1. Anne Hiltz, Director Pharmacy and Renal Program Nova Scotia Health Authority

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

3.  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

4.  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

5.  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

6.  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

7.  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)

8.  Three types of reviews:  Drugs on provincial formulary  Drugs not on provincial formulary and hospital-only drugs  High-cost non-formulary drugs

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

10.  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)

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

12.  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

13.  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

14.  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