeutics committees (DTCs) are presented in the hospitals to improve prescribing and dispensing processes of medicines. Their importance appears in different aspects such as drug selection process, cost-effectiveness, and control of drug losses.¹,²Altogether, DTCs have shown an important role in promoting, controlling and educating activities of rational drug use. This is mostly manifested in demonstrating how the presence of DTCs in hospitals would improve patient’s health outcomes and decrease overall drug expenditures.¹,³Most DTCs are organized with subcommittees. In big hospitals, different subcommittees can be established to address particular issues, like antibiotic use, adverse drug reactions, medication errors, and drug use evaluation.⁴

Jordan is widely recognized as one of the most advanced health care systems in the area. But, since Jordan is a developing country with minimum resources, authorities should find ways to decrease the superfluous costs such as the cost of waste drugs. Hospitals in Jordan established DTCs in their structures in order to meet the increasing demands of prescribing and dispensing processes of drugs to the large number of patients and to improve cost-effective and evidence-based health care national policies.⁵

To date, few studies have been done that have addressed the structure and activities of hospital DTCs in developing countries, specifically in the eastern Mediterranean region. Information on Jordanian hospital DTCs is not available. Therefore, the objective of this research was to describe the extent of DTCs presence in Jordanian hospitals; and the structure, function, and activities of the hospital DTCs.

METHODS

This study was performed as a descriptive, cross-sectional survey, and data were collected from December 2016 to April 2017. A total of 106 Jordanian hospitals (32 governmental, nine military service, two university, and 63 private hospitals) were targeted for this study. However, three hospitals were excluded because they didn’t have pharmacists at the time of study. A questionnaire was emailed to pharmacists of 103 hospitals in Jordan.

RESULTS

Table 1shows respondents’ demographics. The total number of Jordanian hospitals that had pharmacists was 103 hospitals. However, five hospitals refused to participate in the study, yielding a response rate of 95%. The majority of pharmacists (n=66, 67%) had a bachelor’s degree in pharmacy. More than half of study hospitals (n=58, 59%) were private hospitals and slightly less than half (n=44, 45%) of the hospitals had DTC (Table 2).

Pharmacists held the position of secretary and chairman in (n=33, 75%) and (n=11, 25%) of the committees, respectively. The number of committee members varied from 2 to 15. Most of DTCs (n=27, 61%) had fixed structure. Different medical specialties were presented (Table 3).

All of DTCs had hospital or clinical pharmacists in their structures. Committee members were mostly selected by the hospital management. Most of DTCs (n=42, 96%) were responsible for one hospital only. The presence of subcommittees was very low and ranged between (1-5) subcommittees in 38% of hospitals.

About two-thirds of DTCs (n=29, 66%) met monthly and more than half (n=24, 55%) had restricted meetings to members-only (Table 4). The majority (n=41, 93%) had written documentation for the meetings of the DTC. The vast majority of respondents (n=42, 96%) reported that general prescribing is the major responsibility of their DTCs followed by drug selection and hospital formulary editing (n=38, 86%) and reporting of adverse drug effects to external authorities (n=30, 68%).

Most of DTCs (n=34, 77%) used detailed guidelines for drug selection in view of quality assurance and clinicians are obliged to follow specific procedures for formulary drug applications (n=38, 86%). Majority of DTCs (n=37, 84%) developed printed hospital formulary drug application forms, and most of them (n=30, 68%) had a pharmacist that was in charge of collecting and evaluating information with respect to specialized drug selection (Table 4). Regional and national pharmacotherapeutic treatment guidelines (n=29, 66%), product information from pharmaceutical industries (n=29, 66%) were the most used resources in the drug selection process.

As shown in Table 5, “number, frequency, and severity of adverse drug reactions” and “safety or frequency and severity of toxicity” were the most reported criteria for the drug selection process (mean=9). While contents of sodium chloride, sugars, and lactose were the least reported (mean=4).

DISCUSSION

The study provides the readers with a significant insight into DTCs in Jordanian hospitals. To the best of the researcher’s knowledge, this issue has not been investigated in the Jordanian context before.

Presence of DTCs varies considerably between countries. For example, in high-income countries such as the USA, Netherlands, UK, Australia, and Germany, the presence of DTCs in hospitals was 98%, 98%, 97% and 92%, respectively.^{10 11}-¹²However, DTC was present in 65% of Pakistan’s hospitals.¹³A Brazilian study found that about 11.6% of hospitals have DTCs.¹⁴In this study, 45% of hospitals had active DTCs which is considered low compared to developed countries. This could be due to: the presence of many private hospitals with low number of beds (59%); the absence of enforcements that make hospitals to have DTCs; and the absence of the pharmacist’s role in representing the DTC in the hospital due to the low number of pharmacists in hospitals.¹⁰,¹³,¹⁵DTCs are available in 66% of the Ministry of Health (MOH) hospitals and in all university hospitals and Royal Medical Service hospitals in Jordan. This could be due to the participation of MOH hospitals in the Joint Commission International Accreditation (JCIA) which in some ways ensure the presence of DTCs in hospitals’ structure. Also, clinical pharmacists’ presence in the hospitals to meet JCIA policies, encourage the presence of DTCs in these hospitals.⁶,¹⁶-¹⁸

The position of the DTC chairman in many cases held by physicians.³,⁶,⁷,^{19 20}-²¹However, this study found that 25% of DTCs were chaired by pharmacists. The structure and number of DTC members varies according to the type of hospital and medical specialties in the hospital.^{2 3}-⁴,¹¹,²⁰This study also found that there was a variation in the structure and number of DTC members in the hospitals depending on the specialties and number of beds. Also, the representation of clinical expertise varies noticeably since there are not many regulations that define the structure.¹⁶The number of DTC members in this study is with a median of 8 (range of 3-15). This is in line with the number of DTC members in other countries when compared to the total number of beds, in Dutch (median=12), Ireland (median=7) and the USA [median=10].¹¹

Generally, in many countries, the majority of DTC members are physicians and they represent more than half of the DTC members.⁷,¹²,²²On the other hand, pharmacists, nurses and hospital administrators are less represented in DTCs.²,³,⁷,¹¹,¹⁵,²⁰,²³DTCs’ pharmacists have direct access to the information resources and act as a bridge between different specialties of medical fields.¹¹,¹²,²²They have an important role in decision making in their committees.²,³,²⁰Results of this study are in agreement with other studies’ findings which demonstrated that pharmacists in most DTCs (75%) are assigned the position of committee secretary and are present in all DTCs in Jordanian hospitals.¹¹,¹²,²²Despite being experts in their field, the representation of pharmacotherapy and clinical pharmacists is very low and this issue is almost common in different countries.³,¹⁷,²²In our study, their presence was negligible. This coincides with other studies which revealed that pharmacists were mainly in charge of collecting and evaluating information with respect to specialized drug selection.¹²,²¹

Results of this survey suggest that the main responsibilities of DTCs in Jordan are general prescribing policies, drug selection, and formulary management. Worldwide, the main roles of the DTC include drug evaluation and the maintenance of hospitals’ drugs availability.¹²,¹⁵,²²,²⁴,²⁵Formulary management, ADR and medication errors reporting are also of the main responsibilities of DTCs.¹³,¹⁶,¹⁷,¹⁹,²¹,²⁶,²⁷The World Health Organization (WHO) also directs DTCs to write and implement policies and guidelines of drug use in their institutions.²⁸DTC activities and meetings varied according to the type of hospital, number of beds, and the structure of DTC.²,⁷,¹¹,¹³,²⁰DTC meetings help in controlling formulary and the management of drug policies and procedures.²,¹¹,¹³,¹⁷,²⁰,²²On average, in Germany, 47% of DTCs meet bimonthly while about 18% meet monthly.²²While in Pakistan, DTCs meet 3-4 times annually, and in Canada, DTCs meet 8.2 times annually in hospitals with more than 300 beds and 6 times annually in hospitals with less than 300 beds annually.⁷,¹³This study showed that most of DTCs in Jordan meet monthly. This high number of meetings compared to other countries could be explained by the fact that DTCs were organized with a low number of subcommittees. Subcommittees were not present in 62% of hospitals and only one subcommittee was present in 20% of hospitals.

Different issues are raised globally when considering the drug selection process.⁵,²⁷,²⁸For instance, the drug selection process guidelines in the Netherlands are not well used in Dutch hospitals since the drug selection process is a part of quality assurance.²²Drug selection procedures in different countries are similar and use evidence-based medicine concept and pharmacoeconomic information.¹,²,⁶,⁷,¹⁹,²⁰,²²,²⁴,²⁶Information about new drugs’ efficacy is obtained from scientific journals, formulary inclusion, prescriber contact, clinical trials and direct relationship between the pharmaceutical industry and clinicians.²⁹Similar to other studies, our study found that 77% of pharmacists in DTCs use detailed guidelines for the drug selection process in view of quality assurance.¹⁵,²⁰,^{29 30}-³¹Pharmacists in DTCs expand their role in drug selection to ensure safety, effectiveness, and optimal utilization of drugs.¹⁷There are 4-17 indicators that were related to policies or procedures for reporting and documenting drug selection.^{18 19}-²⁰JCIA included policies that are used to ensure the safety of overall drugs.¹⁹Criteria of drug selection process such as; therapeutic effectiveness, toxicity profile and cost are used by most DTCs, but their importance varied according to different issues.^{1 2}-³,⁷,¹¹,¹⁵,²⁰,²⁴Drug availability and acquiring costs were among the most important criteria used in the drug selection process by DTCs in Canada.⁷Also, institutional evidenced-based medicine and antimicrobial resistance rate were infrequently used in drug selection in Canada and Australia.⁷,¹⁰An Australian study found that the inclusion of drugs with a narrow therapeutic index into the formulary is considered valuable.¹⁹Similar to other studies, our study reported that the number, frequency, and severity of ADR, the safety or frequency and severity of toxicity, were the most important criteria used in the drug selection process.⁷,¹⁰,¹⁹,²⁷,³²

Prices of some drugs within the same class could vary according to the institution they are presented in.¹¹,¹²A Canadian study found that 25% of respondents used formulary submission binders with pharmaceutical industries for DTCs.⁷A pleasant relationship with the pharmaceutical industry doesn’t affect drug selection by DTCs.⁴,⁷,¹⁵In fact, pharmaceutical industries have a role in prescribing drugs and in drug selection from the pharmacists’ and clinicians’ points of views. Even if this issue is true, it doesn’t mean that the quality of the selected drug is low, or affects the drug in a negative way.²In large teaching hospitals, pharmaceutical companies were attracted by professors and their students and this could affect drug selection.¹³However, a Nigerian study found that pharmaceutical promotional activities and clinical meetings with pharmaceutical sales representative could affect physicians’ prescriptions negatively.³³

CONCLUSIONS

The low number of hospitals that have DTCs in Jordan is considerable. When present, DTCs differ to some extent with respect to their clinical expertise and some of their activities. However, DTCs in Jordan are relatively similar to those in other countries in terms of structure, activities, and criteria used in the drug selection process. DTCs are mainly present in most large hospitals. The main responsibilities of the DTC in Jordanian hospitals are general prescribing policies, drug selection, hospital formulary editing, and reporting of ADR to external authorities. Policies and legislations should be reviewed to ensure the presence of DTCs in most hospitals in Jordan.