VA CMOPs: producing a pattern of quality and efficiency in government.

OBJECTIVE: To describe the modern, highly efficient, and effective production of prescriptions in a contemporary pharmacy practice setting using large-scale automated dispensing systems. SETTING: 83,000-square-foot Department of Veterans Affairs Consolidated Mail Outpatient Pharmacy (VA CMOP) facility in Tucson, AZ. PRACTICE DESCRIPTION: The Tucson VA CMOP is one of seven highly automated, large-volume mail service pharmacy operations that prepare, dispense, and mail approximately 100 million prescriptions annually to veterans throughout the United States. The sophisticated automated dispensing systems allow production to be accomplished quickly and at a lower cost than performing the same dispensing tasks at local VA Medical Center (VAMC) pharmacies. As a result of CMOP dispensing program support, pharmacists at local VAMC pharmacies and clinics have the opportunity to spend more time counseling patients instead of being distracted by non-clinical product dispensing tasks. CONCLUSION: VA CMOPs contribute to improving patient care by reorganizing the patient prescription dispensing workflow dynamic from a systems perspective, thereby allowing local VA health care facility pharmacists and other health care providers to better address and resolve patients' medication use issues. Ultimately, the VA CMOP network is a dynamic example of an organizational component within the VA health care system that actively contributes to the government's goal of working better and costing less.

Evaluating Medication Day-Supply for Improving Adherence and Clinical Biomarkers of Hemoglobin A1c, Blood Pressure, and Low-Density Lipoprotein.

Objectives: To compare a 90-day-supply and a less than 90-day-supply of medication on adherence to refilling prescriptions and clinical biomarkers for hemoglobin A1c (HbA1c), blood pressure (BP), and low-density lipoprotein (LDL). Methods: A retrospective chart review was completed for a cohort of patients prescribed an oral hypoglycemic agent (OHA), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin II receptor blocker (ARB), and/or a statin. Data were categorized into 90-day-supply and less than 90-day-supply and on the minimum value for control determined by the CMS Star Ratings system. Adherence was defined by the Health Plan Quality Improvement Department as ≥ 85% of days covered. Clinical biomarker cutoffs were HbA1c (<9% or ≥ 9%), BP (Systolic BP ≤ 140 mm Hg and >140 mm Hg or Diastolic BP ≥ 90 mm Hg regardless of SBP), and LDL (<100 mg/dl or ≥100 mg/dl). Results: The analysis included 251 patients: 159 females (mean 64.9 ± 11.7 years) and 92 males (mean 61.5 ± 11.3 years). Patients with medications from multiple classes were included in more than one analysis. Adherence was statistically in favor of the 90-day-supply compared to less than 90-day-supply for all three classes of drugs. The clinical biomarkers were statistically not different for each drug group. Conclusion: A 90-day-supply was statistically greater than a less than 90-day-supply for CMS Star Ratings metrics, but was not statistically significant for clinical biomarkers for HbA1c, SBP, and LDL.

Practitioners' views on computerized drug-drug interaction alerts in the VA system.

OBJECTIVES: To assess Veterans Affairs (VA) prescribers' and pharmacists' opinions about computer-generated drug-drug interaction (DDI) alerts and obtain suggestions for improving DDI alerts. DESIGN: A mail survey of 725 prescribers and 142 pharmacists from seven VA medical centers across the United States. MEASUREMENTS: A questionnaire asked respondents about their sources of drug and DDI information, satisfaction with the combined inpatient and outpatient computerized prescriber order entry (CPOE) system, attitude toward DDI alerts, and suggestions for improving DDI alerts. RESULTS: The overall response rate was 40% (prescribers: 36%; pharmacists: 59%). Both prescribers and pharmacists indicated that the CPOE system had a neutral to positive impact on their jobs. DDI alerts were not viewed as a waste of time and the majority (61%) of prescribers felt that DDI alerts had increased their potential to prescribe safely. However, only 30% of prescribers felt DDI alerts provided them with what they needed most of the time. Both prescribers and pharmacists agreed that DDI alerts should be accompanied by management alternatives (73% and 82%, respectively) and more detailed information (65% and 89%, respectively). When asked about suggestions for improving DDI alerts, prescribers most preferred including management options whereas pharmacists most preferred making it more difficult to override lethal interactions. Prescribers and pharmacists reported primarily relying on electronic references for general drug information (62% and 55%, respectively) and DDI information (51% and 79%, respectively). CONCLUSION: Respondents reported neutral to positive views regarding the effect of CPOE on their jobs. Their opinions suggest DDI alerts are useful but still require additional work to increase their clinical utility.

Therapeutic rationale of combining therapy with gemfibrozil and simvastatin.

OBJECTIVES: To examine specific indications for patients receiving therapy with gemfibrozil plus simvastatin at doses of more than 10 mg daily and determine whether these patient-specific indications met Adult Treatment Panel (ATP) III criteria for combination therapy; and secondarily to identify any complications occurring between August 30, 2002, and May 1, 2003. DESIGN: Retrospective cohort study. SETTING: Tertiary care, university-affiliated, Southern Arizona Veterans Affairs Healthcare System from August 30, 2002, to May 1, 2003. PATIENTS: 80 patients with active prescriptions for gemfibrozil at any dose and simvastatin at doses of more than 10 mg daily as of August 30, 2002; and 23 patients who had been prescribed this drug at other institutions. INTERVENTION: Retrospective chart review. MAIN OUTCOME MEASURES: Frequency of meeting ATP III criteria for combination therapy with gemfibrozil and simvastatin was the primary outcome measure (primary). RESULTS: Of the 80 patients, 45 (56%) met ATP III guidelines for combination therapy. Among the 80 patients started on these drugs at this VA facility, gemfibrozil was added to simvastatin in 61 patients, simvastatin was added to gemfibrozil in 18, and the agents were begun simultaneously for 1 patient. Common errors included combination treatment when LDL cholesterol values could not be calculated (because of serum triglycerides levels exceeding 400 mg/dL); use of gemfibrozil at triglyceride levels lower than the 500 mg/dL with attainment of non-HDL goals; and use of gemfibrozil when triglyceride levels were not measured. One death secondary to rhabdomyolysis occurred in a patient whose care did not meet ATP III guidelines. CONCLUSION: Combination therapy with simvastatin and gemfibrozil often did not meet ATP III standards. A higher risk of serious adverse events results from combining these drugs, and systems to improve adherence to guidelines may improve the safety of treating dyslipidemic patients.

Dosage of beta-adrenergic blockers after myocardial infarction.

Dosages of beta-adrenergic blockers prescribed after myocardial infarction (MI) in a Veterans Affairs medical center were reviewed to determine if dosages were adjusted to target dosages used in clinical trials. The medical records of all patients with a discharge diagnosis of MI were reviewed. The target dosage, selected from major clinical trials, was atenolol 100 mg/day p.o., metoprolol tartrate 200 mg/day p.o., or propranolol 180-240 mg/day p.o. A systolic blood pressure of < or = 100 mm Hg and pulse rate of < or = 50 beats/min were defined as the clinical markers of the maximum tolerated beta-blocker dosage. A discharge diagnosis of MI was identified in 396 patients between January 1999 and December 2000, and 106 patients met the inclusion criteria. The patients had a mean +/- S.D. age of 66.3 +/- 10.7 years, 98% were men, and all received either atenolol or metoprolol. The mean +/- S.D. systolic and diastolic blood pressure and pulse rate on admission were 135 +/- 30 and 75 +/- 18 mm Hg and 80 +/- 20 beats/min, respectively. The mean +/- S.D. dosages for atenolol and metoprolol were 54 +/- 39 and 90 +/- 77 mg/day at the time of discharge, 54 +/- 38 and 95 +/- 81 mg/day at 6 months after discharge, and 53 +/- 40 and 82 +/- 80 mg/day at 12 months, respectively. Only 15% of the patients reached the target dosage, as defined in clinical trials, of a beta-blocker. No reason for maintaining the beta-blocker dosage was documented for 65% of the patients. Beta-blockers were prescribed frequently after MI but usually were not used at dosages that matched those in clinical trials.

Reasons provided by prescribers when overriding drug-drug interaction alerts.

OBJECTIVES: To investigate prescribers' rationales for overriding drug-drug interaction (DDI) alerts and to determine whether these reasons were helpful to pharmacists as a part of prescription order verification. STUDY DESIGN: An observational retrospective database analysis was conducted using override reasons derived from a computerized system at 6 Veterans Affairs medical centers. METHODS: Data on DDI alerts (for interactions designated as "critical" and "significant") were obtained from ambulatory care pharmacy records from July 1, 2003, to June 30, 2004. Prescribers' reasons for overriding alerts were organized into 14 categories and were then rated as clinically useful or not to the pharmacist in the assessment of potential patient harm. RESULTS: Of 291,890 overrides identified, 72% were for critical DDIs. Across the Veterans Affairs medical centers, only 20% of the override reasons for critical DDI alerts were rated as clinically useful for order verification. Despite a mandatory override reason for critical DDI alerts, 53% of the responses were "no reason provided." The top response categories for critical and significant DDI alerts were "no reason provided," "patient has been taking combination," and "patient being monitored." CONCLUSIONS: When given the opportunity to provide a reason for overriding a DDI alert, prescribers rarely enter clinical justifications that are useful to order verification pharmacists. This brings into question how computerized physician order entry systems should be designed.

Comparing hyperlipidemia control with daily versus twice-weekly simvastatin.

BACKGROUND: Costs associated with the use of hydroxymethylglutaryl coenzyme A reductase inhibitors are increasing. Finding ways to manage hyperlipidemia at lower costs is critical to all healthcare systems. OBJECTIVE: To assess effectiveness, safety, cost, and patients' satisfaction when converting hyperlipemic patients taking simvastatin daily to simvastatin twice weekly. METHODS: This nonrandomized, open-label, proof-of-concept study converted patients treated with simvastatin 10 or 20 mg daily to 40 or 80 mg twice weekly, respectively, for 12 weeks. The lipid profiles at enrollment, week 6, and week 12 were compared using repeated-measures ANOVA. The percentage of patients attaining the appropriate low-density lipoprotein cholesterol (LDL-C) goal was determined. RESULTS: Thirty-one patients completed the study. The proportion of patients at the LDL-C goal was not statistically different between enrollment and week 12 (87% vs 68%; p = 0.068). The mean LDL-C value +/- SD at weeks 6 and 12 increased compared with enrollment (112 +/-20, 111 +/-17, and 97 +/- 17 mg/dL, respectively; p < 0.001). Three (10%) patients reported nonadherence to the twice-weekly regimen. Seventeen (55%) patients reported that both regimens were equally convenient or preferred the twice-weekly regimen. Estimated cost-savings at our institution associated with this regimen would be $32 000 per 1000 patients per year. CONCLUSIONS: The twice-weekly regimen safely maintained most of the patients at their LDL-C goal level, and over half the patients found this regimen to be the same or easier to follow than a daily regimen. Large outcome studies evaluating this approach are needed.