Pharmacy Benefits Management in the Veterans Health Administration Revisited: A Decade of Advancements, 2004-2014.

Over the past decade, the Department of Veterans Affairs (VA) Pharmacy Benefits Management Services (PBM) has enhanced its formulary management activities and added programs to ensure that the national drug plan continues to meet the pharmacy needs of veterans and to promote safe and appropriate drug therapy in the face of rising medication expenditures. This article describes the broad range of services provided by the VA PBM that work in partnership to deliver a high-quality and sustainable pharmacy benefit for veterans. In support of formulary management, VA PBM pharmacists prepare extensive clinical guidance documents (e.g., drug monographs and criteria for use) that are used by physicians and pharmacists with operational and clinical oversight of the VA national formulary. The VA PBM has utilized various contracting techniques and continually evaluates drug utilization data to identify opportunities for potential savings. Remarkably, since before 2004, the average acquisition cost for a 1-month supply of medication has remained fairly stable at approximately $13-$15. Two new VA PBM programs are the VA Center for Medication Safety (VA MedSAFE) and the Clinical Pharmacy Practice Office (CPPO). VA MedSAFE is a comprehensive pharmacovigilance program focused on the detection, assessment, and prevention of adverse drug events, and CPPO is dedicated to improving safe and appropriate medication use by supporting and expanding clinical pharmacy practice. Moving forward, the VA PBM will consider new initiatives to stay at the forefront of providing quality care while maintaining economic viability. DISCLOSURES: No outside funding supported this research. This work was supported by VA Pharmacy Benefits Management Services (VA PBM), Hines, Illinois, and VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania. Glassman is co-director of the VA Center for Medication Safety, which is part of the VA PBM. He is also part of the Medical Advisory Panel for the VA PMB. All other authors are employed by the VA PBM. The views expressed in this article are those of the authors, and no official endorsement by the U.S. Department of Veteran Affairs or the U.S. government is intended or should be inferred. Study concept and design were contributed by Valentino, Cunningham, Good, Aspinall, and Sales. Calabrese and Ourth took the lead in data collection, along with Good, Cunningham, Aspinall, Sales, Burk, Moore, Neuhauser, and Golterman. Data interpretation was performed by Burk, Newhauser, and Golterman, along with Glassman, Calabrese, Moore, and Ourth. The manuscript was written by Aspinall and Sales, along with Burk, Newhauser, Golterman, Ourth, and Cunningham. Good, Glassman, and Moore revised the manuscript, along with Calabrese, Valentino, and Aspinall.

Suppression of α-Amylase inactivation in the presence of ethanol: Application of a two-step model.

A number of years ago we reported a two-step inactivation mechanism for α-amylase (enzyme) on the basis of theoretical and experimental studies in aqueous solutions. In the first step the metal (Ca2+ ) ion dissociates reversibly from the enzyme followed by an irreversible thermal inactivation of the apoenzyme. In this study we report inactivation of the enzyme in the presence of ethanol-water solutions. We noticed that as the concentration of ethanol in the aqueous solution is increased, the thermal inactivation of the enzyme is suppressed with almost no inactivation (in 1 h, 30°C) when 50% alcohol is present in the solution. These results are explained by the two-step inactivation model. © 2016 American Institute of Chemical Engineers Biotechnol. Prog., 32:1271-1275, 2016.

Implementation of buprenorphine in the Veterans Health Administration: results of the first 3 years.

BACKGROUND: Compared to non-veterans, veterans are disproportionately diagnosed with opioid dependence. Sublingual buprenorphine provides greater access to opioid agonist therapy. To understand the diffusion of this innovative treatment within a large healthcare system, we describe the introduction of buprenorphine within the Veterans Health Administration (VHA) during the first 3 years of its approval as a VHA non-formulary medication. METHODS: Using VHA pharmacy databases, we examined the number of physicians who have prescribed buprenorphine and the number of veterans who have received office-based buprenorphine within VHA veterans integrated service networks (VISN) from fiscal years (FY) 2003 through FY 2005 (October 2002 through September 2005). RESULTS: From FY2003 through FY2005 the number of veterans with opioid dependence increased from 25,031 to 26,859 (>7.3%) and the number of veterans prescribed office-based buprenorphine increased from 53 to 739. During this interval, 16 of 21 VISNs had prescribed buprenorphine. In FY2005, two VISNs accounted for 31% of buprenorphine prescriptions. The number of buprenorphine prescriptions varied widely by VISN, but increased from 212 to 7076 from FY2003 through FY2005. During this interval, prescriptions per patient increased from 4.0 to 9.6 and physicians prescribing buprenorphine increased from 14 to 170. The ratio of patients prescribed buprenorphine to providers prescribing buprenorphine increased from 3.8 to 4.3 with an average increase of 15.1-41.6 of prescriptions per provider. CONCLUSIONS: VHA increased, but not uniformly, the non-formulary use of office-based buprenorphine during the first 3 years of availability.

Efficacy of a multidisciplinary treatment program on one-year outcomes of individuals with Parkinson's disease.

The efficacy of the multidisciplinary treatment approach to the management of Parkinson's disease (PD) was examined at a regional Veteran's Administration Parkinson's Disease Research, Education and Clinical Center (PADRECC). The records of 43 consecutive individuals with PD were examined. The Unified Parkinson's Disease Rating Scale (UPDRS) was employed to assess disease progression. Changes between initial and one-year follow-up UPDRS motor functioning (Part III) scores were compared to expected disease progression from prior research. In this cohort, thirty patients (69.8%) had improved, 2 were unchanged (4.7%) and 11 patients (25.6%) had worsened at the mean 12.2-month follow-up period. The range of multidisciplinary interventions included neurology (100%), physiatrist (93%), and psychology (41.9%) visits, medication changes (60.5%), rehabilitation therapy (62.8%), functional diagnostic testing (16.3%), support group (9.3%), home exercise programs (86%), and disease and wellness education (83.7%). Statistical analyses of the individual components of the program did not demonstrate significant differences between improvers and non-improvers. Clinical implications and study limitations are discussed.

Effect of splitting simvastatin tablets for control of low-density lipoprotein cholesterol.

The efficacy, safety, and economics of a voluntary conversion from whole simvastatin tablets to split tablets in 6 Veterans Affairs medical centers were retrospectively evaluated in 3,787 patients who received a consistent daily dose (5 to 40 mg) of simvastatin in 1999. Baseline and final low-density lipoprotein cholesterol levels and average change from baseline were not significantly different between groups (p >0.05), nor were the incidence of transaminase increases (p >0.05) or measurements of patient compliance (p = 0.07). Widespread implementation of this initiative resulted in a cost avoidance of >$1.2 million in the 6 medical centers and $10.3 million across the Veterans Affairs medical system in 1999, with >$46 million avoided in 2003.

Efficacy of multidisciplinary treatment program on long-term outcomes of individuals with Parkinson's disease.

We examined the impact of multidisciplinary clinical management of the Parkinson's Disease Research, Education, and Clinical Center program on Parkinson's disease progression. Initial and follow-up scores on the Part III Motor Examination subscale of the Unified Parkinson's Disease Rating Scale (UPDRS) were examined. Overall, 37 (75.5%) of the 49 patients demonstrated stable or improved UPDRS motor scores at 1- to 3-year follow-up; in the 1-year group (n = 28), 22 patients (78.6%) improved, while 6 (21.4%) worsened. In the 2-year group (n = 15), 10 (66.7%) improved, while 5 (33.3%) worsened. In the 3-year group (n = 6), 5 (83.3%) improved, while 1 (16.7%) worsened. Multidisciplinary interventions included neurology (95.9% of patients), physiatry (93.9%), nursing (87.8%), psychology (42.9%), medication changes (59.2% increases, 18.4% decreases), rehabilitation therapies (physical, occupational, speech-language, 67.3%), functional diagnostic testing (18.4%), support group (16.3%), home exercise instruction (85.7%), and disease and wellness education (81.6%). Improved and worsened patients did not significantly differ on the individual program components. Clinical implications and study limitations are discussed.