The Ostomy Files: Creating an Ostomy Product Formulary

Gwen Turnbull, RN, BS, CETN

   The establishment of private and public prospectively paid health insurance plans has forced providers to look for more creative ways to streamline evidence-based care and control costs. One of the first places many providers look to trim and/or control costs is in the medical supplies they use. The focus on medical supplies initially may have been spurred a few years ago by government investigations into the overuse of wound, ostomy, and urological supplies. Although abuse may have played a role in the high utilization of these supplies, more likely, redundant inventories and improper use by uneducated caregivers are the culprits.

   The venues for ostomy care and the people providing it have changed as healthcare trends force ostomy care from specialized WOC nurses to nonspecialized bedside nurses, home care nurses, and personal care and support staff.1 Even though comprehensive and accurate cost data remain elusive, the cost of ostomy care in our country is high. Perhaps a portion of these costs could be related to "trial and error" decision-making frequently associated with ostomy supplies. Trial and error decision-making occurs when supplies are ordered for a patient without a working knowledge of the ostomy supplies and the principles of ostomy fitting. The ordered supplies leak, are inappropriate for the type of ostomy, are the wrong size, or are otherwise unsuitable for the patient. Caregivers continue to order a variety of supplies "willy-nilly" until the pouching or management problem appears to be resolved. Today, not only are clinicians expected to be able to recommend appropriate ostomy supplies for their patients, but they also are expected to base their choices on sound clinical and financial evidence.

   Years ago, hospitals began stocking their pharmacy shelves only with those drugs that had been preapproved for in-house use by physicians practicing in the facility. Today, the idea of a drug formulary has expanded to include medical supplies. The theory behind this trend is simple: link approved supplies that integrate cost-effectiveness and clinical efficacy to evidence-based care provided by an educated staff. Hastening and streamling the process of finding the right pouching system for a patient seems a logical means of reducing resource utilization and compressing rehabilitation time. Setting up a formulary of ostomy supplies is one of the steps toward achieving these goals.

   The key to the success of your ostomy formulary is the process you use and the time and trouble you take to set it up. It is far more than simply stocking certain supplies. First, identify the people and organizations directly impacted by the formulary. Eliminating or overlooking physician involvement in this process increases the chance of failure. Remember that physicians are responsible for the patient’s overall care; therefore, they write the orders for supplies. Substantial buy-in from physicians who have not been involved in the evaluation and selection of the supplies included in the ostomy formulary is unlikely.

   Product manufacturers and suppliers also should be a part of ostomy formulary development because they can contribute their formulary building expertise, their knowledge of product usage and effectiveness, and other value-added services.2 Value-added services are the services provided to customers at no additional charge such as clinical tools, algorithms, professional customer services, and patient education materials that would otherwise be quite costly for a provider to develop. The variety and caliber of value-added services vary among manufacturers and should be evaluated as carefully as their products.

   Next, evaluate the current processes for selecting ostomy supplies for patients, product usage patterns, and ostomy supply costs, including the cost of the labor for the care providers using them. Are there state-of-the-art protocols or critical pathways available to which specific product usage could be linked? Are products currently being purchased under contract? What are the clinical outcomes of the current process (or lack of one) for ostomy supply selection? Mapping some of the current processes so costs may be more accurately calculated by assigning costs to each step in the process may be helpful. What are the advantages or disadvantages of the current systems? What can be done to streamline these processes?

   Now, compare the ostomy supplies currently being used to those under consideration for the formulary. Ask the manufacturer for published evidence, cost-effectiveness data, and proof of efficacy for supplies. Construct a cost-effectiveness model for current and considered supplies.3 Conduct a product evaluation with the caregivers who regularly use the supplies in the settings where they practice to determine their ease of use, clinical effectiveness, and user satisfaction.

   Once a decision has been reached regarding the exact ostomy supplies to include in the formulary, establish an agreement with the manufacturer. If true cost-effectiveness studies have been conducted, the per-unit cost of the product will play a lesser role in this decision-making. A lower per-unit cost can be quickly erased by shortened wear times, product failure, leakage, peristomal irritation, and end-user confusion or frustration with the product. Each of these scenarios increases resource utilization and overall costs. Selecting a large manufacturer with a full range of products allows you to better negotiate for best price and eliminates the need for multiple contracts and vendors as it simplifies core product selection.

   An ostomy formulary cannot exist as a separate entity from ostomy care. It must be linked to every segment of the care process. Linking it to critical pathways or standards of care alleviates bedside decision-making about what product to use when, who provides the care, and the cost-effectiveness of the product’s use. If the staff has been adequately educated, an ostomy formulary could increase the ease of use because bedside caregivers and other stakeholders are already familiar with the products and how to use them.

   The establishment of an ostomy formulary is just one step toward building a comprehensive evidence-based and standardized plan of care within an organization and across care settings. The result is that the ostomy patient becomes the recipient of more efficient quality state-of-the-art ostomy care for a lower cost.

The Ostomy Files is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ.

References: 

1. Turnbull GB. The ostomy assessment inventory: a data-gathering process to enhance appropriate pouching system selection. Ostomy/Wound Management. 1998;44(2):28-37.

2. Turnbull GB, Turnbull RW. A winning combination: industry and healthcare providers. In: Krasner DL, Rodeheaver GT, Sibbald RG (eds). Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 3rd ed. Wayne, Pa.: HMP Communications, 2001:219-223.

3. Bolton L, van Rijswijk L, Shafer F. Quality wound care equals cost-effective wound care: a clinical model. Nursing Management. 1996;27(7):30-37.