-
[show abstract]
[hide abstract]
ABSTRACT: Erythropoiesis-stimulating agents (ESAs) are associated with serious adverse events, and maintaining hemoglobin levels within a narrow range can be difficult. We examined the quality of ESA prescribing and monitoring in pharmacist-managed ESA clinics versus usual care in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD).
Historical cohort.
Outpatients receiving ESAs for NDD-CKD at 10 Veterans Affairs Medical Centers with both pharmacist-managed ESA clinics (n = 314) and physician-based care (ie, usual care; n = 91) and 6 sites with usual care only (n = 167) on January 1, 2009, were followed up for 6 months.
Type/site of care (ie, pharmacist-managed ESA clinic, usual care at ESA clinic site, usual-care site).
Primary outcomes were proportion of hemoglobin values in the target range of 10-12 g/dL, ESA dose, and frequency of hemoglobin monitoring. Factors associated with hemoglobin values out of target range were identified using multinomial logistic regression.
More hemoglobin values were in the target range in pharmacist-managed ESA clinics (71.1% vs 56.9% for usual-care sites; P < 0.001). The average 30-day dose of darbepoetin was 163 μg in pharmacist-managed ESA clinic patients versus 240 μg in usual-care site patients and 258 μg in usual-care patients at ESA clinic sites. For epoetin, corresponding average 30-day doses were 44,890 versus 47,141 and 57,436 IU. Veterans in pharmacist-managed ESA clinics had more hemoglobin measurements on average (5.8 vs 3.6 in usual-care sites and 3.8 in usual care at ESA clinic sites; P = 0.007). In the multinomial model, usual care was associated with hemoglobin levels out of target range, whereas heart failure and diabetes were associated with values in range.
We could not assess whether different hemoglobin targets were used by usual-care providers.
Relative to usual care, pharmacist-managed clinics provided improved quality of ESA dosing and monitoring for patients with NDD-CKD.
American Journal of Kidney Diseases 05/2012; 60(3):371-9. · 5.43 Impact Factor
-
Sherrie L Aspinall,
Xinhua Zhao,
Chester B Good,
Roslyn A Stone,
Joy Boresi,
Sarah Cox,
Chad Bartholomew,
David Jansen,
Sarah Guterman,
Mauricio Patino,
Giselle Rivera-Miranda,
Mark Burlingame,
Justin Frazer,
Janelle Sellers,
Valerie Stanard Steele,
Lauri Witt, Francesca E Cunningham
[show abstract]
[hide abstract]
ABSTRACT: The objectives of this study were to describe changes in glyburide prescribing in cohorts that were and were not targeted by a risk reduction project, assess factors associated with glyburide discontinuation, and evaluate changes in glycated hemoglobin (ie, HbA(1c)) levels and rates of serious hypoglycemia.
This historical cohort study included a targeted cohort of 4368 outpatient veterans aged ≥65 years with active prescriptions for glyburide between April 1, 2007 and June 30, 2007 and serum creatinine (SCr) ≥2 mg/dL and a nontargeted cohort of 1886 outpatients meeting these same criteria between July 1, 2007 and September 3, 2007. The intervention in the risk reduction project took place on September 4, 2007 and entailed giving regional pharmacy leaders information about the increased risk of hypoglycemia with glyburide and the list of targeted patients for follow up with providers. For each patient, the study period was the time between the date they first met the eligibility criteria and March 31, 2008. All data were obtained from Veterans Affairs (VA) administrative databases. The primary outcome was the discontinuation of glyburide. Secondary outcomes were the change in HbA(1c) after stopping glyburide and the rate of serious hypoglycemia after intervention.
Incidence rate ratios (IRRs) for glyburide discontinuation in targeted versus nontargeted cohorts were statistically significantly elevated in September (IRR 2.1; 95% CI 1.7-2.5), October (IRR 1.3; 95% CI 1.1-1.6), and November 2007 (IRR 1.4; 95% CI 1.1-1.7). The intervention, black race, SCr, Charlson comorbidity score, new glyburide use, and VA region were independently associated with discontinuation. Among patients in the targeted cohort who discontinued glyburide, mean (SD) HbA(1c) at baseline and after discontinuation were 7.17% (1.35%), and 7.22% (1.34%), respectively (P = 0.36). The hypoglycemia rates/1000 person-days were 0.093 before the intervention and 0.070 afterwards (P = 0.10).
A one-time intervention in a risk reduction project decreased glyburide use over a 3-month period in elderly outpatients with renal insufficiency without compromising glucose control.
The American journal of geriatric pharmacotherapy. 02/2011; 9(1):58-68.
-
[show abstract]
[hide abstract]
ABSTRACT: To compare the cost-effectiveness of four, six, and eight doses per month of vardenafil in the context of pharmacy benefit decision making.
A Markov model was used to estimate the incremental cost-effectiveness of zero, four, six, or eight doses of vardenafil per month in hypothetical cohorts of 60-year-old male veterans with erectile dysfunction. Efficacy values for vardenafil were obtained from the literature, and vardenafil costs were obtained from Veterans Affairs pharmacy data. The analysis was conducted from a third-party payer perspective with a lifetime horizon, and the effect of parameter uncertainty was explored in one-way and probabilistic sensitivity analyses.
In the base case analysis, the cost per quality-adjusted life-year gained for four doses of vardenafil per month compared with no therapy was $576. Six doses per month compared with four cost $2585/quality-adjusted life-year gained, and eight doses per month compared with six cost $5169/quality-adjusted life-year gained. In one-way sensitivity analyses of six doses per month compared with four, variation of two parameters caused the incremental cost-effectiveness ratio to cross a willingness-to-pay threshold of $20,000: when the increased utility associated with giving two additional doses/month was less than 0.001 (baseline 0.01) and when the cost per dose increased to $15.00 (baseline $1.69).
Although four doses per month of vardenafil was the most cost-effective strategy, the use of six or eight doses per month also compares favorably with other accepted medical treatments. The results were stable across a range of inputs and help to support the current Veterans Affairs policy on the number of vardenafil doses provided per month for erectile dysfunction.
Value in Health 01/2011; 14(1):97-101. · 2.19 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To compare users and nonusers of Veterans Affairs (VA) pharmacy services by age group.
Cross-sectional.
We used data on sociodemographics, health status, and medical conditions from the Medical Expenditure Panel Survey (MEPS) to compare users and nonusers of VA pharmacies for medications. Data were pooled for 2003-2005 to ensure adequate sample sizes. Student t tests were used to compare the means for each variable, and all analyses were adjusted for the complex sample design of the MEPS.
Among both nonelderly (18-64 years) and elderly (>or=65 years) veterans, a higher proportion who used VA pharmacy services versus those who did not use VA pharmacy services (1) were black (nonelderly: 17.7 % vs 7.4%, P <.001; elderly: 9.4% vs 4.7%, P <.001); (2) had no alternative insurance (nonelderly: 27.2% vs 4.8%, P <.001; elderly: 36.3% vs 19.9%, P <.001); (3) had lower incomes (nonelderly: 32.4% vs 11.5%, P <.001; elderly: 32.4% vs 25.4%, P = .01); (4) had less than a high school education (nonelderly: 13.0% vs 6.5%, P <.001; elderly: 27.5% vs 17.6%, P <.001); (5) were disabled; and (6) reported poorer health. A higher percentage of nonelderly users reported a mental health condition (31.6% vs 19.4%, P <.001).
Veterans who use VA pharmacy services appear to be more ill than those who do not use VA pharmacy services. In addition, the VA appears to be a safety net for uninsured veterans who have mental health problems.
The American journal of managed care 10/2009; 15(10):701-8. · 2.46 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Although gatifloxacin is no longer available, other fluoroquinolones may significantly interfere with glucose homeostasis. The objective of the present study was to compare the risk of severe hypo- and hyperglycemia in a cohort of patients treated with gatifloxacin, levofloxacin, ciprofloxacin, or azithromycin.
This was a retrospective inception cohort study of outpatients with a new prescription for gatifloxacin, levofloxacin, ciprofloxacin, or azithromycin from 1 October 2000 through 30 September 2005 in the Veterans Affairs health care system. For patients who received one of these antibiotics, we identified outcomes of hospitalization with a primary diagnosis of hypo- or hyperglycemia. Multivariable logistic regression was used to determine the odds of hypo- and hyperglycemia with the individual fluoroquinolones versus azithromycin.
The crude incidence rates for severe hypo- and hyperglycemia among those who received gatifloxacin, levofloxacin, ciprofloxacin, and azithromycin were 0.35 and 0.45, 0.19 and 0.18, 0.10 and 0.12, and 0.07 and 0.10 cases per 1000 patients, respectively. Among patients with diabetes, the odds ratios for hypoglycemia compared with azithromycin were 4.3 (95% confidence interval [CI], 2.7-6.6) for gatifloxacin, 2.1 (95% CI, 1.4-3.3) for levofloxacin, and 1.1 (95% CI, 0.6-2.0) for ciprofloxacin. The odds ratios for hyperglycemia were 4.5 (95% CI, 3.0-6.9) for gatifloxacin, 1.8 (95% CI, 1.2-2.7) for levofloxacin, and 1.0 (95% CI, 0.6-1.8) for ciprofloxacin.
The odds of severe hypo- and hyperglycemia were significantly greater with gatifloxacin and levofloxacin, but not ciprofloxacin, than with azithromycin. Thus, the risk of a clinically relevant dysglycemic event appears to vary among the fluoroquinolones.
Clinical Infectious Diseases 07/2009; 49(3):402-8. · 9.15 Impact Factor
-
Elaine M Furmaga, Francesca E Cunningham,
William C Cushman,
Diane Dong,
Rong Jiang,
Jan Basile,
Lois A Katz,
Gale H Rutan,
Dan R Berlowitz,
Vasilios Papademetriou,
Peter A Glassman
[show abstract]
[hide abstract]
ABSTRACT: The authors sought to determine the prescribing practices of clinicians treating veterans with hypertension. A descriptive analysis was performed using a national pharmacy database of patients with a diagnosis of hypertension receiving antihypertensive medication in the fiscal years 2000 to 2006. Angiotensin-converting enzyme inhibitors were the most frequently prescribed antihypertensive class, with utilization increasing from 56.0% in fiscal year 2000 to 63.2% of patients in 2006. Utilization of thiazide-type diuretics increased from 31.9% of patients in fiscal year 2000 to 42.0% in 2006. When patient comorbidities were taken into consideration, 48.1% of patients defined as having uncomplicated hypertension had at least one prescription for a thiazide diuretic in fiscal year 2006. Utilization by monotherapy and combination therapy were also evaluated. The trends in utilization allowed for identification of areas in which a change in prescribing practices may improve blood pressure control and health outcomes in the Veterans Health Administration.
Journal of Clinical Hypertension 11/2008; 10(10):770-8. · 1.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The aim of this study was to provide national annualized estimates of drug costs and use by drug classes for long-stay nursing home (NH) residents.
National, descriptive, secondary data analysis.
National, Veterans Health Administration (VHA), 136 NHs.
Our study population consisted of 6554 VHA long-stay NH residents, identified from the Minimum Data Set (MDS), who had an annual assessment during FY 2005 linked with 8,847,561 inpatient pharmacy claims.
Descriptive statistics of the annual drug costs and use by VHA therapeutic drug classes obtained from FY 2005 national pharmacy claims linked at the individual resident level.
The total cost of the drugs was $23,782,717 in 326 drug classes for 6554 VHA NH residents. Average annual drug cost was $3629 per resident (99% Confidence Interval [CI], $3343-$3915). The top 20 drug classes accounted for nearly 70% of total drug costs for long-stay NH residents. Approximately three quarters (73.3%) of these residents received a non-opioid analgesic (eg, acetaminophen, aspirin). Over half of these residents received antidepressants (selective serotonin reuptake inhibitors [SSRIs]) (54.3%), or other anti-infective drugs (eg, bacitracin, ciprofloxacin) (53.3%).
This is the first national study of drug costs and use for long-stay veterans in VHA NHs. It is essential in any study analyzing drug costs and use in NH patients to differentiate long-stay residents from short-stay patients. This kind of detailed cost and use analysis has implications for projecting future costs associated with the Medicare Part D prescription benefit for dually eligible NH residents.
Journal of the American Medical Directors Association 11/2007; 8(8):515-8. · 4.64 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To identify the extent of inappropriate prescribing using criteria for proper use developed by the Agency for Healthcare Research and Quality (AHRQ) and dose-limitation criteria defined by Beers, as well as to describe duration of use and patient characteristics associated with inappropriate prescribing for older people.
Retrospective national Veterans Health Administration (VA) administrative database analysis.
VA outpatient facilities during fiscal year 2000 (FY00). Participants: Veterans aged 65 and older having at least one VA outpatient visit in FY00 (N=1,265,434).
Operational definitions of appropriate use were developed based on recommendations of an expert panel convened by the AHRQ (Zhan criteria). Inappropriate use was identified based on these criteria and inappropriate use of drugs per Beers criteria for dose-limitations in older people. Furthermore, duration of use and patient characteristics associated with inappropriate use were described.
After adjusting for diagnoses, dose, and duration, inappropriate prescribing decreased from 33% to 23%. Exposure to inappropriate drugs was prolonged. Pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents constituted 61% of inappropriate prescribing. Whites, patients with psychiatric comorbidities, and patients receiving more medications were most likely to receive inappropriate drugs. Women were more likely to receive Zhan criteria drugs; men were more likely to receive dose-limited drugs
For the most part, the Zhan criteria did not explain inappropriate prescribing, which includes problems related to dose and duration of prescriptions. Interventions targeted at prescriptions for pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents may dramatically decrease inappropriate prescribing and improve patient outcomes.
Journal of the American Geriatrics Society 09/2005; 53(8):1282-9. · 3.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The Department of Veterans Affairs (VA) Pharmacy Benefits Management Strategic Healthcare Group (VA PBM) oversees the formulary for the entire VA system, which serves more than 4 million veterans and provides more than 108 million prescriptions per year. Since its establishment in 1995, the VA PBM has managed pharmaceuticals and pharmaceutical-related policies, including drug safety and efficacy evaluations, pharmacologic management algorithms, and criteria for drug use. These evidence-based practices promote, optimize, and assist VA providers with the safe and appropriate use of pharmaceuticals while allowing for formulary decisions that can result in substantial cost savings. The VA PBM also has utilized various contracting techniques to standardize generic agents as well as specific drugs and drug classes (eg, antihistamines, angiotensin-converting enzyme inhibitors, alpha-blockers, and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors [statins]). These methods have enabled the VA to save approximately dollar 1.5 billion since 1996 even as drug expenditures continued to rise from roughly dollar 1 billion in fiscal year (FY) 1996 to more than dollar 3 billion in FY 2003. Furthermore, the VA PBM has established an outcomes research section to undertake quality-improvement and safety initiatives that ultimately monitor and determine the clinical impact of formulary decisions on the VA system nationwide. The experiences of this pharmacy benefits program, including clinical and contracting processes/procedures and their impact on the VA healthcare system, are described.
The American journal of managed care 03/2005; 11(2):104-12. · 2.46 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Objective: In view of the widespread concerns against prescribing short-acting nifedipine in the treatment of hypertension, the Veterans Health Administration initiated efforts to decrease the common but unapproved use of that agent for treating high blood pressure. Methods: A multitiered approach was implemented, using a national pharmaceutical database to assess drug utilization, followed by educational or remedial intervention at each tier. The first tier of the study determined the total quantity of short-acting nifedipine dispensed, the second tier evaluated data on the prescriptions for the drug, and the third and fourth tiers evaluated patient-specific information to determine to whom and why the drug was prescribed. Results: The first intervention demonstrated a 34 percent decrease in the total quantity of short-acting nifedipine dispensed, compared with the previous year. An action or change was noted in 78 percent of prescriptions in the second intervention. In the third intervention, short-acting nifedipine was prescribed for hypertension in 46.5 percent of the remaining 559 patients, 96 percent of which resulted in an intervention. The final intervention (75 patients) resulted in one patient prescribed short-acting nifedipine for hypertension under special circumstances. Conclusion: A tiered approach, using a national pharmaceutical database, complemented by local education and intervention, assisted in reducing the use of short-acting nifedipine for hypertension.
01/2005;
-
[show abstract]
[hide abstract]
ABSTRACT: Am J Hypertens (2004) 17, 107A–107A; doi: 10.1016/j.amjhyper.2004.03.276
P-201: Treatment and control of hypertension in the veterans health administration
Elaine M. Furmaga1, Francesca E. Cunningham1, William C. Cushman1, Peter A. Glassman1, Jan Basile1, Diane Dong1, Lois A. Katz1 and Gale H. Rutan11Pharmacy Benefits Management-Strategic Healthcare Group, Department of Veterans Affairs, Hines, IL; PBM Pharmacoepidemiologic Outcomes Research, Department of Veterans Affairs, Hines, IL; Preventive Medicine, Memphis VAMC, Memphis, TN; Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA; Medicine, Charleston VAMC, Charleston, SC; Special Emphasis Programs and Quality Management, VA NY Harbor Healthcare System, New York, NY; Medicine, Roudebush VAMC, Indianapolis, IN, USA
American Journal of Hypertension 04/2004; · 3.18 Impact Factor
-
Journal of managed care pharmacy: JMCP 18(1):73. · 2.25 Impact Factor
