The Effect of Proton Pump Inhibitors on Glycemic Control in Patients with Type 2 Diabetes.

Background: Type 2 diabetes patients have decreased pancreatic beta cell mass with a decline in beta cell function. Gastrin has increased beta cell proliferation in vitro and in animal studies. High gastric acid levels inhibit gastrin secretion. Proton pump inhibitors (PPIs) lower gastric acid, subsequently increasing gastrin levels. This may stimulate beta cell proliferation and function, and improve glycemic control. Studies with small numbers of type 2 diabetes patients have shown a slightly lower A1C in those taking PPI versus non-PPI users. Methods: This study was a retrospective multicenter electronic data analysis using data obtained from health care facilities within Veterans Integrated Service Network (VISN) 21. Patients were included if they had established care within VISN 21 and had type 2 diabetes with an A1C > 6.5%, were started on a PPI concurrently with stable doses of metformin or sulfonylurea (SFU) monotherapy, had at least two documented A1C values, and had a medication possession ratio >80% for metformin, SFU, or a PPI. Veterans were excluded if they were using insulin, combination antihyperglycemic therapy, or oral corticosteroids. A control group not using PPI was also identified. Results: There was a statistically significant decrease in A1C within each group. However, there was no statistically significant difference between the PPI and control group in the post-A1C. Conclusion: In patients with type 2 diabetes, A1C improved in both groups, but PPI addition did not affect glycemic control. Future randomized controlled trials are needed to determine the value of PPIs as a treatment option for patients with type 2 diabetes.

Leveraging electronic medical record data for population health management in the Veterans Health Administration: Successes and lessons learned.

PURPOSE: The process and operational elements to establish a population health program using electronic medical record data in a Veterans Health Administration region are described. SUMMARY: Pharmacists are uniquely qualified to assume important roles in population health through the use of their clinical knowledge, assisted by electronic tools that consolidate and report patient-specific data for clinical care. Veterans Integrated Services Network (VISN) 21 has developed 300 dashboards and reports to improve the quality, safety, and value of healthcare to veterans. Within a group of specialty task forces, physicians, nurses, and pharmacists assist in the design and development of evidence-based tools to leverage timely electronic health information into metrics, benchmarks, and targets to assist with goal achievement. Examples of programs designed to improve care in 3 areas were selected for further description and review of outcomes. Population health improvement using Healthcare Effectiveness Data and Information Set and hepatitis C metrics were used to describe populations that may have an indication for evidence-based care but are not receiving it. Deprescribing efforts are described, as are medication safety monitoring efforts to prevent potential adverse events known to be associated with therapy. CONCLUSION: Quality, safety, and value outcomes are the measures of success for population health programs in VISN 21. Data-rich project dashboards and reports are developed by pharmacist data analysts and implemented and used by teams of clinicians who provide continuous feedback and support to improve population health. The use of task forces, metrics, benchmarks, targets, and teams is instrumental in the successful application of these tools.

El metabolismo de la glucosa en pacientes con hipertensión arterial / Glucose metabolism in hypertension patients

Thiazide diuretics (TD) are recommended as first-line therapy in uncomplicated hypertension by several professional organizations. However, they also may pose a risk of glucose metabolism abnormalities in certain individuals. Early studies showed TD cause a small increase in fasting glucose. These effects may be related to exacerbation of insulin resistance as insulin blood levels increased. It could be postulated that long-term use may result in a higher risk of developing diabetes. This was not seen in the Systolic Hypertension in the Elderly study which used low doses of chlorthalidone but an increase in the odds of developing diabetes was demonstrated for chlorthalidone in comparison to lisinopril or amlodipine in the ALLHAT study. Nonetheless, in ALLHAT there was no increased risk of adverse cardiovascular outcomes. In addition, use of chlorthalidone in the ALLHAT study in patients with pre-existing diabetes maintained the same advantage in lower stroke rate versus lisinopril and lower heart failure rate versus amlodipine or lisinopril. Other factors that may play a role in thiazide-induced glucose elevation are potassium levels and weight. In a meta-analysis of 59 trials a correlation existed for lower potassium levels and higher fasting glucose. pidemiological studies suggest that elevated BMI and the level of pre-thiazide fasting glucose predict glucose elevation and new onset diabetes after thiazide therapy. Patients with a BMI over 32.3 kg/m2 had a 6.5% risk of developing diabetes. Whether co-administration of a thiazide diuretic with other classes of antihypertensives modulates the glucose alteration remains unknown. Studies suggest combination with valsartan may reduce the effect perhaps by conserving potassium. Practical implications of these observations would suggest reserving thiazide diuretics to later stages in treatment for patients who are obese, particularly if they have fasting blood glucoses in the pre-diabetic range. However, for the majority of patients thiazide diuretics remain an excellent choice given their long track record of safety and beneficial long-term cardiovascular outcomes

Los diuréticos tiazídicos (DT) se recomiendan como tratamiento de primera línea para la hipertensión no complicada, por varias organizaciones profesionales. Sin embargo, también pueden suponer un riesgo de alteraciones del metabolismo de la glucosa en ciertos individuos. Los primeros estudios mostraron que los DT causan un pequeño aumento de la glucemia en ayunas. Estos efectos pueden estar relacionados con la exacerbación de la resistencia a la insulina y los niveles de insulina plasmáticos están incrementados. Se podría postular que el uso a largo plazo puede resultar en un mayor riesgo de presentar diabetes. Esto no se observó en el estudio Systolic Hypertension in the Elderly, realizado con adultos mayores que utilizaban bajas dosis de clortalidona; sin embargo, un aumento en las probabilidades de contraer diabetes fue demostrado por el uso de clortalidona en comparación con lisinopril y amlodipina en el estudio ALLHAT. No obstante, en el ALLHAT no hubo mayor riesgo de eventos cardiovasculares adversos. Además, el uso de clortalidona en el estudio ALLHAT en pacientes con diabetes preexistente mantuvo la misma ventaja en la baja tasa de accidentes cerebrovasculares, en comparación con lisinopril, y la menor tasa de paro cardíaco, en comparación con amlodipina o lisinopril. Otros factores que pueden desempeñar un papel en la elevación de la glucosa inducida por tiazidas son los niveles de potasio y el peso del paciente. En un metanálisis de 59 ensayos se encontró una correlación entre los niveles de potasio más bajos y los niveles más elevados de glucemia en ayunas. Los estudios epidemiológicos sugieren que el índice de masa corporal (IMC) elevado y el nivel de la glucemia previo al tratamiento con tiazidas pueden predecir la elevación de la glucosa y la diabetes de nueva aparición después de la terapia con tiazidas. Los pacientes con un IMC superior a 32.3 kg/m2 tenían un riesgo de 6.5% de presentar diabetes. Se desconoce aún si la administración de un diurético tiazídico con otras clases de antihipertensivos modula la alteración de la glucosa. Los estudios sugieren que la combinación con valsartán puede reducir el efecto, quizá mediante la conservación del potasio. Las repercusiones prácticas de estas observaciones sugieren reservar los diuréticos tiazídicos para etapas posteriores del tratamiento para los pacientes que son obesos, sobre todo si han presentado glucemia en ayunas en el rango de prediabetes. Sin embargo, para la mayoría de los pacientes, los diuréticos tiazídicos siguen siendo una excelente opción dado su largo historial de seguridad y los resultados cardiovasculares beneficiosos a largo plazo

Evaluating Vitamin D Repletion Regimens and Effects in Veteran Patients.

BACKGROUND: There are wide variations in recommended dosing for vitamin D repletion. The identification of specific dosing thresholds to optimize repletion of 25-hydroxyvitamin D3 (also known as 25(OH)D) may help narrow the wide spectrum of vitamin D dosing. OBJECTIVE: The primary objective of this study was to evaluate vitamin D treatment regimens and their dose response effect on vitamin D serum levels. Secondary outcomes include evaluation of the frequency of monitoring vitamin D serum levels and prescription adherence. METHODS: This was a multicenter, retrospective data extraction analysis conducted in patients who initiated monotherapy of ergocalciferol and cholecalciferol between January 1, 2005 and December 31, 2010. Following vitamin D therapy initiation, changes in laboratory values, frequency of laboratory monitoring, and prescription adherence were assessed. Ergocalciferol and cholecalciferol groups were separately organized into quartiles to identify dosing ranges that had the most impact on changes in 25(OH)D laboratory values. RESULTS: There were 2272 and 4140 monotherapy patients in the ergocalciferol and cholecalciferol groups, respectively. Cholecalciferol mean doses between 600 and 1100 IU had similar changes in 25(OH)D ranging from 8 to 9.1 ng/mL. Cholecalciferol mean doses of 2700 IU had 12.7 ng/mL 25(OH)D increase (P < 0.05). Ergocalciferol at mean doses of 11 000 IU had a 19.9 ng/mL increase of 25(OH)D (P < 0.05). At baseline 25(OH)D levels less than 15 ng/mL, 90% of subjects reached a therapeutic 25(OH)D level with a cumulative 300 000 IU cholecalciferol dose. Adherence, calculated by medication possession ratio, was greater with cholecalciferol than ergocalciferol (87% compared with 68%). CONCLUSIONS: Lower vitamin D dose ranges had a comparable effect on 25(OH)D change. Higher doses can produce higher levels, but the relationship is not linear.

Comparing fracture absolute risk assessment (FARA) tools: an osteoporosis clinical informatics tool to improve identification and care of men at high risk of first fracture.

BACKGROUND: Fracture absolute risk assessment (FARA) is recommended for guiding osteoporosis treatment decisions in males. The best strategy for applying FARA in the clinic setting is not known. OBJECTIVES: We compared 2 FARA tools for use with electronic health records (EHRs) to determine which would more accurately identify patients known to be high risk for fracture. Tools evaluated were an adaptation of the World Health Organization's Fracture Risk Assessment Tool used with electronic data (eFRAX) and the Veterans Affairs (VA)-based tool, VA-FARA. METHODS: We compared accuracies of VA-FARA and eFRAX for correctly classifying male veterans who fractured and who were seen in the VA's Sierra Pacific Network in 2002-2013. We then matched those cases to nonfracture controls to compare odds of fracture in patients classified as high risk by either tool. RESULTS: Among 8740 patients, the mean (SD) age was 67.0 (11.1) years. Based on risk factors present in the EHR, VA-FARA correctly classified 40.1% of fracture patients as high risk (33.0% and 34.6% for hip and any major fracture, respectively); eFRAX classified 17.4% correctly (17.4% for hip and 0.2% for any major fracture). Compared with non-high-risk patients, those classified as high risk by VA-FARA were 35% more likely to fracture (95% CI = 23%-47%; P < 0.01) compared with 17% for eFRAX (95% CI = 5%-32%; P < 0.01). CONCLUSIONS: VA-FARA is more predictive of first fracture than eFRAX using EHR data. Decision support tools based on VA-FARA may improve early identification and care of men at risk.

Comparative efficacy of ezetimibe/simvastatin, rosuvastatin, and atorvastatin in uncontrolled hyperlipidemia patients.

OBJECTIVE: Treatment of dyslipidemia in high-risk patients specifies a low-density lipoprotein (LDL) cholesterol <100 mg/dL. The efficacy of higher-potency regimens in clinical practice in patients who have not achieved their LDL goal on generic therapy is not well characterized. The primary objective of this study was to determine the LDL-lowering efficacy of higher-potency strategies (ezetimibe/simvastatin, rosuvastatin, and atorvastatin) in high-risk patients who were switched from simvastatin therapy. Secondary objectives were to evaluate patient adherence to these therapies, determine the efficacy of these interventions on other lipid parameters, and define the incidence of adverse effects. STUDY DESIGN: Retrospective data analysis derived from the Veterans Affairs Health Care System VISN 21 over a 3-year time period. METHODS: Lipid data were assessed prior to and within 2 to 6 months following the conversion from simvastatin. Adherence to therapy was determined by medication refill data. RESULTS: Treatment with ezetimibe/simvastatin resulted in significantly greater reductions in LDL compared with rosuvastatin or atorvastatin (37 vs 25 and 26 mg/dL, respectively; P <0.05). Adherence to therapy was 51% of all patients studied. All treatments significantly lowered total cholesterol, high-density lipoprotein, and triglycerides when compared with simvastatin. There was no difference between treatment groups in the number of adverse events. CONCLUSIONS: At the doses used in this population, ezetimibe/simvastatin resulted in greater LDL reductions than rosuvastatin or atorvastatin. The clinical impact of these differences is as yet undetermined.

Long-term maintenance of glucose control in veterans with type 2 diabetes mellitus using oral agents.

PURPOSE OF STUDY: The aim of this study was to evaluate long-term glycemic control in individuals with type 2 diabetes mellitus on oral hypoglycemic agents. METHODS: We identified the cohort of veterans prescribed hypoglycemic agents every year from July, 1992, through June, 2007 (n=191). Glycosylated hemoglobin (HbA1c) was used to assess glycemic control. Data are expressed as mean±standard deviation (SD); statistics are expressed by t-test and chi-squared. P<0.05 was considered significant. RESULTS: In the first year, 96 of the select group of 191 veterans identified above received oral agents only (OAO), 74 insulin only, and 21 both insulin and oral agents. Fifteen years later, 59 were OAO, 78 insulin only, and 54 both. Six patients receiving insulin in 1992-1993 were OAO-treated in 2006-2007. In the subgroup on OAO both at baseline and at the end (n=53), HbA1c decreased from 7.89±1.21 to 7.09±1.13 (P<0.001). These veterans were older at baseline (62.4±6.2) and leaner at the 15-year follow-up [body mass index (BMI) 28.1±4.9] than those who received insulin in 2006-2007 (n=43; age=57.9±9.6; BMI=32.3±7.9; P<0.05 and 0.005, respectively). Patients in the stable OAO group (n=53) were 74.0% Caucasian, compared to 51.2% in former-OAO [n=43; P<0.05 (chi-squared)]. CONCLUSIONS: Over half (n=53; 55%) of patients originally in the OAO group remained so 15 years later. These stable patients were in better glycemic control, both at baseline and follow-up, less obese, older, and more likely to be Caucasian, than those who eventually received insulin. Currently used oral agents often maintain, or even improve, glucose control, over 2 decades after diagnosis of diabetes mellitus.

Resistant hypertension and undiagnosed primary hyperaldosteronism detected by use of a computerized database.

A pharmacy database was used to identify patients with resistant hypertension who could then be tested for the presence of primary hyperaldosteronism. Inclusion criteria were: (1) resistant hypertension defined as uncontrolled hypertension and use of 3 antihypertensive medication classes or ≥ 4 antihypertensive classes regardless of blood pressure; (2) low or normal potassium levels (≤ 4.9 mEq/L); and (3) continuous health care from October 1, 2008, to February 28, 2009. Exclusion criteria were: (1) past or current use of an aldosterone antagonist, or (2) a medication possession ratio (adherence) <80% for any antihypertensive drug. Hyperaldosteronism was classified as an aldosterone/renin ratio (ARR) ≥ 30. Using the computer, 746 patients were identified who met criteria. After manual chart review to verify inclusion and exclusion criteria, 333 patients remained. Of 184 individuals in whom an ARR was obtained, 39 (21.2%) had a ratio of ≥ 30. A computer database is useful to identify patients with resistant hypertension and those who may have primary aldosteronism.

The effect of body mass index on fasting blood glucose and development of diabetes mellitus after initiation of extended-release niacin.

BACKGROUND: Niacin increases blood glucose, but whether the degree of increase is associated with increasing body mass index (BMI) is unknown. We evaluated the effect of extended-release niacin initiation on fasting plasma glucose (FPG) and the development of new-onset diabetes mellitus (DM) in relation to body mass index (kg/m(2)) in nondiabetic patients. METHODS: This retrospective observational study used data from six facilities within a geographical region of the Department of Veterans Affairs (VA). Patients included were 18 years of age or older and on a stable extended-release niacin dose (minimum 100 days) of at least 250 mg/day between January, 2001, and April, 2007. Patients were excluded if they were new to the VA, on corticosteroids or insulin, if medication adherence was <80%, or if they met criteria for DM. RESULTS: A total of 811 nondiabetic patients taking extended-release niacin initiation were studied. FPG after niacin initiation was stastically significantly correlated with increasing BMI (P < 0.001, R = 0.144 Pearson correlation coefficient). Factors independently associated with change in FPG using multiple linear regression were BMI (P = 0.043), baseline average glucose (P < 0.001), and baseline average triglycerides (P = 0.037). Of all patients started on niacin, 220 (27.1%) patients developed DM after niacin initiation. BMI, (P = 0.002) and baseline average glucose (P < 0.001) were independent predictors of the development of new-onset DM (logistic regression analysis). CONCLUSIONS: We found an association between increasing BMI and increasing FPG and diagnosis of new-onset DM after initiation of extended-release niacin initiation. This suggests that extended-release niacin may increase FPG into the diabetic range, especially for obese patients.

Computer confirmation of improved blood pressure control in diabetic patients.

In order to evaluate efforts to improve blood pressure (BP) control in veterans with diabetes, the authors performed a retrospective review of computerized health records in the Veterans Affairs Northern California Health Care System (VANCHCS). A total of 6624 diabetic patients with BP data were identified and a comparison was made to earlier surveys. There was an overall improvement in BP control. In a cohort of 1791 patients followed since 1999, there was a progressive improvement in both systolic BP (patients at goal increased from 28% to 35%; P<.001, chi(2)) and diastolic BP (patients at goal increased from 69% to 79%; P<.001). There was a corresponding increase in both number of drug classes used and use of antiangiotensin treatment. The authors conclude that the improvement in BP control in these veterans with diabetes was temporally associated with intensification in antihypertensive pharmacotherapy and sustained provider education and patient-specific computerized reminders.

Computer-based screening of veterans for metabolic syndrome.

BACKGROUND: The worldwide obesity epidemic has focused attention on the prevalence of the metabolic syndrome, which is greater than previously believed. However, estimates of its overall prevalence vary widely. We wished to ascertain the prevalence of metabolic syndrome in the Veteran Affairs Northern California Health Care System (VANCHCS). METHODS: We used the VA computerized clinical database and modified Adult Treatment Panel III (ATP III) criteria of fasting blood glucose (FBG) >or=110 mg/dL, blood pressure >or=130/>or=85, triglyceride >or=150 mg/dL, high-density lipoprotein cholesterol (HDL-C) <40 mg/dL (men) or <50 mg/dL (women), but body mass index (BMI) >or=30 in lieu of waist circumference >102 cm (40 inches) for men and 88 cm (35 inches) for women. We also accepted current pharmacotherapy for diabetes as qualifying for elevated fasting blood sugar (FBS); current therapy with niacin, gemfibrozil, or fenofibrate for elevated triglyceride concentrations; and recent use of multiple International Classification of Diseases, 9(th) Revision (ICD-9) codes for hypertension for elevated blood pressure. RESULTS: We examined all clinical records for veterans registered in VANCHCS who filled any prescription between July 1, 2004, and June 30, 2005 (n = 51,026). Their average age was 63 years; 93% were male. In all 25% (n = 13,010) were diagnosed as having metabolic syndrome by meeting at least 3 of the above 5 criteria. Because only 60% (n = 30,727) of the population had data for 3 or more criteria, the actual percent with metabolic syndrome is probably substantially higher. CONCLUSIONS: Over one quarter of veterans in the VANCHCS may have metabolic syndrome based on our modified ATP III criteria. We urge screening more veterans with fasting laboratory testing. Computerized screening of a large clinical database can provide an effective strategy to aid clinicians in identifying more patients at risk for cardiovascular disease.

Capacity of hospitals to partner with academia to meet experiential education requirements for pharmacy students.

PURPOSE: Current hospital and health-system participation in and the future capacity for experiential education for pharmacy students was investigated. METHODS: An online survey of ASHP members identified as U.S. pharmacy directors was conducted to assess their current and future involvement in partnering with colleges and schools to meet the experiential education requirements for doctor of pharmacy students and the current status of the student learning experiences. Questionnaire items examined the factors on which expanded involvement in experiential education would depend, the nature of support provided by colleges and schools, the types of experiences available for students, respondents' perceptions of factors influencing the quality of experiential education, the value of experiential education to the sites, respondents' challenges and concerns about experiential education, and respondents' current capacity and projections for introductory and advanced experiences through 2012. RESULTS: Data from 549 respondents were analyzed. Most respondents indicated that they had conducted advanced experiences for their 2007 graduates and anticipated that they would continue to do so. Among the top challenges identified regarding advanced experiences were concerns about time to serve and be trained as preceptors and a lack of standardization and coordination among colleges and schools. Hospitals forecasting their future capacity to accommodate students indicated that their projections were highly dependent on the number of pharmacists at their hospitals. Many respondents noted that their capacity projections were tied to their ability to expand clinical services at their hospitals. CONCLUSION: A survey of pharmacy directors suggested an ability of U.S. hospitals to conduct advanced experiential education opportunities for pharmacy students through 2012 and to expand introductory experiences.

The effect of body mass index on fasting blood glucose after initiation of thiazide therapy in hypertensive patients.

BACKGROUND: The prevalence of obesity, hypertension, and type 2 diabetes mellitus is increasing in the United States. In this setting, it is important to understand the effects of antihypertensives on glucose metabolism. We therefore examined the association between body mass index (BMI) (kg/m(2)) and fasting blood glucose (FBG) in subjects in whom thiazide antihypertensive therapy had been initiated. METHODS: A retrospective observational study was carried out on individuals with hypertension who had been started on thiazide therapy. The subjects' age, thiazide dose, BMI, serum potassium, FBG, new onset of diabetes mellitus, and concurrent use of other antihypertensives were included in the analysis. Predictors of change in FBG were analyzed using multiple linear regression analysis, while predictors of new-onset diabetes mellitus were determined using multiple logistic regression. RESULTS: A total of 2,624 individuals who had been started on thiazide therapy for hypertension were divided into quartiles of increasing BMI. FBG was found to be associated with baseline BMI and, after thiazide initiation, there was a step-wise increase in the magnitude of change in FBG with increasing BMI (P < 0.001 for both). Analysis using multiple linear regression found that BMI and baseline FBG predicted the magnitude of FBG change in subjects initiated on thiazide treatment (P < 0.001 for both). Analysis with logistic regression found that, after thiazide initiation, BMI, serum potassium baseline (P < 0.05 for both), and baseline FBG (P < 0.001) predicted the development of diabetes mellitus. CONCLUSIONS: There is an overall increase in FBG in individuals who are started on treatment with thiazides for hypertension. The magnitude of change in FBG and the development of new-onset diabetes mellitus after thiazide initiation were associated with increases in BMI and baseline FBG. American Journal of Hypertension (2008) doi:10.1038/ajh.2007.75American Journal of Hypertension (2008); 21 4. 438-442 doi:10.1038/ajh.2007.75.

Antihypertensive medication adherence in the Department of Veterans Affairs.

PURPOSE: Adherence measures the extent to which patients take medications as prescribed by their health care provider. The control of hypertension is dependent on medication adherence and may vary on the basis of antihypertensive medication class and other factors. METHODS: The Department of Veterans Affairs' automated pharmacy database captures pharmacy medication use; International Classification of Diseases, 9th Revision, diagnostic codes; and laboratory and patient demographic data on a monthly basis. Hypertensive patients who used thiazide diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel antagonists, and alpha-blockers from July 2002 to December 2003 were studied. The first date of prescription filling for each patient within the date range was the index date from which fill and refill dates were collected for up to 18 months to calculate medication possession ratios and days out of medication ratios. Patients were categorized as adherent if the medication possession ratio was 80% or greater. Logistic regression was used to study the association of medication class, age, gender, ethnicity, Veterans Affairs facility, and co-diagnosis with diabetes, schizophrenia/psychosis, depression, and dementia with medication adherence. RESULTS: We studied 40,492 hypertensive patients taking at least one antihypertensive drug class. The average age per class ranged from 67.4 to 72.9 years; 96% were male; and 51% were white, 8% were African-American, 4% were Asian-American, and 3% were Hispanic. Unadjusted adherence rates based on the medication possession ratio ranged from 78.3% for thiazide diuretics to 83.6% for angiotensin receptor blockers (P<.001). The number of medications (either total or antihypertensive) and age were independent predictors of better adherence. Black ethnicity and depression were associated with worse adherence. CONCLUSIONS: Adherence rates with all antihypertensive medications were high. Although there were statistical differences by drug class, these differences were small. Ethnicity and depression identified groups that might benefit from programs to improve adherence.

Antihypertensive medication use in the Department of Veterans Affairs: a national analysis of prescribing patterns from 2000 to 2002.

BACKGROUND: Studies describe differences between recommendations for hypertension treatment and actual drug use. Antihypertensive use data from the Department of Veterans Affairs (VA) for 1995 to 1999 showed a downward trend for calcium antagonist (CA) use and increased use of beta-blockers (BB) and thiazide diuretics (TD). This study evaluates national VA antihypertensive treatment for 2000 to 2002 and compares these data to treatment data for 1995 to 1999. METHODS: National VA pharmacy data were used to determine use of BB, TD, CA, angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and combinations of antihypertensive drugs for 2000 to 2002. Dispensing data were converted to treatment days. In addition to national trends, data were analyzed regionally to examine geographic differences. Pharmacoeconomic analysis estimated the financial impact of medication changes. RESULTS: Antihypertensive drug use in the VA represented more than 1 billion days in 2002. The ACEI were most commonly used, representing 33.4% and 33.5% of treatment days in 2000 and 2002, respectively. Changes from 2000 to 2002 were 21.9% to 24.2% for BB, 29.3% to 24.4% for CA, and 13.2% to 14.2% for TD. Use of ARB increased from 2.1% to 3.7% of treatment days. Analysis of the 21 VA regions showed geographic variation. For example, the proportion of BB treatment days is highest in a northeast VA region (28.6%) and lowest in a southeast region (19.9%). In 2002 the VA has saved an estimated US 8.5 million dollars because of changes in medication use. CONCLUSIONS: As a proportion of antihypertensive agent use, CA continues to fall in the VA, whereas BB, TD, and ARB use have increased. However, TD use remains low, despite national guidelines that promote use of this class of agent.

Academic detailing to improve antihypertensive prescribing patterns.

Several studies indicate that treatment of hypertension in the United States does not follow recommendations from expert bodies. We thus implemented a program using academic detailers to increase practitioner compliance with antihypertensive treatment guidelines. Five Veterans Affairs medical facilities including academic medical centers and community based outpatient clinics were chosen for the intervention. Pharmacists were trained as academic detailers, and the intervention included lectures, educational materials, provider profiling, and meetings with 25 to 50 providers each. After intervention, the proportion of hypertensives receiving calcium antagonists decreased from 43% to 38% (P <.001), whereas the proportion receiving a beta blocker or thiazide diuretic increased from 58% to 64% (P <.001). For hypertensive subjects with diabetes mellitus or congestive heart failure, the proportion receiving an angiotensin converting enzyme inhibitor or angiotensin receptor blocker increased from 72% to 76% for the former and from 74% to 78% for the latter (P <.001 for both). Among hypertensive subjects with coronary artery disease an increase in beta blocker use was noted after intervention (P <.001 for change from baseline). Prescribing patterns after academic detailing more closely followed national recommendations.

Clinical and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center.

Pharmacist recommendations and their clinical and economic outcomes in a Veterans Affairs (VA) medical center were studied. The first 600 pharmacist recommendations that met study criteria were evaluated for type and frequency, rate of acceptance by physicians, potential benefit or harm, and economic consequences. The study site included inpatient and outpatient settings and a skilled-nursing facility. The most frequent types of pharmacist recommendations involved adjusting the dosage or frequency of administration and discontinuing a drug that was not indicated for the patient's medical problem. The rate of acceptance of the recommendations was 92%. The recommendations led to improved clinical outcomes in over 30% of cases in each setting and no change in over 40% of cases in each setting. Evaluators determined that patient harm was avoided by the recommendations in 90% of cases; patient harm was caused in less than 1% of cases. The overall mean cost avoidance per recommendation was $700, and the mean total cost avoidance for all 600 recommendations was $420,155. Pharmacist recommendations improved clinical outcomes and saved money at a VA medical center.

Reduction in self-monitoring of blood glucose in persons with type 2 diabetes results in cost savings and no change in glycemic control.

OBJECTIVE: Recent Veterans Affairs (VA) guidelines recommend that persons with stable type 2 diabetes controlled on oral agents or diet therapy perform self-monitoring of blood glucose (SMBG) twice weekly. We assessed the impact of a modification of these guidelines on hemoglobin A1c (HbA1c) and monitoring cost. STUDY DESIGN: Retrospective, noncrossover clinical trial. PATIENTS AND METHODS: We instructed persons with type 2 diabetes to perform SMBG testing according to modified adapted VA guidelines. We compared patients' baseline average testing frequency and HbA1c with those obtained during a 6-month interval beginning 2 months after implementation of the modified guidelines. The impact on the cost of monitoring was calculated. RESULTS: At baseline, 913 of 1,213 SMBG users with diabetes on oral hypoglycemic agents had HbA1c tested (HbA1c = 7.83% +/- 1.34%); their frequency of SMBG was 1.36 +/- 0.95 strips per patient per day. Postimplementation, 974 of 1,278 persons with diabetes had HbA1c tested (HbA1c = 7.86% +/- 1.54%; P= .63 vs baseline); frequency of SMBG decreased by 46% to 0.74 +/- 0.50 strips per patient per day (P < .0001). At baseline, 154 of 254 SMBG users with diabetes on diet therapy had HbA1c tested (HbA1c = 6.85% +/- 0.97%); their frequency of SMBG was 1.07 +/- 0.90 strips per patient per day. Postimplementation, 177 of 282 diet-treated persons with diabetes had HbA1c tested (HbA1c = 6.78% +/- 1.20%; P = .56 vs baseline); frequency of SMBG decreased by 35% to 0.70 +/- 0.51 strips per patient per day (P < .0001). Similar findings were observed in a cohort of 421 drug-treated patients with paired HbA1c data before and after implementation, and a cohort of 50 diet-treated patients with paired HbA1c data. Linear regression analysis showed no significant impact on individuals' HbA1c with reduction in strip use. Average monthly cost savings were $8,800, or $6.37 per patient per month. CONCLUSIONS: This program decreased the frequency of SMBG in persons with type 2 diabetes, resulting in substantial cost savings without affecting glucose control.