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Jasuja GK, Reisman JI, Miller DR, Ansara ED, Chiulli DL, Moore T, Ourth HL, Tran MH, Smith EG, Morreale AP, McCullough MM. Complexity of patients with mental healthcare needs cared for by mental health clinical pharmacist practitioners in Veterans Affairs. Am J Health Syst Pharm 2024:zxae007. [PMID: 38468398 DOI: 10.1093/ajhp/zxae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Indexed: 03/13/2024] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The complexity of patients with mental healthcare needs cared for by clinical pharmacists is not well delineated. We evaluated the complexity of patients with schizophrenia, bipolar disorder, and major depressive disorder (MDD) in Veterans Affairs (VA) cared for by mental health clinical pharmacist practitioners (MH CPPs). METHODS Patients at 42 VA sites with schizophrenia, bipolar disorder, or MDD in 2016 through 2019 were classified by MH CPP visits into those with 2 or more visits ("ongoing MH CPP care"), those with 1 visit ("consultative MH CPP care"), and those with no visits ("no MH CPP care"). Patient complexity for each condition was defined by medication regimen and service utilization. RESULTS For schizophrenia, more patients in ongoing MH CPP care were complex than those with no MH CPP care, based on all measures examined: the number of primary medications (15.3% vs 8.1%), inpatient (13.7% vs 9.1%) and outpatient (42.6% vs 29.7%) utilization, and receipt of long-acting injectable antipsychotics (36.7% vs 25.8%) and clozapine (20.5% vs 9.5%). For bipolar disorder, more patients receiving ongoing or consultative MH CPP care were complex than those with no MH CPP care based on the number of primary medications (27.9% vs 30.5% vs 17.7%) and overlapping mood stabilizers (10.1% vs 11.6% vs 6.2%). For MDD, more patients receiving ongoing or consultative MH CPP care were complex based on the number of primary medications (36.8% vs 35.5% vs 29.2%) and augmentation of antidepressants (56.1% vs 54.4% vs 47.0%) than patients without MH CPP care. All comparisons were significant (P < 0.01). CONCLUSION MH CPPs provide care for complex patients with schizophrenia, bipolar disorder, and MDD in VA.
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Affiliation(s)
- Guneet K Jasuja
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
| | - Joel I Reisman
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Donald R Miller
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, and Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, MA, USA
| | | | - Dana L Chiulli
- W.G. (Bill) Hefner Salisbury Department of Veterans Affairs Medical Center, Salisbury, NC, USA
| | - Tera Moore
- VA Pharmacy Benefits Management Services, Clinical Pharmacy Practice Office, Washington, DC, USA
| | - Heather L Ourth
- VA Pharmacy Benefits Management Services, Clinical Pharmacy Practice Office, Washington, DC, USA
| | - Michael H Tran
- VA Pharmacy Benefits Management Services, Clinical Pharmacy Practice Office, Washington, DC, USA
| | - Eric G Smith
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, Departmentof Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, and Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Anthony P Morreale
- VA Pharmacy Benefits Management Services, Clinical Pharmacy Practice Office, Washington, DC, USA
| | - Megan M McCullough
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, and Department of Public Health, Zuckerberg School of Health Sciences, University of Massachusetts, Lowell, MA, USA
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McFarland MS, Tran M, Ourth HL, Morreale AP. Evaluation of Patient Experience with Veterans Affairs Clinical Pharmacist Practitioners Providing Comprehensive Medication Management. J Pharm Pract 2023; 36:1356-1361. [PMID: 35924640 DOI: 10.1177/08971900221117892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patient experience is considered an important dimension of health care quality and thus is included as part of the quadruple aim of health care. The VHA Clinical Pharmacist Practitioner (CPP) operates as an advanced practice provider (APP) providing comprehensive medication management (CMM) with authority to initiate, discontinue or modify medication under a scope of practice (SOP). The VHA CPP practices in many different outpatient clinical areas to include but not limited to primary care, mental health, pain management, cardiology, substance use disorder and anticoagulation. While literature regarding the ability of the VHA CPP to increase access and quality of care is well published, very little information exist regarding patient experience with the VHA CPP. We sought to report the patient experience with VHA CPP as measured electronically over 1 year by Veterans. Patient experience surveys were electronically sent to randomly selected Veterans via email to evaluate a recent outpatient healthcare encounter at a VA medical center or outpatient clinic with a CPP with scoring on a Likert scale of 1-5 with 5 being optimal. A total of 743 Veteran surveys were completed for a response rate of 20%. For individual domains of patient experience based on respondent scores of 4 or 5, ease and simplicity were rated at 94.4%, quality 91.9%, employee helpfulness 94.9%, satisfaction 95.0% and confidence/trust 91.9%. Results demonstrate that Veterans' experience with the CPP in every patient care experience domain was positive with scores ranging from the low to high 90th percentile.
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Affiliation(s)
- Michael S McFarland
- U.S. Department of Veterans Affairs, Clinical Pharmacy Practice Office, Washington, D.C, USA
| | - Michael Tran
- U.S. Department of Veterans Affairs, Clinical Pharmacy Practice Office, Washington, D.C, USA
| | - Heather L Ourth
- U.S. Department of Veterans Affairs, Clinical Pharmacy Practice Office, Washington, D.C, USA
| | - Anthony P Morreale
- U.S. Department of Veterans Affairs, Clinical Pharmacy Practice Office, Washington, D.C, USA
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Miller DR, Reisman JI, McDannold SE, Kleinberg F, Gillespie C, Zogas A, Ndiwane N, Ourth HL, Morreale AP, Tran M, McCullough MB. Clinical pharmacist practitioners on primary care teams play an important role in caring for complex patients with diabetes. Am J Health Syst Pharm 2023; 80:1637-1649. [PMID: 37566141 DOI: 10.1093/ajhp/zxad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Indexed: 08/12/2023] Open
Abstract
PURPOSE To evaluate whether clinical pharmacist practitioners (CPPs) are being utilized to care for patients with complex medication regimens and multiple chronic illnesses, we compared the clinical complexity of diabetes patients referred to CPPs in team primary care and those in care by other team providers (OTPs). METHODS In this cross-sectional comparison of patients with diabetes in the US Department of Veterans Affairs (VA) healthcare system in the 2017-2019 period, patient complexity was based on clinical factors likely to indicate need for more time and resources in medication and disease state management. These factors include insulin prescriptions; use of 3 or more other diabetes medication classes; use of 6 or more other medication classes; 5 or more vascular complications; metabolic complications; 8 or more other complex chronic conditions; chronic kidney disease stage 3b or higher; glycated hemoglobin level of ≥10%; and medication regime nonadherence. RESULTS Patients with diabetes referred to one of 110 CPPs for care (n = 12,728) scored substantially higher (P < 0.001) than patients with diabetes in care with one of 544 OTPs (n = 81,183) on every complexity measure, even after adjustment for age, sex, race, and marital status. Based on composite summary scores, the likelihood of complexity was 3.42 (interquartile range, 3.25-3.60) times higher for those in ongoing CPP care (ie, those with 2 or more visits) versus OTP care. Patients in CPP care also were, on average, younger, more obese, and had more prior outpatient visits and hospital stays. CONCLUSION The greater complexity of patients with diabetes seen by CPPs in primary care suggests that CPPs are providing valuable services in comprehensive medication and disease management of complex patients.
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Affiliation(s)
- Donald R Miller
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
- Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, MA, USA
| | - Joel I Reisman
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Sarah E McDannold
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Felicia Kleinberg
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Chris Gillespie
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Anna Zogas
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - Ndindam Ndiwane
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Heather L Ourth
- Pharmacy Benefits Management Services, National Clinical Pharmacy Practice Office, US Department of Veterans Affairs, Washington, DC, USA
| | - Anthony P Morreale
- Pharmacy Benefits Management Services, National Clinical Pharmacy Practice Office, US Department of Veterans Affairs, Washington, DC, USA
| | - Michael Tran
- Pharmacy Benefits Management Services, National Clinical Pharmacy Practice Office, US Department of Veterans Affairs, Washington, DC, USA
| | - Megan B McCullough
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
- Zuckerberg School of Health Sciences, Department of Public Health, University of Massachusetts, Lowell, MA, USA
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McCullough MB, Zogas A, Gillespie C, Kleinberg F, Reisman JI, Ndiwane N, Tran MH, Ourth HL, Morreale AP, Miller DR. Introducing clinical pharmacy specialists into interprofessional primary care teams: Assessing pharmacists' team integration and access to care for rural patients. Medicine (Baltimore) 2021; 100:e26689. [PMID: 34559093 PMCID: PMC8462613 DOI: 10.1097/md.0000000000026689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/17/2021] [Indexed: 01/05/2023] Open
Abstract
Clinical pharmacy specialists (CPS) were deployed nationally to improve care access and relieve provider burden in primary care.The aim of this study was to assess CPS integration in primary care and the Clinical Pharmacy Specialist Rural Veteran Access (CRVA) initiative's effectiveness in improving access.Concurrent embedded mixed-methods evaluation of participating CRVA CPS and their clinical team members (primary care providers, others).Health care providers on primary care teams in Veterans Health Administration (VHA).Perceived CPS integration in comprehensive medication management assessed using the MUPM and semi-structured interviews, and access measured with patient encounter data.There were 496,323 medical encounters with CPS in primary care over a 3-year period. One hundred twenty-four CPS and 1177 other clinical team members responded to a self-administered web-based questionnaire, with semi-structured interviews completed by 22 CPS and clinicians. Survey results indicated that all clinical provider groups rank CPS as making major contributions to CMM. CPS ranked themselves as contributing more to CMM than did their physician team members. CPS reported higher job satisfaction, less burn out, and better role fit; but CPS gave lower scores for communication and decision making as clinic organizational attributes. Themes in provider interviews focused on value of CPS in teams, relieving provider burden, facilitators to integration, and team communication issues.This evaluation indicates good integration of CPS on primary care teams as perceived by other team members despite some communication and role clarification challenges. CPS may play an important role in improving access to primary care.
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Affiliation(s)
- Megan B. McCullough
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
- University of Massachusetts, Lowell, Zuckerberg School of Health Sciences, Department of Public Health, Lowell, MA
| | - Anna Zogas
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Chris Gillespie
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
| | - Felicia Kleinberg
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
| | - Ndindam Ndiwane
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
| | - Michael H. Tran
- Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, DC
| | - Heather L. Ourth
- Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, DC
| | - Anthony P. Morreale
- Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, DC
| | - Donald R. Miller
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
- University of Massachusetts, Lowell, Center for Population Health, Department of Biomedical and Nutritional Sciences, Lowell, MA
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Ourth HL, Heyworth L, Galpin K, Morreale AP. Virtual care revolution: Impact on clinical pharmacy practices in the Department of Veterans Affairs. J Am Coll Clin Pharm 2021. [DOI: 10.1002/jac5.1475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Heather L. Ourth
- Department of Veterans Affairs Pharmacy Benefits Management Services, Veterans Health Administration Central Office Washington District of Columbia USA
| | - Leonie Heyworth
- Department of Veterans Affairs Office of Connected Care, Veterans Health Administration Central Office Washington District of Columbia USA
- Department of Medicine University of California, San Diego San Diego California USA
| | - Kevin Galpin
- Department of Veterans Affairs Office of Connected Care, Veterans Health Administration Central Office Washington District of Columbia USA
| | - Anthony P. Morreale
- Department of Veterans Affairs Pharmacy Benefits Management Services, Veterans Health Administration Central Office Washington District of Columbia USA
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Tran MH, Ourth HL, Morreale AP. Development and Implementation of National Time in Therapeutic Range Reports and Establishing Quality Standards Within Veterans Health Administration. J Gen Intern Med 2021; 36:1418-1421. [PMID: 33469776 PMCID: PMC8131411 DOI: 10.1007/s11606-020-06422-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Michael H Tran
- VA Pharmacy Benefits Management Services, Washington, DC, USA. .,VA Great Lakes Health Care System Pharmacy Benefits Management, Westchester, IL, USA.
| | - Heather L Ourth
- VA Pharmacy Benefits Management Services, Washington, DC, USA
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Ourth HL, Jorgenson TL, Moore T, McFarland MS, Nelson J, Morreale AP. Increasing access to care for rural veterans through intensive hands‐on‐training of advanced practice pharmacists. J Am Coll Clin Pharm 2021. [DOI: 10.1002/jac5.1367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Heather L. Ourth
- Department of Veterans Affairs Pharmacy Benefits Management Services, Veterans Health Administration Central Office Washington District of Columbia USA
| | - Terri L. Jorgenson
- Department of Veterans Affairs Pharmacy Benefits Management Services, Veterans Health Administration Central Office Washington District of Columbia USA
| | - Tera Moore
- Department of Veterans Affairs Pharmacy Benefits Management Services, Veterans Health Administration Central Office Washington District of Columbia USA
| | - M. Shawn McFarland
- Department of Veterans Affairs Pharmacy Benefits Management Services, Veterans Health Administration Central Office Washington District of Columbia USA
| | - Jordan Nelson
- Department of Veterans Affairs Pharmacy Benefits Management Services, Veterans Health Administration Central Office Washington District of Columbia USA
| | - Anthony P. Morreale
- Department of Veterans Affairs Pharmacy Benefits Management Services, Veterans Health Administration Central Office Washington District of Columbia USA
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Groppi JA, Ourth H, Tran M, Morreale AP, McFarland MS, Moore TD, Jorgenson T, Torrise V. Increasing rural patient access using clinical pharmacy specialist providers: Successful practice integration within the Department of Veterans Affairs. Am J Health Syst Pharm 2021; 78:712-719. [PMID: 33580241 DOI: 10.1093/ajhp/zxab011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Access to care is a critical issue facing healthcare and affects patients living in rural and underserved areas more significantly. This led the Department of Veterans Affairs (VA) to launch a project that leveraged the expertise of the clinical pharmacy specialist (CPS) provider, embedding 180 CPS providers into primary care, mental health, and pain management across the nation. METHODS This multidimensional project resulted in hiring 111 CPS providers in primary care, 40 CPS providers in mental health, and 35 CPS providers in pain management to serve rural veterans' needs. From October 2017 to March 2020, CPS providers provided direct patient care to 213,477 veterans within 606,987 visits. This was an average of 43,000 additional visits each quarter to support comprehensive medication management services, demonstrating an additional 219,823 visits in fiscal year 2018 and 232,030 visits in fiscal year 2019. Over the course of the project, the team provided mentorship to 164 CPS providers, performed consultative visits at 27 VA facilities, and trained 180 CPS providers in educational boot camps. CONCLUSION VA funding of rural health initiatives adding CPS providers to primary care, mental health, and pain teams has resulted in positive measures of comprehensive medication management, interdisciplinary team satisfaction, facility leadership acceptance, and multiple positive outcomes.
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Affiliation(s)
- Julie A Groppi
- Pharmacy Benefits Management Services, US Department of Veterans Affairs, Washington, DC
| | - Heather Ourth
- Pharmacy Benefits Management Services, US Department of Veterans Affairs, Washington, DC
| | - Michael Tran
- Pharmacy Benefits Management Services, US Department of Veterans Affairs, Washington, DC
| | - Anthony P Morreale
- Pharmacy Benefits Management Services, US Department of Veterans Affairs, Washington, DC
| | | | - Tera D Moore
- Pharmacy Benefits Management Services, US Department of Veterans Affairs, Washington, DC
| | - Terri Jorgenson
- Pharmacy Benefits Management Services, US Department of Veterans Affairs, Washington, DC
| | - Virginia Torrise
- Pharmacy Benefits Management Services, US Department of Veterans Affairs, Washington, DC
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Abstract
In a recent IJHPR article, Schwartzberg and colleagues report on clinical and other specialty services offered by pharmacists in the community in Israel and in the international arena. The article covers examples of activities recently introduced due to legislative changes which expanded the pharmacist's scope of practice, along with obstacles that are serving to slow broader expansion and availability of these services. This commentary details the success of clinical pharmacy services being provided by the United States Veterans Health Administration, and offers a framework of elements that support clinical pharmacy practice expansion.
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Affiliation(s)
- Anthony P. Morreale
- Department of Veterans Affairs, Clinical Pharmacy Practice Office, Pharmacy Benefits Management (PBM) Services, Washington D.C, USA
| | - Julie A. Groppi
- Department of Veterans Affairs, Clinical Pharmacy Practice Office, Pharmacy Benefits Management (PBM) Services, Washington D.C, USA
| | - Heather Ourth
- Department of Veterans Affairs, Clinical Pharmacy Practice Office, Pharmacy Benefits Management (PBM) Services, Washington D.C, USA
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Ourth HL, Groppi JA, Morreale AP, Jorgenson T, Himsel AS, Jacob DA. Increasing access for veterans with hepatitis C by enhancing use of clinical pharmacy specialists. J Am Pharm Assoc (2003) 2019; 59:398-402. [PMID: 30853345 DOI: 10.1016/j.japh.2019.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 01/23/2019] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To increase access to hepatitis C virus (HCV) care and cure by deploying clinical pharmacy specialist (CPS) providers across the largest integrated health care system in the United States. SETTING National integrated health care system. PRACTICE DESCRIPTION In late 2016, the Department of Veterans Affairs (VA) Pharmacy Benefits Management Clinical Pharmacy Practice Office (CPPO) partnered with the VA HIV, Hepatitis, and Related Conditions Program with the central priority of expanding veteran access to novel HCV treatments and timely cure to ultimately prevent morbidity and mortality associated with HCV disease progression. This successful collaboration resulted in clinical resource funding to bolster access to HCV treatment through the deployment of CPS providers. This enterprise-wide initiative to expand clinical pharmacy services for unmet health care needs in HCV treatment resulted in 52 VA facilities submitting full-time employment equivalent (FTEE) funding requests totaling more than $10 million dollars. Facilities may have requested funding for 1 or more FTEEs. RESULTS Facilities hired 47 CPS providers and 5 clinical pharmacy technicians. CPS providers in this project recorded 24,888 patient care encounters providing care for 9593 unique patients and initiated new HCV treatment for 1191 treatment-naïve patients. For an additional 8402 patients, the CPS provided HCV care activities such as evaluation and monitoring before, during, and after treatment. CPPO estimates that the same care delivered by nonpharmacist provider specialists (e.g., specialty physicians) cost an additional $936,535, or 48% more. CONCLUSION The deployment of HCV CPS resulted in a significant number of new HCV patients being screened and treated within the VA system.
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Ourth HL, Hur K, Morreale AP, Cunningham F, Thakkar B, Aspinall S. Comparison of clinical pharmacy specialists and usual care in outpatient management of hyperglycemia in Veterans Affairs medical centers. Am J Health Syst Pharm 2018; 76:26-33. [DOI: 10.1093/ajhp/zxy004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Kwan Hur
- VA Pharmacy Benefits Management Services, Hines, IL
| | | | | | | | - Sherrie Aspinall
- VA Pharmacy Benefits Management Services, Hines, IL
- VA Center for Health Equity Research and Promotion, Pittsburgh, PA
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12
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Ourth H, Nelson J, Spoutz P, Morreale AP. Development of a Pharmacoeconomic Model to Demonstrate the Effect of Clinical Pharmacist Involvement in Diabetes Management. J Manag Care Spec Pharm 2018; 24:449-457. [PMID: 29694293 PMCID: PMC10398278 DOI: 10.18553/jmcp.2018.24.5.449] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND A data collection tool was developed and nationally deployed to clinical pharmacists (CPs) working in advanced practice provider roles within the Department of Veterans Affairs to document interventions and associated clinical outcomes. Intervention and short-term clinical outcome data derived from the tool were used to populate a validated clinical outcomes modeling program to predict long-term clinical and economic effects. OBJECTIVE To predict the long-term effect of CP-provided pharmacotherapy management on outcomes and costs for patients with type 2 diabetes. METHODS Baseline patient demographics and biomarkers were extracted for type 2 diabetic patients having > 1 encounter with a CP using the tool between January 5, 2013, and November 20, 2014. Treatment biomarker values were extracted 12 months after the patient's initial visit with the CP. The number of visits with the CP was extracted from the electronic medical record, and duration of visit time was quantified by Current Procedural Terminology codes. Simulation modeling was performed on 3 patient cohorts-those with a baseline hemoglobin A1c of 8% to < 9%, 9% to < 10%, and ≥ 10%-to estimate long-term cost and clinical outcomes using modeling based on pivotal trial data (the Archimedes Model). A sensitivity analysis was conducted to assess the extent to which our results were dependent on assumptions related to program effectiveness and costs. RESULTS A total of 7,310 patients were included in the analysis. Analysis of costs and events on 2-, 3-, 5-, and 10-year time horizons demonstrated significant reductions in major adverse cardiovascular events (MACEs), myocardial infarctions (MIs), episodes of acute heart failure, foot ulcers, and foot amputations in comparison with a control group receiving usual guideline-directed medical care. In the cohort with a baseline A1c of ≥ 10%, the absolute risk reduction was 1.82% for MACE, 1.73% for MI, 2.43% for acute heart failure, 5.38% for foot ulcers, and 2.03% for foot amputations. The incremental cost-effectiveness ratios for cost per quality-adjusted life-year during the 2-, 3-, 5-, and 10-year time horizons were cost-effective for the cohorts of patients with a baseline A1c of 9% to < 10% and ≥ 10%. CONCLUSIONS CPs acting as advanced practice providers reduced A1c from baseline for veterans with type 2 diabetes compared with modeled usual care. Archimedes modeling of the A1c reductions projects a decreased incidence of diabetes complications and overall health care spending when compared with modeled usual care. DISCLOSURES There was no outside funding source or sponsor for this project. None of the authors report any conflicts of interest. The views expressed in this article are those of the authors and do not necessarily reflect the views or policies of the U.S. Department of Veterans Affairs. Preliminary data from this project were previously presented in abstract form at the Academy of Managed Care Pharmacy 27th Annual Meeting and Expo; April 8-10, 2015; in San Diego, California.
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Affiliation(s)
- Heather Ourth
- 1 Pharmacy Benefit Management Services, Department of Veterans Affairs, Washington, DC
| | - Jordan Nelson
- 2 Pharmacoeconomics, Clinical Informatics and Geriatrics, South Texas Veterans Health Care System, San Antonio, Texas
| | | | - Anthony P Morreale
- 1 Pharmacy Benefit Management Services, Department of Veterans Affairs, Washington, DC
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Groppi JA, Ourth H, Morreale AP, Hirsh JM, Wright S. Advancement of clinical pharmacy practice through intervention capture. Am J Health Syst Pharm 2018; 75:886-892. [DOI: 10.2146/ajhp170186] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Julie A. Groppi
- Pharmacy Benefits Management Service, Clinical Pharmacy Practice Office, Department of Veterans Affairs, Palm Beach Gardens, FL
| | - Heather Ourth
- Pharmacy Benefits Management Service, Clinical Pharmacy Practice Office, Department of Veterans Affairs, Des Moines, IA
| | - Anthony P. Morreale
- Pharmacy Benefits Management Service, Clinical Pharmacy Practice Office, Department of Veterans Affairs, San Diego, CA
| | - Jennifer M. Hirsh
- VISN 12 Pharmacy Benefits Management Service, Clinical Pharmacy Practice Office, Department of Veterans Affairs, Naperville, IL
| | - Samantha Wright
- VA Great Lakes Health Care System (VISN 12), Department of Veterans Affairs, Westchester, IL
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Luoma LA, Morales VK, Castelvecchi AN, Wolf VA, Farnsworth FA, Groppi JA, Morreale AP. Workforce Assessment of VA Home-Based Primary Care Pharmacists. Fed Pract 2018; 35:22-27. [PMID: 30766361 PMCID: PMC6368022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The majority of clinical pharmacy specialists are using global scopes of practice, which allow more autonomy to provide direct patient care and comprehensive medication management services to home-based primary care veterans.
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Affiliation(s)
- Lori A Luoma
- is a Clinical Pharmacy Specialist in Home-Based Primary Care at VA Montana Health Care in Great Falls. is a Clinical Pharmacy Specialist in Home-Based Primary Care at South Texas Veterans Health Care System in San Antonio. is a Clinical Pharmacy Specialist in Home-Based Primary Care at William Jennings Bryan Dorn Veterans Affairs Medical Center in Columbia, South Carolina. was a Clinical Pharmacy Specialist in Home-Based Primary Care at New Mexico VA Health Care System in Las Vegas at the time the article was written. is Chief of Pharmacy Service at Corporal Michael J. Crescenz VAMC in Philadelphia, Pennsylvania. is the National PBM Program Manager of Clinical Pharmacy Practice Policy and Standards, and is Assistant Chief Consultant for Clinical Pharmacy Services and Healthcare Services Research at VA Clinical Pharmacy Practice Office in Pharmacy Benefits
| | - Vanessa K Morales
- is a Clinical Pharmacy Specialist in Home-Based Primary Care at VA Montana Health Care in Great Falls. is a Clinical Pharmacy Specialist in Home-Based Primary Care at South Texas Veterans Health Care System in San Antonio. is a Clinical Pharmacy Specialist in Home-Based Primary Care at William Jennings Bryan Dorn Veterans Affairs Medical Center in Columbia, South Carolina. was a Clinical Pharmacy Specialist in Home-Based Primary Care at New Mexico VA Health Care System in Las Vegas at the time the article was written. is Chief of Pharmacy Service at Corporal Michael J. Crescenz VAMC in Philadelphia, Pennsylvania. is the National PBM Program Manager of Clinical Pharmacy Practice Policy and Standards, and is Assistant Chief Consultant for Clinical Pharmacy Services and Healthcare Services Research at VA Clinical Pharmacy Practice Office in Pharmacy Benefits
| | - Ashley N Castelvecchi
- is a Clinical Pharmacy Specialist in Home-Based Primary Care at VA Montana Health Care in Great Falls. is a Clinical Pharmacy Specialist in Home-Based Primary Care at South Texas Veterans Health Care System in San Antonio. is a Clinical Pharmacy Specialist in Home-Based Primary Care at William Jennings Bryan Dorn Veterans Affairs Medical Center in Columbia, South Carolina. was a Clinical Pharmacy Specialist in Home-Based Primary Care at New Mexico VA Health Care System in Las Vegas at the time the article was written. is Chief of Pharmacy Service at Corporal Michael J. Crescenz VAMC in Philadelphia, Pennsylvania. is the National PBM Program Manager of Clinical Pharmacy Practice Policy and Standards, and is Assistant Chief Consultant for Clinical Pharmacy Services and Healthcare Services Research at VA Clinical Pharmacy Practice Office in Pharmacy Benefits
| | - Valerie A Wolf
- is a Clinical Pharmacy Specialist in Home-Based Primary Care at VA Montana Health Care in Great Falls. is a Clinical Pharmacy Specialist in Home-Based Primary Care at South Texas Veterans Health Care System in San Antonio. is a Clinical Pharmacy Specialist in Home-Based Primary Care at William Jennings Bryan Dorn Veterans Affairs Medical Center in Columbia, South Carolina. was a Clinical Pharmacy Specialist in Home-Based Primary Care at New Mexico VA Health Care System in Las Vegas at the time the article was written. is Chief of Pharmacy Service at Corporal Michael J. Crescenz VAMC in Philadelphia, Pennsylvania. is the National PBM Program Manager of Clinical Pharmacy Practice Policy and Standards, and is Assistant Chief Consultant for Clinical Pharmacy Services and Healthcare Services Research at VA Clinical Pharmacy Practice Office in Pharmacy Benefits
| | - Francine A Farnsworth
- is a Clinical Pharmacy Specialist in Home-Based Primary Care at VA Montana Health Care in Great Falls. is a Clinical Pharmacy Specialist in Home-Based Primary Care at South Texas Veterans Health Care System in San Antonio. is a Clinical Pharmacy Specialist in Home-Based Primary Care at William Jennings Bryan Dorn Veterans Affairs Medical Center in Columbia, South Carolina. was a Clinical Pharmacy Specialist in Home-Based Primary Care at New Mexico VA Health Care System in Las Vegas at the time the article was written. is Chief of Pharmacy Service at Corporal Michael J. Crescenz VAMC in Philadelphia, Pennsylvania. is the National PBM Program Manager of Clinical Pharmacy Practice Policy and Standards, and is Assistant Chief Consultant for Clinical Pharmacy Services and Healthcare Services Research at VA Clinical Pharmacy Practice Office in Pharmacy Benefits
| | - Julie A Groppi
- is a Clinical Pharmacy Specialist in Home-Based Primary Care at VA Montana Health Care in Great Falls. is a Clinical Pharmacy Specialist in Home-Based Primary Care at South Texas Veterans Health Care System in San Antonio. is a Clinical Pharmacy Specialist in Home-Based Primary Care at William Jennings Bryan Dorn Veterans Affairs Medical Center in Columbia, South Carolina. was a Clinical Pharmacy Specialist in Home-Based Primary Care at New Mexico VA Health Care System in Las Vegas at the time the article was written. is Chief of Pharmacy Service at Corporal Michael J. Crescenz VAMC in Philadelphia, Pennsylvania. is the National PBM Program Manager of Clinical Pharmacy Practice Policy and Standards, and is Assistant Chief Consultant for Clinical Pharmacy Services and Healthcare Services Research at VA Clinical Pharmacy Practice Office in Pharmacy Benefits
| | - Anthony P Morreale
- is a Clinical Pharmacy Specialist in Home-Based Primary Care at VA Montana Health Care in Great Falls. is a Clinical Pharmacy Specialist in Home-Based Primary Care at South Texas Veterans Health Care System in San Antonio. is a Clinical Pharmacy Specialist in Home-Based Primary Care at William Jennings Bryan Dorn Veterans Affairs Medical Center in Columbia, South Carolina. was a Clinical Pharmacy Specialist in Home-Based Primary Care at New Mexico VA Health Care System in Las Vegas at the time the article was written. is Chief of Pharmacy Service at Corporal Michael J. Crescenz VAMC in Philadelphia, Pennsylvania. is the National PBM Program Manager of Clinical Pharmacy Practice Policy and Standards, and is Assistant Chief Consultant for Clinical Pharmacy Services and Healthcare Services Research at VA Clinical Pharmacy Practice Office in Pharmacy Benefits
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Echevarria K, Groppi J, Kelly AA, Morreale AP, Neuhauser MM, Roselle GA. Development and application of an objective staffing calculator for antimicrobial stewardship programs in the Veterans Health Administration. Am J Health Syst Pharm 2017; 74:1785-1790. [PMID: 28947624 DOI: 10.2146/ajhp160825] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The development and validation of a staffing calculator and its use in creating staffing guidance for antimicrobial stewardship programs (ASPs) in Veterans Health Administration (VHA) facilities are described. METHODS The Tools and Resources Work Group of the Antimicrobial Stewardship Task Force and PBM Clinical Pharmacy Practice Office of the Department of Veterans Affairs developed, tested, and validated a staffing calculator to track patient care and ASP management activities needed to maintain a comprehensive ASP. Time spent on activities was based on time-in-motion tracking studies and input from experienced antimicrobial stewards. The staffing calculator was validated across VHA facilities of varying sizes and complexities to determine the number of needed clinical pharmacist full-time equivalents (FTEs) to implement and maintain ASPs per 100 occupied beds. RESULTS A total of 12 facilities completed the staffing calculator for 1 calendar week. The median number of occupied beds was 226. Most facilities had at least 100 occupied beds, and 6 of the 12 were considered high complexity facilities. The median calculated FTE personnel requirement was 2.62, or 1.01 per 100 occupied beds. The majority of FTE time (70%) was spent on patient care activities and 30% on program management activities, including infectious diseases or ASP rounds. The final recommendations indicated that in order to implement and manage a robust ASP, a pharmacist FTE investment of 1.0 per 100 occupied beds would be needed. CONCLUSION A staffing calculator to account for the time needed to implement ASP activities and provide staffing guidance across a large health-care system was validated.
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Affiliation(s)
- Kelly Echevarria
- Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, TX .,University of Texas at Austin College of Pharmacy, Austin, TX.
| | - Julie Groppi
- Clinical Pharmacy Practice Office, Pharmacy Benefits Management Service, Washington, DC
| | - Allison A Kelly
- National Infectious Diseases Services, Veterans Health Administration, Washington, DC.,University of Cincinnati College of Medicine, Cincinnati, OH
| | - Anthony P Morreale
- Clinical Pharmacy Practice Office, Pharmacy Benefits Management Service, Washington, DC
| | | | - Gary A Roselle
- National Infectious Diseases Services, Veterans Health Administration, Washington, DC.,University of Cincinnati College of Medicine, Cincinnati, OH
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Jasuja GK, Bhasin S, Rose AJ, Reisman JI, Hanlon JT, Miller DR, Morreale AP, Pogach LM, Cunningham FE, Park A, Wiener RS, Gifford AL, Berlowitz DR. Provider and Site-Level Determinants of Testosterone Prescribing in the Veterans Healthcare System. J Clin Endocrinol Metab 2017; 102:3226-3233. [PMID: 28911150 PMCID: PMC5587071 DOI: 10.1210/jc.2017-00468] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 05/26/2017] [Indexed: 01/05/2023]
Abstract
CONTEXT Testosterone prescribing rates have increased substantially in the past decade. However, little is known about the context within which such prescriptions occur. OBJECTIVE We evaluated provider- and site-level determinants of receipt of testosterone and of guideline-concordant testosterone prescribing. DESIGN This study was cross-sectional in design. SETTING This study was conducted at the Veterans Health Administration (VA). PARTICIPANTS Study participants were a national cohort of male patients who had received at least one outpatient prescription within the VA during fiscal year (FY) 2008 to FY 2012. A total of 38,648 providers and 130 stations were associated with these patients. MAIN OUTCOME MEASURE This study measured receipt of testosterone and guideline-concordant testosterone prescribing. RESULTS Providers ranging in age from 31 to 60 years, with less experience in the VA [all adjusted odds ratio (AOR), <2; P < 0.01] and credentialed as medical doctors in endocrinology (AOR, 3.88; P < 0.01) and urology (AOR, 1.48; P < 0.01) were more likely to prescribe testosterone compared with older providers, providers of longer VA tenure, and primary care providers, respectively. Sites located in the West compared with the Northeast [AOR, 1.75; 95% confidence interval (CI), 1.45-2.11] and care received at a community-based outpatient clinic compared with a medical center (AOR, 1.22; 95% CI, 1.20-1.24) also predicted testosterone use. Although they were more likely to prescribe testosterone, endocrinologists were also more likely to obtain an appropriate workup before prescribing compared with primary care providers (AOR, 2.14; 95% CI, 1.54-2.97). CONCLUSIONS Our results highlight the opportunity to intervene at both the provider and the site levels to improve testosterone prescribing. This study also provides a useful example of how to examine contributions to prescribing variation at different levels of the health care system.
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Affiliation(s)
- Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
| | - Shalender Bhasin
- Research Program in Men’s Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School Boston, Boston, Massachusetts 02115
| | - Adam J. Rose
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
| | - Joseph T. Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania 15213
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Donald R. Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
| | - Anthony P. Morreale
- Clinical Pharmacy Services and Healthcare Services Research, VA Pharmacy Benefits Management Services VACO, San Diego, California 92161
| | - Leonard M. Pogach
- Department of Veterans Affairs, New Jersey Healthcare System, East Orange, New Jersey 07018
| | | | - Angela Park
- New England Veterans Engineering Resource Center, Boston, Massachusetts 02130
| | - Renda S. Wiener
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Medicine, The Pulmonary Center, Boston University, Boston, Massachusetts 02118
| | - Allen L. Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Dan R. Berlowitz
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
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17
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Hirsch JD, Bounthavong M, Arjmand A, Ha DR, Cadiz CL, Zimmerman A, Ourth H, Morreale AP, Edelman SV, Morello CM. Estimated Cost-Effectiveness, Cost Benefit, and Risk Reduction Associated with an Endocrinologist-Pharmacist Diabetes Intense Medical Management “Tune-Up” Clinic. J Manag Care Spec Pharm 2017; 23:318-326. [PMID: 28230459 PMCID: PMC10398331 DOI: 10.18553/jmcp.2017.23.3.318] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In 2012 U.S. diabetes costs were estimated to be $245 billion, with $176 billion related to direct diabetes treatment and associated complications. Although a few studies have reported positive glycemic and economic benefits for diabetes patients treated under primary care physician (PCP)-pharmacist collaborative practice models, no studies have evaluated the cost-effectiveness of an endocrinologist-pharmacist collaborative practice model treating complex diabetes patients versus usual PCP care for similar patients. OBJECTIVE To estimate the cost-effectiveness and cost benefit of a collaborative endocrinologist-pharmacist Diabetes Intense Medical Management (DIMM) "Tune-Up" clinic for complex diabetes patients versus usual PCP care from 3 perspectives (clinic, health system, payer) and time frames. METHODS Data from a retrospective cohort study of adult patients with type 2 diabetes mellitus (T2DM) and glycosylated hemoglobin A1c (A1c) ≥ 8% who were referred to the DIMM clinic at the Veterans Affairs San Diego Health System were used for cost analyses against a comparator group of PCP patients meeting the same criteria. The DIMM clinic took more time with patients, compared with usual PCP visits. It provided personalized care in three 60-minute visits over 6 months, combining medication therapy management with patient-specific diabetes education, to achieve A1c treatment goals before discharge back to the PCP. Data for DIMM versus PCP patients were used to evaluate cost-effectiveness and cost benefit. Analyses included incremental cost-effectiveness ratios (ICERs) at 6 months, 3-year estimated total medical costs avoided and return on investment (ROI), absolute risk reduction of complications, resultant medical costs, and quality-adjusted life-years (QALYs) over 10 years. RESULTS Base case ICER results indicated that from the clinic perspective, the DIMM clinic costs $21 per additional percentage point of A1c improvement and $115-$164 per additional patient at target A1c goal level compared with the PCP group. From the health system perspective, medical cost avoidance due to improved A1c was $8,793 per DIMM patient versus $3,506 per PCP patient (P = 0.009), resulting in an ROI of $9.01 per dollar spent. From the payer perspective, DIMM patients had estimated lower total medical costs, a greater number of QALYs gained, and appreciable risk reductions for diabetes-related complications over 2-, 5- and 10-year time frames, indicating that the DIMM clinic was dominant. Sensitivity analyses indicated results were robust, and overall conclusions did not change appreciably when key parameters (including DIMM clinic effectiveness and cost) were varied within plausible ranges. CONCLUSIONS The DIMM clinic endocrinologist-pharmacist collaborative practice model, in which the pharmacist spent more time providing personalized care, improved glycemic control at a minimal cost per additional A1c benefit gained and produced greater cost avoidance, appreciable ROI, reduction in long-term complication risk, and lower cost for a greater gain in QALYs. Overall, the DIMM clinic represents an advanced pharmacy practice model with proven clinical and economic benefits from multiple perspectives for patients with T2DM and high medication and comorbidity complexity. DISCLOSURES No outside funding supported this study. The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Preliminary versions of the study data were presented in abstract form at the American Pharmacists Association Annual Meeting & Exposition; March 27, 2015; San Diego, California, and the Academy of Managed Care Pharmacy Annual Meeting; April 21, 2016; San Francisco, California. Study concept and design were contributed by Hirsch, Bounthavong, and Edelman, along with Morello and Morreale. Arjmand, Ourth, Ha, Cadiz, and Zimmerman collected the data. Data interpretation was performed by Ha, Morreale, and Morello, along with Cadiz, Ourth, and Hirsch. The manuscript was written primarily by Hirsch and Zimmerman, along with Arjamand, Ourth, and Morello, and was revised by Hirsch and Cadiz, along with Bounthavong, Ha, Morreale, and Morello.
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18
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Rose AJ, Park A, Gillespie C, Van Deusen Lukas C, Ozonoff A, Petrakis BA, Reisman JI, Borzecki AM, Benedict AJ, Lukesh WN, Schmoke TJ, Jones EA, Morreale AP, Ourth HL, Schlosser JE, Mayo-Smith MF, Allen AL, Witt DM, Helfrich CD, McCullough MB. Results of a Regional Effort to Improve Warfarin Management. Ann Pharmacother 2016; 51:373-379. [PMID: 28367699 DOI: 10.1177/1060028016681030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. OBJECTIVE To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). METHODS Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. RESULTS VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. CONCLUSIONS A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.
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Affiliation(s)
- Adam J Rose
- 1 Bedford VA Medical Center, MA, USA.,2 Boston University School of Medicine, MA, USA
| | - Angela Park
- 3 New England Veterans Engineering Resource Center, Boston, MA, USA
| | | | - Carol Van Deusen Lukas
- 1 Bedford VA Medical Center, MA, USA.,4 Boston University School of Public Health, MA, USA
| | - Al Ozonoff
- 1 Bedford VA Medical Center, MA, USA.,5 Boston Children's Hospital, MA, USA.,6 Harvard Medical School, Boston, MA, USA
| | | | | | - Ann M Borzecki
- 1 Bedford VA Medical Center, MA, USA.,2 Boston University School of Medicine, MA, USA.,4 Boston University School of Public Health, MA, USA
| | | | - William N Lukesh
- 3 New England Veterans Engineering Resource Center, Boston, MA, USA
| | | | - Ellen A Jones
- 8 VA Central Western Massachusetts Healthcare System, Northampton, MA, USA
| | | | | | | | | | | | - Daniel M Witt
- 14 University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Christian D Helfrich
- 15 VA Portland Healthcare System, OR, USA.,16 VA Center for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Megan B McCullough
- 1 Bedford VA Medical Center, MA, USA.,4 Boston University School of Public Health, MA, USA
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19
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Ourth H, Groppi J, Morreale AP, Quicci-Roberts K. Clinical pharmacist prescribing activities in the Veterans Health Administration. Am J Health Syst Pharm 2016; 73:1406-15. [DOI: 10.2146/ajhp150778] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Heather Ourth
- Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, DC
| | - Julie Groppi
- Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, DC
| | - Anthony P. Morreale
- Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, DC
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20
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McCullough MB, Solomon JL, Petrakis BA, Park AM, Ourth H, Morreale AP, Rose AJ. Balancing collaborative and independent practice roles in clinical pharmacy: a qualitative research study. Ann Pharmacother 2014; 49:189-95. [PMID: 25429093 DOI: 10.1177/1060028014561473] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Clinical pharmacists (CPs) with a scope of practice operate as direct care providers and health care team members. Research often focuses on one role or the other; little is understood about the dynamic relationship between roles in practice settings. OBJECTIVE To identify the challenges CPs face in balancing dual roles as direct care providers and health care team members and the implications for CP effectiveness and quality of care. METHODS Pharmacists were interviewed with a primary purpose of informing an implementation effort. Besides the implementation, there were emergent themes regarding the challenges posed for CPs in negotiating dual roles. This study is, therefore, a secondary analysis of semistructured interviews and direct observation of 48 CPs, addressing this phenomenon. Interview data were entered into NVivo 10 and systematically analyzed using an emergent thematic coding strategy. RESULTS Pharmacists describe role ambiguity, where they perform as direct providers or team members simultaneously or in quick succession. They note the existence of a "transaction cost," where switching causes loss of momentum or disruption of work flow. Additionally, pharmacists feel that fellow providers lack an understanding of what they do and that CP contributions are not evaluated accurately by other health professionals. CONCLUSION It is a challenge for CPs to balance the distinct roles of serving as collaborators and primary providers. Frequent role switching is not conducive to optimal work efficiency or patient care. Our findings suggest concrete steps that medical centers can take to improve both CP worklife and quality of patient care.
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Affiliation(s)
- Megan B McCullough
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, MA, USA
| | - Jeffrey L Solomon
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, MA, USA
| | - Beth Ann Petrakis
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, MA, USA
| | - Angela M Park
- VA New England Healthcare System, ENRM VAMC, Bedford, MA, USA
| | - Heather Ourth
- Clinical Pharmacy Practice Program and Outcomes Assessment, VA Pharmacy Benefits Management Services VACO, Ackworth, IA, USA
| | - Anthony P Morreale
- Clinical Pharmacy Services and Healthcare Services Research, VA Pharmacy Benefits Management Services VACO, San Diego, CA, USA
| | - Adam J Rose
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, MA, USA Boston University School of Medicine, Boston, MA, USA
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21
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Nguyen CM, Bounthavong M, Mendes MAS, Christopher MLD, Tran JN, Kazerooni R, Morreale AP. Cost utility of tumour necrosis factor-α inhibitors for rheumatoid arthritis: an application of Bayesian methods for evidence synthesis in a Markov model. Pharmacoeconomics 2012; 30:575-93. [PMID: 22640174 DOI: 10.2165/11594990-000000000-00000] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a chronic autoimmune disease that affects approximately 1.5 million people in the US. Tumour necrosis factor (TNF)-α inhibitors have been shown to effectively treat and maintain remission in patients with moderately to severely active RA compared with conventional agents. The high acquisition cost of TNF-α inhibitors prohibits access, which mandates economic investigations into their affordability. The lack of head-to-head comparisons between these agents makes it difficult to determine which agent is the most cost effective. OBJECTIVE This study aimed to determine which TNF-α inhibitor was the most cost-effective agent for the treatment of moderately to severely active RA from the US healthcare payer's perspective. METHODS A Markov model was constructed to analyse the cost utility of five TNF-α inhibitors (in combination with methotrexate [+MTX]) versus MTX monotherapy using Bayesian methods for evidence synthesis. The model had a cycle length of 3 months and an overall time horizon of 5 years. Transition probabilities and utility scores were based on published studies. Total direct costs were adjusted to year 2009 $US using the medical component of the Consumer Price Index. All costs and QALYs were discounted at a rate of 3% per year. Patient response to the different strategies was determined by the American College of Rheumatology (ACR)50 criteria. One-way and probabilistic sensitivity analyses (PSAs) were performed to test the robustness of the base-case scenario. The base-case scenario was changed to ACR20 criteria (scenario 1) and ACR70 criteria (scenario 2) to determine the model's robustness. Cost-effectiveness acceptability curves and cost-effectiveness frontiers were used to estimate the cost-effectiveness probability of each treatment strategy. A willingness-to-pay (WTP) threshold was defined as three times the US GDP per capita ($US139,143 per additional QALY gained). Primary results were presented as incremental cost-effective ratios (ICERs). RESULTS Etanercept+MTX was the most cost-effective treatment strategy in the base-case scenario up to a WTP threshold of $US2 185,497 per QALY gained. At a WTP threshold of greater than $US2 185,497 per QALY gained, certolizumab+MTX was the most cost-effective treatment strategy. One-way analyses showed that the base-case scenario was sensitive to the probability of achieving ACR50 criteria for MTX and each TNF-α inhibitor, and changes in the utility score for patients who achieved the ACR50 criteria. With the exception of infliximab, all of the TNF-α inhibitors were sensitive to drug cost per cycle. In the scenario analyses, certolizumab+MTX was a dominant treatment strategy using ACR20 criteria, but etanercept+MTX was a dominant treatment strategy using ACR70 criteria. CONCLUSIONS Etanercept+MTX was a cost-effective treatment strategy in the base-case scenario; however, the model was sensitive to parameter uncertainties and ACR response criteria. Although Bayesian methods were used to determine transition probabilities, future studies will need to focus on head-to-head comparisons of multiple TNF-α inhibitors to provide valid comparisons.
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22
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Patel JJ, Mendes MAS, Bounthavong M, Christopher MLD, Boggie D, Morreale AP. Cost-utility analysis of bevacizumab versus ranibizumab in neovascular age-related macular degeneration using a Markov model. J Eval Clin Pract 2012; 18:247-55. [PMID: 20846318 DOI: 10.1111/j.1365-2753.2010.01546.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of intravitreal bevacizumab to ranibizumab in patients with neovascular age-related macular degeneration (AMD). METHODS A cost-utility analysis using a Markov model was performed to evaluate incremental cost-effectiveness ratio [ICER, $US per quality-adjusted life year (QALY) gained] between bevacizumab and ranibizumab from a US payer perspective. Transition probabilities for ranibizumab and bevacizumab were extrapolated from published studies and local institutional data. Utility values, likewise, were obtained from another published study. Mortality rates were determined from the Centers for Disease Control 2003 Life Tables. Resource utilization and total direct costs were estimated using the Centers for Medicare and Medicaid Services and the Veterans Affairs Decision Support System. A hypothetical cohort of 1000 patients was simulated through the model for 20 years. Sensitivity analyses were performed using univariate and probabilistic sensitivity analysis (PSA) on all costs, transition probabilities and utility values. An acceptability curve was generated to illustrate the cost-effectiveness probability of bevacizumab to ranibizumab with increasing willingness-to-pay (WTP). RESULTS The cost-effectiveness ratios (CER) for bevacizumab and ranibizumab were $1405 per QALY and $12,177 per QALY, respectively. The ICER for bevacizumab was dominant compared to ranibizumab. The base-case CER was sensitive to drug costs of the study medications with a breakeven point of $44 for ranibizumab and $2666 for bevacizumab. PSA revealed a 95% probability of bevacizumab being more cost-effective than ranibizumab at a WTP of $50,000 per QALY gained. CONCLUSION Based on a WTP defined at $50,000 per QALY gained, bevacizumab was cost-effective versus ranibizumab 95% of the time because of lower acquisition costs and increased efficacy.
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Affiliation(s)
- Jignesh J Patel
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
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23
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Aldridge VE, Park HK, Bounthavong M, Morreale AP. Implementing a comprehensive, 24-hour emergency department pharmacy program. Am J Health Syst Pharm 2009; 66:1943-7. [DOI: 10.2146/ajhp080660] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Victoria E. Aldridge
- Inpatient Pharmacy, and Veterans Affairs Learning Opportunities Residency Coordinator
| | - Helen K. Park
- Inpatient Pharmacy, and Veterans Affairs Learning Opportunities Residency Coordinator
| | - Mark Bounthavong
- Pharmacy Services, Veterans Affairs San Diego Healthcare System, San Diego, CA
| | - Anthony P. Morreale
- Pharmacy Services, Veterans Affairs San Diego Healthcare System, San Diego, CA
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Harris J, Lee SB, Plowman BK, Morreale AP, Boggie DT, Delattre ML. Identification of patients taking NSAIDs at high risk for GI bleeding. Am J Health Syst Pharm 2005; 62:1543, 1548. [PMID: 16030358 DOI: 10.2146/ajhp040308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Plowman BK, Boggie DT, Morreale AP, Schaefer MG, Delattre ML, Chan H. Sleep attacks in patients receiving dopamine-receptor agonists. Am J Health Syst Pharm 2005; 62:537-40. [PMID: 15745920 DOI: 10.1093/ajhp/62.5.537] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Brian K Plowman
- Veterans Affairs San Diego Healthcare System (VASDHS), San Diego, CA 92161, USA.
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Tran F, Boggie DT, Delattre ML, Schaefer MG, Morreale AP, Plowman BK. Therapeutic interchange involving replacement of rofecoxib or celecoxib with valdecoxib. Am J Health Syst Pharm 2004; 61:1391-4. [PMID: 15287237 DOI: 10.1093/ajhp/61.13.1391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Fionna Tran
- Veterans Affairs San Diego Healthcare System, CA 92161, USA
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Watanabe SL, Morreale AP, Zelman LA. Quantity and cost of commonly used ophthalmic solutions at a Veterans Affairs Health System. Am J Health Syst Pharm 2004; 61:612-6. [PMID: 15061434 DOI: 10.1093/ajhp/61.6.612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sherry L Watanabe
- o VA San Diego Healthcare System (119), 3350 La Jolla Village Drive, San Diego, CA 92161, USA
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Skog JH, Morreale AP, Plowman BK, Rapier R, Dole S. Clinical effectiveness and cost-effectiveness of Helicobacter pylori testing and treatment in patients receiving long-term ulcer prophylaxis. Am J Health Syst Pharm 2004; 61:608-12. [PMID: 15061433 DOI: 10.1093/ajhp/61.6.608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jilian H Skog
- Veterans Affairs San Diego Health Care System (VASDHCS), San Diego, CA, USA.
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Le GH, Schaefer MG, Plowman BK, Morreale AP, Delattre M, Okino L, Felicio L. Assessment of potential digoxin-rabeprazole interaction after formulary conversion of proton-pump inhibitors. Am J Health Syst Pharm 2003; 60:1343-5. [PMID: 12901036 DOI: 10.1093/ajhp/60.13.1343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Grace H Le
- Veterans Affairs San Diego Healthcare System (VASDHS), 3350 La Jolla Village Drive, San Diego, CA 92161, USA
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Abstract
The interaction of celecoxib and rofecoxib with warfarin was studied. Patients stable on warfarin therapy and concurrently taking a cyclooxygenase-2 (COX-2) inhibitor comparator (traditional nonsteroidal antiinflammatory medications, salsalate, or acetaminophen) randomly received celecoxib 200 mg/day or rofecoxib 25 mg/day for three weeks. After a one-week washout period, the patients were crossed over to treatment with the opposite COX-2 inhibitor for three more weeks. The International Normalized Ratio (INR) was measured at baseline and at weeks 1, 2, and 3 of therapy with each COX-2 inhibitor by testing blood samples obtained by finger stick. Data for 16 patients were analyzed. The INR increased by 13%, 6%, and 5% on average in patients taking celecoxib at weeks 1, 2, and 3, respectively, and by 5%, 9%, and 5% in patients taking rofecoxib. Changes in the INR were statistically significant at week 1 for celecoxib and at week 2 for rofecoxib. Of the 12 subjects who had a clinically significant > or = 15% change in the INR while receiving either COX-2 inhibitor, 4 showed this change for both agents. Adverse drug reactions were similar for each COX-2 inhibitor, but the rate of edema requiring medical intervention was higher in the rofecoxib group. Significant increases in the INR were observed in patients who were stable on warfarin therapy after the addition of therapy with rofecoxib or celecoxib.
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Affiliation(s)
- Monica G Schaefer
- VA San Diego Healthcare System, Pharmacy (119), 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
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Dolder NM, Wilhardt MS, Morreale AP. Justifying a multidisciplinary high-intensity hepatitis C clinic by using decision analysis. Am J Health Syst Pharm 2002; 59:867-71. [PMID: 12004469 DOI: 10.1093/ajhp/59.9.867] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Nicole M Dolder
- Veterans Affairs San Diego Healthcare System (119), 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
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Ito MK, Lin JC, Morreale AP, Marcus DB, Shabetai R, Dresselhaus TR, Henry RR. Effect of pravastatin-to-simvastatin conversion on low-density-lipoprotein cholesterol. Am J Health Syst Pharm 2001; 58:1734-9. [PMID: 11571816 DOI: 10.1093/ajhp/58.18.1734] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The effects of a pravastatin-to-simvastatin conversion program on low-density-lipoprotein (LDL) cholesterol levels were studied. Patients receiving pravastatin at a Veterans Affairs medical center were switched to simvastatin beginning in 1997. The dosage of simvastatin was based on the additional percent reduction in LDL cholesterol needed to achieve the goal specified by the National Cholesterol Education Program. The primary endpoint was the change in the percentage of patients meeting their LDL cholesterol goal at baseline and follow-up. Changes in lipid indices, the relative risk (RR) of coronary heart disease (CHD), and program costs were also evaluated. A total of 1032 patients completed the program. The mean +/- S.D. daily doses of pravastatin and simvastatin were 25.2 +/- 11.3 and 22.7 +/- 13.3 mg, respectively. Median baseline and follow-up LDL cholesterol concentrations were 116 and 99 mg/dL, respectively (p < 0.001). Overall, 44% of the patients met their LDL cholesterol goal while taking pravastatin, compared with 69% after conversion to simvastatin (p < 0.001). The predicted mean RR of a future CHD event (based on changes in serum lipids) was 0.87 (95% confidence interval, 0.83-0.91) four years after conversion. The total cost of the program was $40,644 in the first year, and there was a net saving thereafter. Therapeutic interchange between pravastatin and simvastatin increased the number of patients meeting their LDL cholesterol goal.
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Affiliation(s)
- M K Ito
- Southern California Clinical Experience Program, School of Pharmacy and Health Sciences, University of the Pacific (UOP), Stockton, USA.
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Bidwell Goetz M, Morreale AP, Rhew DC, Berman S, Ing M, Eldridge D, Justis JC, Lott E. Effect of highly active antiretroviral therapy on outcomes in Veterans Affairs Medical Centers. AIDS 2001; 15:530-2. [PMID: 11242153 DOI: 10.1097/00002030-200103090-00015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- M Bidwell Goetz
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Ito MK, Stolley SN, Morreale AP, Lin JC, Marcus DB. Rationale, design, and baseline results of the Pravastatin-to-Simvastatin Conversion Lipid Optimization Program (PSCOP). Am J Health Syst Pharm 1999; 56:1107-13. [PMID: 10385458 DOI: 10.1093/ajhp/56.11.1107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A program designed to increase the percentage of patients at a Department of Veterans Affairs health system who meet their cholesterol goals as recommended by the National Cholesterol Education Program (NCEP) is described, and baseline results are reported. Patients with an active prescription for pravastatin between February 4 and June 4, 1997, were identified for conversion to simvastatin by means of the Pravastatin-to-Simvastatin Conversion Lipid-Optimization Program; 1361 patients were eligible for conversion. Each patient was mailed a survey for determining risk factors for coronary heart disease (CHD) and NCEP-recommended low-density lipoprotein (LDL) cholesterol goal and was asked to provide a fasting blood sample for determination of lipid profile, liver function, and serum creatine phosphokinase concentration. The patients were asked to make a follow-up laboratory visit six to seven weeks after they had started taking simvastatin. The percentage change from baseline and the percentage of patients who meet their LDL cholesterol goal before and after the conversion will be determined. A total of 1115 patients were converted to simvastatin. Only 35.4% of patients taking pravastatin to prevent a second CHD-related event met or exceeded their LDL cholesterol goal. Only 36.2% of patients with two or more CHD risk factors who were taking pravastatin for primary prevention met or exceeded their LDL cholesterol goal. In a veterans population, less than half of patients receiving a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor had LDL cholesterol concentrations that met goals recommended by the NCEP.
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Affiliation(s)
- M K Ito
- School of Pharmacy, University of the Pacific, Stockton, CA, USA
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Condra LJ, Morreale AP, Stolley SN, Marcus D. Assessment of patient satisfaction with a formulary switch from omeprazole to lansoprazole in gastroesophageal reflux disease maintenance therapy. Am J Manag Care 1999; 5:631-8. [PMID: 10537869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
OBJECTIVE To determine if patients perceived a difference in the efficacy, side effects, and value of omeprazole versus lansoprazole for gastroesophageal reflux disease (GERD) maintenance therapy after a formulary conversion, and to evaluate the costs of the conversion. STUDY DESIGN An unblinded questionnaire was mailed to patients who were currently receiving GERD maintenance therapy with lansoprazole from the Veterans Affairs San Diego Healthcare System. PATIENTS AND METHODS Three hundred patients who had been on omeprazole for a minimum of 2 months prior to the formulary conversion and on lansoprazole for a minimum of 2 months after the formulary conversion were surveyed. Patients were asked to rate the severity and frequency of their symptoms (pain, heartburn, and regurgitation) on a scale from 0 to 9 for each medication. Questions regarding side effects, medication preference, and satisfaction with the formulary conversion process were also addressed. RESULTS Fifty-two percent of the surveys were returned. There was no statistically significant difference between median total symptom scores for omeprazole and lansoprazole (1.33 vs. 1.34, respectively). More patients reported side effects to lansoprazole (P < 0.001) than to omeprazole. Sixty-four percent of patients preferred omeprazole (P < 0.005). The formulary conversion was estimated to save $29,000 per year. CONCLUSIONS Omeprazole was the medication preferred by patients for GERD maintenance therapy. Patients were willing to pay an additional fee for their preferred agent. Fewer adverse events were reported with omeprazole. The potential cost savings of the formulary conversion may have been at the expense of patient satisfaction.
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Affiliation(s)
- L J Condra
- Department of Pharmacy, Veteran Affairs San Diego Healthcare System, CA 92161, USA.
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Lin JC, Ito MK, Stolley SN, Morreale AP, Marcus DB. The effect of converting from pravastatin to simvastatin on the pharmacodynamics of warfarin. J Clin Pharmacol 1999; 39:86-90. [PMID: 9987704 DOI: 10.1177/00912709922007598] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Forty-six adult patients maintained on warfarin therapy were converted from pravastatin to simvastatin. Mean international normalized ratio (INR) significantly increased from 2.42 to 2.74, p = 0.002. Although warfarin doses were reduced in 7 patients and increased in 4 patients following the post-conversion INR measurements, the pre- and postconversion median weekly warfarin dose of all 46 patients did not differ significantly. The number of patients with an INR > 3.0 increased significantly from 6 to 16 following the conversion. There was no report of unusual episodes of bleeding. The results indicate that antihyperlipidemic therapy can be changed safely from pravastatin to simvastatin in patients who are taking warfarin concomitantly. Additional anticoagulation monitoring is not necessary in institutions where patients are followed in formal anticoagulation clinics.
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Affiliation(s)
- J C Lin
- Cardiovascular Pharmacodynamics Laboratory, Veterans Administration Healthcare System, San Diego, California, USA
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Duong TM, Plowman BK, Morreale AP, Janetzky K. Retrospective and prospective analyses of the treatment of overanticoagulated patients. Pharmacotherapy 1998; 18:1264-70. [PMID: 9855325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
STUDY OBJECTIVE To compare withholding warfarin therapy with low-dose (2.5 mg) oral vitamin K therapy in excessively anticoagulated patients without bleeding complications. DESIGN Prospective and retrospective studies. SETTING Anticoagulation clinic at a Veterans Affairs institution. PATIENTS Twenty-eight men were matched according to initial international normalized ratio (INR) and INR goal ranges. INTERVENTIONS The retrospective arm of the study consisted of chart reviews of overanticoagulated patients whose warfarin doses were held until therapeutic INR values were reached. The prospective arm included overanticoagulated patients who were administered a single 2.5-mg dose of oral vitamin K. MEASUREMENTS AND MAIN RESULTS Mean days to therapeutic INR values were 2.3+/-0.6 and 1.4+/-0.6 (p=0.001), and mean reduction in INR 1 day after treatment intervention was 1.32+/-0.79 and 3.46+/-1.31 (p<001) U for the withholding and vitamin K groups, respectively. CONCLUSION Compared with withholding the warfarin dose, administration of 2.5 mg of oral vitamin K to excessively anticoagulated patients receiving warfarin significantly reduced the time required to reach a therapeutic INR as well as final INR.
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Affiliation(s)
- T M Duong
- Veterans Affairs San Diego Healthcare Systems, California 92161, USA
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Affiliation(s)
- K Janetzky
- Pharmacy Service, Veterans Affairs Medical Center, San Diego, CA 92161-0155, USA
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Abstract
A pharmacist-managed Helicobacter pylori assessment clinic for ambulatory patients is described. The pharmacy service at a 400-bed Veterans Affairs Medical Center established a pharmacist-managed clinic to assess patients who were receiving long-term acid-suppressive medications (histamine H2-receptor antagonists, sucralfate, or omeprazole). Patients with active ulcer disease and those receiving ulcer prophylaxis are screened for the presence of H. pylori. Those who test positive are treated with combinations of the following agents: omeprazole, clarithromycin, amoxicillin, tetracycline, and metronidazole. The pharmacist also may adjust or discontinue acid-suppressive drug regimens. The pharmacist is responsible for ordering all appropriate laboratory tests, monitoring patients for adverse effects, collecting data on patient outcomes, and providing patient education. The clinic provides opportunities for pharmacists to study the clinical effectiveness and pharmacoeconomics of various regimens for treating H. pylori-associated disease and for pharmacy students and residents to interact with patients. As of fall 1994, 20 patients had been evaluated at the clinic: 12 tested positive for H. pylori and were treated with antimicrobials and all were pain-free without medication at the end of treatment. An H. pylori assessment clinic enabled pharmacists to assume a primary care role, document improvement in patient outcomes, and study the effectiveness of various antimicrobial regimens.
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Affiliation(s)
- A P Morreale
- Pharmacy Services, Veterans Affairs Medical Center, 3350 La Jolla Village Drive, San Diego, CA 92161, USA
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Ito MK, Morreale AP. Acceptability of cholestyramine and colestipol formulations in three common vehicles. Clin Pharm 1991; 10:138-40. [PMID: 2009732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- M K Ito
- San Diego Program, School of Pharmacy, University of the Pacific, Stockton, CA
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