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Introduction Home-based telebehavioural healthcare improves access to mental health care for patients restricted by travel burden. However, there is limited evidence assessing the economic value of home-based telebehavioural health care compared to in-person care. We sought to compare the economic impact of home-based telebehavioural health care and in-person care for depression among current and former US service members. Methods We performed trial-based cost-minimisation and cost-utility analyses to assess the economic impact of home-based telebehavioural health care versus in-person behavioural care for depression. Our analyses focused on the payer perspective (Department of Defense and Department of Veterans Affairs) at three months. We also performed a scenario analysis where all patients possessed video-conferencing technology that was approved by these agencies. The cost-utility analysis evaluated the impact of different depression categories on the incremental cost-effectiveness ratio. One-way and probabilistic sensitivity analyses were performed to test the robustness of the model assumptions. Results In the base case analysis the total direct cost of home-based telebehavioural health care was higher than in-person care (US$71,974 versus US$20,322). Assuming that patients possessed government-approved video-conferencing technology, home-based telebehavioural health care was less costly compared to in-person care (US$19,177 versus US$20,322). In one-way sensitivity analyses, the proportion of patients possessing personal computers was a major driver of direct costs. In the cost-utility analysis, home-based telebehavioural health care was dominant when patients possessed video-conferencing technology. Results from probabilistic sensitivity analyses did not differ substantially from base case results. Discussion Home-based telebehavioural health care is dependent on the cost of supplying video-conferencing technology to patients but offers the opportunity to increase access to care. Health-care policies centred on implementation of home-based telebehavioural health care should ensure that these technologies are able to be successfully deployed on patients' existing technology.

Background: Previous estimates of the economic burden of Crohn's disease (CD) varied widely from $2.0 to $18.2 billion per year (adjusted to 2015 $US). However, these estimates do not reflect recent changes in pharmaceutical treatment options and guidelines., Objective: The goal of this study was to update cost estimates of Crohn's disease based on a representative sample of the US population from the most recent 11 years (2003-2013) of the Medical Expenditure Panel Survey (MEPS). A secondary aim described expenditure trends in respondents with and without Crohn's disease pre-post FDA approvals of new biologics and the American College of Gastroenterology Crohn's disease treatment guidelines., Methods: Average annual expenditures (total, prescription, inpatient, and outpatient) were evaluated using a pooled cross-sectional design. Respondent data from the most recent 11 years (2003-2013) of MEPS were analyzed. Two-part generalized linear models with power-link were used to estimate the average annual expenditures per patient adjusted to multiple covariates. Confidence intervals (CI) were estimated using bootstrap methods. Difference-in-differences estimations were performed to compare the changes in health care expenditures pre-post FDA approvals of new biologics and the American College of Gastroenterology Crohn's disease treatment guidelines., Results: The annual aggregate economic burden of CD was $6.3 billion in the US. Respondents with CD had higher total (+$6442; 95% CI: $4864 to $8297), prescription (+$3283; 95% CI: $2289 to $4445), inpatient (+$1764; 95% CI: $748 to $3551), and outpatient (+$1191; 95% CI: $592 to $2160) expenditures compared to respondents without CD. In the difference-in-differences estimation, respondents with CD had significantly higher total (P = 0.001) and prescription (P < 0.001) expenditures compared with respondents without CD. Although inpatient and outpatient expenditures were higher in respondents with CD, they were not statistically significant., Conclusions: Respondents with CD diagnosis had higher expenditures compared to respondents without CD diagnosis from 2003 to 2013. This study captured the most recent availability of new treatment options and changes to treatment guidelines, while providing updated estimates of the economic burden of CD in the US. However, this research was unable to study the causes of these increased health care expenditures in respondents with CD. Future investigations will need to determine the causal factors for increased expenditures in CD., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: To prevent opioid-related mortality, the Veterans Health Administration (VHA) developed a national Opioid Overdose Education and Naloxone Distribution (OEND) program., Setting: VHA's OEND program sought national implementation of OEND across all medical facilities (n = 142)., Practice Description: This paper describes VHA's efforts to facilitate nationwide health care system-based OEND implementation, including the critical roles of VHA's national pharmacy services and academic detailing services., Practice Innovation: VHA is the first large health care system in the United States to implement OEND nationwide. Launching the national program required VHA to translate a primarily community-based public health approach to OEND into a health care system-based approach that distributed naloxone to patients with opioid use disorders as well as to patients prescribed opioid analgesics. Key innovations included developing steps to implement OEND, pharmacy developing standard naloxone rescue kits, adding those kits to the VHA National Formulary, centralizing kit distribution, developing clinical guidance for issuing naloxone kits, and supporting OEND as a focal campaign of academic detailing. Other innovations included the development of patient and provider education resources (e.g., brochures, videos, accredited training) and implementation and evaluation resources (e.g., technical assistance, clinical decision support tools)., Evaluation: Clinical decision support tools that leverage VHA national data are available to clinical staff with appropriate permissions. These tools allow staff and leaders to evaluate OEND implementation and provide actionable next steps to help them identify patients who could benefit from OEND., Results: Through fiscal year 2016, VHA dispensed 45,178 naloxone prescriptions written by 5693 prescribers to 39,328 patients who were primarily prescribed opioids or had opioid use disorder. As of February 2, 2016, there were 172 spontaneously reported opioid overdose reversals with the use of VHA naloxone prescriptions., Conclusion: VHA has successfully translated community-based OEND into health care system-based OEND targeting 2 patient populations. There is a tremendous amount that can be learned from VHA's experience implementing this novel health care innovation nationwide., (Published by Elsevier Inc.)

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.

Objectives: To evaluate the effects of the U.S. Veterans Health Administration (VA) National Academic Detailing Service alongside the Opioid Overdose Education and Naloxone Distribution (OEND) program on naloxone prescriptions prescribed from October 2014 to September 2016., Methods: A retrospective, repeated measures cohort study was conducted to evaluate the effectiveness of a real-world application of academic detailing (AD) alongside OEND on providers' outpatient naloxone prescribing from October 2014 to September 2016. Outcome was the number of naloxone prescriptions prescribed per month per provider. During the study period, VA providers were aware of OEND, but may not have been exposed to academic detailing. Therefore, providers were categorized as exposed when the first OEND-specific academic detailing session was provided during the study period. Generalized estimating equations were used to estimate the association between exposure to academic detailing and monthly naloxone prescriptions prescribed while taking into account the correlation within each provider. Incident rate ratios with 95% CIs were reported., Results: Seven hundred fifty (22.6%) of 3313 providers received at least 1 OEND-specific academic detailing visit. At 1 year, the average number of naloxone prescriptions per month was 3-times greater in AD-exposed providers compared with AD-unexposed providers (95% CI 2.0-5.3); and at 2 years, the average number of naloxone prescriptions was 7-times greater (95% CI 3.0-17.9). Moreover, the average difference in naloxone prescribing from baseline to 2 years was 7.1% greater in AD-exposed providers compared with AD-unexposed providers (95% CI 2.0%-12.5%)., Conclusions: This preliminary analysis provides the first evidence that academic detailing influenced naloxone prescribing rates in a large, integrated health care system at 1 and 2 years. In addition, AD-exposed providers had a higher average difference in naloxone prescribing rate compared with AD-unexposed providers after 2 years of follow-up., (Published by Elsevier Inc.)

Background: Anesthesia drugs can be prepared by anesthesia providers, hospital pharmacies or outsourcing facilities. The decision whether to outsource all or some anesthesia drugs is challenging since the costs associated with different anesthesia drug preparation methods remain poorly described., Methods: The costs associated with preparation of 8 commonly used anesthesia drugs were analyzed using a budget impact analysis for 4 different syringe preparation strategies: (1) all drugs prepared by anesthesiologist, (2) drugs prepared by anesthesiologist and hospital pharmacy, (3) drugs prepared by anesthesiologist and outsourcing facility, and (4) all drugs prepared by outsourcing facility., Main Results: A strategy combining anesthesiologist and hospital pharmacy prepared drugs was associated with the lowest estimated annual cost in the base-case budget impact analysis with an annual cost of $225 592, which was lower than other strategies by a margin of greater than $86 000., Conclusion: A combination of anesthesiologist and hospital pharmacy prepared drugs resulted in the lowest annual cost in the budget impact analysis. However, the cost of drugs prepared by an outsourcing facility maybe lower if the capital investment needed for the establishment and maintenance of the US Pharmacopeial Convention Chapter <797> compliant facility is included in the budget impact analysis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Increasing use of oral chemotherapy drugs increases the challenges for drug and patient management. An oral chemotherapy management clinic was developed to provide patients with oral chemotherapy management, concurrent medication (CM) education, and symptom management services. This evaluation aims to measure the need and effectiveness of this practice model due to scarce published data., Methods: This is a case series report of all patients referred to the oral chemotherapy management clinic. Data collected included patient demographics, depression scores, CMs, and types of intervention, including detection and management outcomes collected at baseline, 3-day, 7-day, and 3-month follow-ups. Persistence rate was monitored. Secondary analysis assessed potential cost avoidance., Results: A total of 86 evaluated patients (32 men and 54 women, mean age of 63.4 years) did not show a high risk for medication nonadherence. The 3 most common cancer diagnoses were rectal, pancreatic, and breast, with capecitabine most prescribed. Patients had an average of 13.7 CMs. A total of 125 interventions (detection and management of adverse drug event detection, compliance, drug interactions, medication error, and symptom management) occurred in 201 visits, with more than 75% of interventions occurring within the first 14 days. A persistence rate was observed in 78% of 41 evaluable patients. The total estimated annual cost avoidance per 1.0 full time employee (FTE) was $125,761.93., Conclusions: This evaluation demonstrated the need for additional support for patients receiving oral chemotherapy within standard of care medical service. A comprehensive oral chemotherapy management referral service can optimize patient care delivery via early interventions for adverse drug events, drug interactions, and medication errors up to 3 months after initiation of treatment., (Copyright © 2016 by the National Comprehensive Cancer Network.)

Background: The extant literature reveals a lack of psychometrically validated tools measuring patient satisfaction with pharmacist clinical services. The Patient Satisfaction with Pharmacist Services Questionnaire (PSPSQ 2.0) was developed to address this need using a mixed methods approach., Objective: To assess the psychometric properties of the PSPSQ 2.0, an instrument developed to measure patient satisfaction with clinical services provided by pharmacists., Methods: Validation studies were conducted in two Veterans Affairs (VA)-based and two community-based (diabetes and psychiatric care) disease management/medication therapy management clinics. The PSPSQ 2.0 consisted of 22-items related to three domains identified as quality of care, patient-pharmacist relationship and overall satisfaction using a 4-point, Likert-type scale. It was administered to participants following their session with a pharmacist at the clinics. Collected data were analyzed for descriptive statistics, internal consistency, and validity using exploratory factor analysis., Results: A total of 149 patients completed the survey. Patients from VA clinics were on average 61 years old, mostly white (63%), and predominantly male (95%). Patients from non-VA clinics were on average 47 years old, mostly White (47%) and male (53%). Non-VA patients mostly had Medicaid (42%) and commercial health insurance (31%), whereas VA patients retained benefits with the US Department of Veterans Affairs. Reliability of the scale using internal consistency metrics revealed a Cronbach's alpha of 0.98, 0.98 and 0.95 for VA, diabetes, and psychiatric care clinics, respectively, whereas the Cronbach's alpha for the pooled sample was 0.96. Factor analyses resulted in a three-factor solution accounting for 91% and 69% variance for diabetes and psychiatric care clinics, respectively; however, VA clinics and pooled sample yielded only 2-factor solution with 80% and 66% variance, respectively, with more items loading on patient-pharmacist relationship domain., Conclusions: The results suggest that the PSPSQ 2.0 can serve as a reliable and valid tool for measuring patient satisfaction with pharmacists providing clinical services in VA- and non-VA settings upon further validation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: The complete capture of all values for each variable of interest in pharmacy research studies remains aspirational. The absence of these possibly influential values is a common problem for pharmacist investigators. Failure to account for missing data may translate to biased study findings and conclusions. Our goal in this analysis was to apply validated statistical methods for missing data to a previously analyzed data set and compare results when missing data methods were implemented versus standard analytics that ignore missing data effects., Design: Using data from a retrospective cohort study, the statistical method of multiple imputation was used to provide regression-based estimates of the missing values to improve available data usable for study outcomes measurement. These findings were then contrasted with a complete-case analysis that restricted estimation to subjects in the cohort that had no missing values. Odds ratios were compared to assess differences in findings of the analyses. A nonadjusted regression analysis ("crude analysis") was also performed as a reference for potential bias., Setting: Veterans Integrated Systems Network that includes VA facilities in the Southern California and Nevada regions., Patients: New statin users between November 30, 2006, and December 2, 2007, with a diagnosis of dyslipidemia., Main Outcome Measure: We compared the odds ratios (ORs) and 95% confidence intervals (CIs) for the crude, complete-case, and multiple imputation analyses for the end points of a 25% or greater reduction in atherogenic lipids., Results: Data were missing for 21.5% of identified patients (1665 subjects of 7739). Regression model results were similar for the crude, complete-case, and multiple imputation analyses with overlap of 95% confidence limits at each end point. The crude, complete-case, and multiple imputation ORs (95% CIs) for a 25% or greater reduction in low-density lipoprotein cholesterol were 3.5 (95% CI 3.1-3.9), 4.3 (95% CI 3.8-4.9), and 4.1 (95% CI 3.7-4.6), respectively. The crude, complete-case, and multiple imputation ORs (95% CIs) for a 25% or greater reduction in non-high-density lipoprotein cholesterol were 3.5 (95% CI 3.1-3.9), 4.5 (95% CI 4.0-5.2), and 4.4 (95% CI 3.9-4.9), respectively. The crude, complete-case, and multiple imputation ORs (95% CIs) for 25% or greater reduction in TGs were 3.1 (95% CI 2.8-3.6), 4.0 (95% CI 3.5-4.6), and 4.1 (95% CI 3.6-4.6), respectively., Conclusion: The use of the multiple imputation method to account for missing data did not alter conclusions based on a complete-case analysis. Given the frequency of missing data in research using electronic health records and pharmacy claims data, multiple imputation may play an important role in the validation of study findings., (© 2015 Pharmacotherapy Publications, Inc.)

Objectives: To evaluate utilization of 90-day-supply prescriptions of aripiprazole., Study Design: One year (April 1, 2011, to March 31, 2012) retrospective cohort study from the Veterans Affairs San Diego Healthcare System., Methods: The primary outcome was to determine the difference in adherence for new starts versus continuing users on aripiprazole, as determined by medication possession ratio (MPR). Secondary outcomes included odds of adherence and refilling at least once associated with being a new start. Adherence was defined as MPR ≥ 0.8. Separate regression models (linear and logistic) were run for the entire population, as well as a subgroup analysis of 90-day prescription patients only., Results: A total of 749 patients, 328 of whom were new starts, were included in the analysis. Both new starts (41.2%) and continuing users (69.1%) had a large portion who received 90-day supplies. New-start patients had significantly lower MPR than continuing users (-0.13; 95% CI, -0.18 to -0.08). Logistic regressions showed that new starts also had lower odds of adherence (odds ratio [OR], 0.46; 95% CI, 0.33-0.65) and of refilling at least once (OR, 0.43; 95% CI, 0.28-0.66) compared with continuing users., Conclusions: Patients who were continuing users of aripiprazole were more likely to be adherent and refill their medication. Overutilization of 90-day supplies of high-cost agents, particularly in new starts, may lead to waste. It is recommended that patients newly started on high-cost agents should initially be provided a 30-day-supply prescription until it is established that effectiveness and tolerance have been achieved.

Purpose: To evaluate the effectiveness of the Pharmacist-Managed Telephone Tobacco Cessation Clinic (PMTTCC) compared to the standard of care (SOC) at the Veterans Affairs San Diego Healthcare System., Method: A retrospective cohort study was performed investigating the proportion of veterans who quit smoking at 6 months while enrolled in the PMTTCC. Chart review was performed using the Veterans Affairs Computerized Patient Record System. The PMTTCC group included patients who had received medication and counseling from the tobacco cessation pharmacists. The cohort was compared to a matched SOC group who did not receive counseling, only tobacco cessation medication therapy through a primary care provider. The primary outcome for this study was patient-reported tobacco cessation at 6 months. Secondary outcomes were abstinence at 1 and 3 months., Results: A total of 1,006 patients were included in the analysis, 503 patients from the PMTTCC and 503 patients from SOC. The overall study population was 54 years old on average, 92.5% male, 70.0% Caucasian, 45.5% with history of psychiatric conditions, and had an average smoking history of 33-pack years. Patients in the PMTTCC group had statistically significant improvements in abstinence at 6 months versus the SOC group (81/503, 16.1% vs. 48/503, 9.5%; p < .0001). Quitters were older on average versus non-quitters (56.03 vs. 53.65 years; p = .01)., Conclusion: Patients enrolled in the PMTTCC had improved tobacco abstinence rates at 6 months compared to SOC. Although the study was not designed to test for causality, the results lend support for using intensive tobacco cessation management in veteran population., (© 2013 Society for Public Health Education.)

Purpose: Improved outcomes achieved by an oral chemotherapy management (OCM) clinic, including a reduction in the need for medication-related interventions, are reported., Summary: A retrospective observational cohort study was conducted to assess the effectiveness of an OCM clinic providing comprehensive medication therapy management (MTM) services, including education on various oral chemotherapy agents, concurrent medications, and symptom management, as well as insurance assistance. Patient demographics, self-rated depression scores, and data on concurrent medication use, types of interventions, and intervention outcomes were collected at baseline and at follow-up visits for up to three months. Thirty clinic patients (9 men and 21 women with a mean age of 64.5 years) were evaluated; the majority had advanced-stage cancer and no live-in caregiver. On average, the patients had 2.8 comorbid conditions, including hypertension (43%), chronic pain (43%), and diabetes (37%), and were taking 12.7 concurrent medications (range, 3-26). In general, OCM clinic interventions in five categories (adverse events, adherence, drug interactions, medication errors, and symptom management) decreased during the measured time periods. About 70% of OCM clinic interventions were associated with positive outcomes (i.e., complete resolution of event or improved response to therapy), with 67% and 36% of interventions resulting in potential cost avoidance and cost savings, respectively. Rates of optimal oral chemotherapy adherence and persistence were estimated at 70%., Conclusion: An OCM clinic with comprehensive MTM services was effective in delivering early interventions, resulting in decreased rates of adverse effects, nonadherence, drug interactions, and medication errors over time., (Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Introduction. Anti-tumor necrosis factor (TNF) agents are effective for several immunologic conditions (rheumatoid arthritis (RA), Crohn's disease (CD), and psoriasis). The purpose of this study was to evaluate the efficacy and safety of anti-TNF agents via chart review. Methods. Single-site, retrospective cohort study that evaluated the efficacy and safety of anti-TNF agents in veterans initiated between 2010 and 2011. Primary aim evaluated response at 12 months post-index date. Secondary aims evaluated initial response prior to 12 months post-index date and infection events. Results. A majority of patients were prescribed anti-TNF agents for CD (27%) and RA (24%). Patients were initiated on etanercept (41%), adalimumab (40%), and infliximab (18%) between 2010 and 2011. No differences in patient demographics were reported. Response rates were high overall. Sixty-five percent of etanercept patients, 82% of adalimumab patients, and 59% of infliximab patients were either partial or full responders, respectively. Approximately 16%, 11%, and 12% of etanercept, adalimumab, and infliximab were non-responders, respectively. Infections between the groups were non-significant. Etanercept and adalimumab patients had higher but non-significant odds of being a responder relative to infliximab. Conclusions. Most patients initiated with anti-TNF agent were responders at 12 months follow-up for all indications in a veteran population.

Background: Statins remain a fundamental component of pharmacologic therapy for hyperlipidemia. Health benefits of statin therapy are jeopardized when adherence is reduced., Objectives: To (a) assess the association between copayment and copayment type on statin adherence using 2 different thresholds of adherence and (b) identify the incremental change in statin adherence associated with presence of copayment and copayment type., Methods: We executed a retrospective cohort study of new users of statins with dyslipidemia from the Veterans Health Administration (VHA) within the Veterans Integrated Service Network 22 who initiated a statin between November 30, 2006, and December 2, 2007. We used exposure categories of Any Copayment versus No Copayment, indicating a patient had a copayment or had no copayment in order to obtain medications, respectively. As a separate analysis, we varied the exposures to the standard VHA copayment categories: (a) Service-Connected (SC) Copayment (patients with service-related injury), (b) Non-Service-Connected (NSC) Copayment (patients without a service-related injury), and (c) No Copayment. Using each set of exposures, we conducted separate multiple logistic regression analyses using 2 different adherence outcomes based on medication possession ratio (MPR) threshold: (1) adherence defined as MPR ≥ 0.8 and (2) adherence defined as MPR ≥ 0.9. We then proceeded with multiple linear regression models to determine the incremental change in MPR associated with the 2 sets of exposures. Subjects were required to be enrolled in VHA services for at least 2 years prior to index date and throughout the 1-year study period., Results: A total of 4,886 subjects were identified for analysis based on the inclusion and exclusion criteria. Patients who did not pay a copayment for their statin medications were more likely to have adherence rates of ≥ 0.8 MPR and ≥ 0.9 MPR relative to the No Copayment Group with odds ratios (OR) of 1.19 (95% CI = 1.03-1.37) and 1.28 (95% CI = 1.11-1.48), respectively. The second analysis applied the VHA exposure categories of SC Copayment, NSC Copayment, and No Copayment. Using the 0.8 MPR or greater adherence threshold, the No Copayment group was associated with an increased likelihood of adherence versus the SC Copayment category as reference group with an OR of 1.31 (95% CI = 1.10-1.58). The NSC Copayment was associated with a nonsignificant increase in odds of adherence at the 0.8 MPR level or greater with OR of 1.12 (95% CI = 0.98-1.39). Using the 0.9 MPR level or greater, adherence threshold findings were similar. The No Copayment group produced an OR of 1.42 (95% CI = 1.17-1.71) compared with the SC Copayment group. The NSC Copayment group was associated with a nonsignificant increase in odds of adherence at the 0.9 MPR level or greater with an OR of 1.12 (95% CI = 0.97-1.38).The No Copayment group was associated with an increase in MPR of 0.02 (95% CI = 0.002-0.035) versus the Any Copayment category. Using the VHA copayment categories, we observed an increase in MPR for the No Copayment group versus the SC Copayment group of 0.03 (95% CI = 0.01-0.05). The NSC Copayment group was associated with a nonsignificant increase in MPR versus the SC Copayment group of 0.02 (95% CI = -0.003-0.036)., Conclusions: Patients without out-of-pocket payments for their statins were more likely to adhere to therapy. Patients who pay a copayment for their statin medications were also compared with each other based on whether they (a) received any of their nonstatin prescriptions without a copayment or (b) paid a copayment on all of their prescriptions including statins. Our findings suggest that, among those that pay for their statins, patients are less adherent to their statins if other medications they are prescribed are copayment free. Thus, patient consumption behavior may be influenced by the relative cost of medications in patient prescription lists. Additional counseling on the necessity of adherence should be given to patients paying a copayment for their statin prescriptions.

Background: There is a growing body of evidence supporting means testing out of copayment for high-value therapies such as statins., Objective: To investigate association between statin adherence and copayment when stratified by socioeconomic status., Methods: This was a retrospective cohort study set in a network of VA facilities that includes Southern California and Nevada, with an enrollment of 1.4 million veterans. Socioeconomic status was estimated using zip code median household income. Differences in medication possession ratio (MPR) associated with copayment was the primary outcome measure. Odds of attaining low-density lipoprotein cholesterol (LDL) <100 mg/dL was the secondary outcome measure. Separate regression models for each income quintile were performed for each outcome measure, respectively., Results: A total of 4748 patients were included in the analysis. Patients in quintiles two (-0.057, 95% confidence interval [CI] = -0.095 to -0.020) and three (-0.044, CI = -0.081 to -0.007) had statistically significant decreases in MPR associated with having a copayment versus not having a copayment. Quintiles two (odds ratio [OR] = 0.68; 95% CI = 0.47 to 0.98) and three (OR = 0.66; 95% CI = 0.45 to 0.96) also had lower odds of attaining LDL <100 mg/dL when having a copayment. Patients in higher earning quintiles (four and five) did not show any associations with copayment., Conclusion: In the veteran population studied, the association of statin copayment status with adherence varied by socioeconomic status. Middle-income and lower-middle-income patients were more likely to have adherence negatively influenced by having a copayment for statin therapy.

Study Objective: To investigate the association between statin adherence and changes in lipid panel outcomes from baseline in a veteran population., Design: Retrospective cohort study using multiple linear regression models., Setting: Veterans Affairs health care system within the Veterans Integrated Service Network 22, a network of Veterans Affairs facilities in the southwest region of the United States that includes Los Angeles, San Diego, Loma Linda, and Long Beach, California, and Las Vegas, Nevada, with an enrollment of approximately 1.4 million veterans., Patients: A total of 5365 patients who were new statin users between December 1, 2006, and November 30, 2007; 2674 patients were in the adherent group and 2691 were in the nonadherent group., Measurements and Main Results: Adherence was determined by the medication possession ratio. Patients were categorized as adherent if the medication possession ratio at follow-up was 0.80 or more. Adherent patients exhibited significant differences in baseline demographic and clinical characteristics than nonadherent patients in our study sample. Baseline laboratory values for adherent patients were significantly lower for low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), non-high-density lipoprotein cholesterol (non-HDL), and total cholesterol levels. The primary outcome was change in LDL level from baseline at 12 months. Secondary outcomes were changes in non-HDL and total cholesterol levels from baseline at 12 months. Independent variables controlled for in the multiple linear regression included age, sex, body mass index, race-ethnicity, baseline lipid panel (LDL, HDL, total cholesterol, and triglycerides), statin copayment status, income quintile (according to ZIP code median household income), baseline medication count, statin prescribed, and comorbidities. Multiple linear regression revealed that adherent patients demonstrated significantly greater reductions in LDL of 20.98 mg/dl versus nonadherent patients (p<0.0001). Adherent patients similarly demonstrated larger reductions of 24.31 mg/dl in non-HDL and 24.06 mg/dl in total cholesterol versus nonadherent patients (p<0.0001 for both comparisons)., Conclusion: Patients adherent to statin therapy had significant associations with clinically relevant reductions in LDL, non-HDL, and total cholesterol from baseline at 12 months compared with nonadherent patients when controlling for potential confounders. Adherence to statin therapy may have important consequences in decreasing clinical outcomes such as myocardial infarctions, strokes, and mortality due to large reductions in lipid panel outcomes from baseline at 12 months., (© 2013 Pharmacotherapy Publications, Inc.)

Background: The relationship between multiple medication consumption and medication adherence is not well understood., Objective: To determine the association between the number of active medications on the patient medication profile at baseline and adherence in new users of statins., Methods: This was a retrospective cohort study of new users of statin medications from the Veterans Health Administration. We explored the correlation between the number of baseline medications and adherence, grouping patients by number of active medications on the study index date via Cochran-Armitage trend test and multiple linear regression. The adherence metric calculated for each patient was the medication possession ratio (MPR). Adherence was defined as achieving a 0.8 MPR or greater in primary analysis and a 0.9 MPR or greater in the secondary analysis., Results: There was a statistically significant trend of increasing proportion of adherent participants as baseline medication count grew (P value < .001). The regression further demonstrated that statin MPR was increased by 0.04, 0.07, 0.10, and 0.14 for the 6 to 10 medication count, 11 to 15 medication count, 16 to 20 medication count, and >20 medication count groups, respectively, in comparison with the reference 1 to 5 medication count group (P < .001 for all comparisons). An MPR threshold of 0.9 provided consistent evidence of improved adherence as number of medications increased (P < .001)., Conclusions: Increased medication count at baseline was associated with improved adherence for new users of statins.

Objective: We sought to evaluate the relationship between different levels of medication possession ratio (MPR) attained and achievement of clinically meaningful reductions in lipid levels., Research Design and Methods: This was a retrospective cohort study of 4691 new statin users from the Department of Veteran Affairs (VA). Subjects were required to be eligible for VA medical and pharmacy services throughout the 1 year study period from index date and to have complete data for exposure, outcome, and adjustment variables. MPR was defined as number of days supplied with prescription medication divided by days of observation., Main Outcome Measures: Achieving 25% or greater reduction from baseline in lipid levels for three lipid outcomes: non-high-density lipoprotein (non-HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and total cholesterol (TC)., Results: We observed a statistically significant trend of an increasing proportion of study subjects achieving a 25% reduction or more for all three lipid outcomes (p-values <0.001 for each of the three outcomes using the Cochran-Armitage trend test). Using multiple logistic regression, odds ratios (ORs) for each of the three outcomes were at a maximum for the 0.9-1.0 MPR category with ORs of 12.90 (95% confidence interval (CI), 9.60, 17.35) for the non-HDL cholesterol outcome; 11.29 (95% CI, 8.61, 14.80) for the LDL cholesterol outcome; and 9.11 (95% CI, 6.62, 12.53) for the TC outcome. Direct comparison of the 0.9-1.0 MPR category versus the 0.8-0.89 MPR category demonstrated an increase in odds of achieving 25% or more reduction for all three lipid outcomes., Conclusions: We conclude that significant improvements in outcomes are achieved with higher MPR thresholds than commonly targeted. The authors propose consideration of an MPR-adherence threshold of 0.9 MPR. Limitations include the possible modification of study findings in non-VA settings. MPR is a secondary adherence measure based on refill frequency.

Linezolid is a novel oxazolidinone antibacterial agent with a broad clinical application, especially in methicillin-resistant Staphylococcus aureus skin and soft-tissue infections and skin and skin-structure infections. Pharmacoeconomic advantages include decreased hospital duration, reduction in intravenous antibiotic use and early discharge opportunities that contribute to an overall reduction in healthcare resources. Linezolid's oral formulation has a pharmacokinetic profile that is similar to its intravenous formulation, which creates opportunities for early discharge not available to comparators like vancomycin and daptomycin. Both vancomycin and daptomycin require intravenous therapy, which compounds the resources required in treating methicillin-resistant S. aureus skin and soft tissue/skin and skin structure infections. Pharmacoeconomic studies have demonstrated an overall reduction in total direct costs to the payer in favor of linezolid over its comparators. Its overall reduction in healthcare utilization makes it an appropriate alternative to the standard therapy, vancomycin.

A retrospective cohort study (1.5 years) was performed to investigate the efficacy of celecoxib vs non-celecoxib use in patient who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study time frame encompassed a pre and post period of a local policy decision opening access to short-term celecoxib use after TKA/THA. Primary end point was the amount of opioid use during their inpatient stay postprocedure. The TKA (n = 81) and THA (n = 60) groups were analyzed independently. Both celecoxib groups used significantly less opioids during their inpatient stay vs noncelecoxib groups, given in oral morphine milligram equivalents (TKA: 203 vs 337 mg, P = .002; THA: 214 vs 336 mg, P = .005). Other secondary outcome measures showed that the celecoxib groups also reported reduction in pain scores, total as needed (PRN) opioid doses, PRN opioid doses per day, average dose of PRN opioids, total PRN opioids, use of intravenous opioids, and rehabilitation facility admissions (in the TKA group only). Linear regression analysis showed a statistically significant inverse relationship between opioid consumption and age. Short-term celecoxib use after TKA/THA may lead to a reduction in overall opioid use and improved pain scores; however, further studies will be required to validate the results of this study., (Published by Elsevier Inc.)

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., (© 2010 Blackwell Publishing Ltd.)

Background: Methicillin-resistant Staphylococcus aureus (MRSA) complicated skin and skin structure infection (cSSSI) is a prominent infection encountered in hospital and outpatient settings that is associated with high resource use for the health-care system., Objective: A decision analytic (DA) model was developed to evaluate the cost-effectiveness analysis (CEA) of linezolid, daptomycin, and vancomycin in MRSA cSSSI., Methods: Bayesian methods for evidence synthesis were used to generate efficacy and safety parameters for a DA model using published clinical trials. CEA was done from the US health-care perspective. Efficacy was defined as a successfully treated patient at the test of cure without any adverse reaction. Primary outcome was the incremental cost-effectiveness ratio between linezolid and vancomycin, daptomycin and vancomycin, and linezolid and daptomycin in MRSA cSSSI. Univariate and probabilistic sensitivity analyses were performed to test the robustness of the model., Results: The total direct costs of linezolid, daptomycin, and vancomycin were $18,057, $20,698, and $23,671, respectively. The cost-effectiveness ratios for linezolid, daptomycin, and vancomycin were $37,604, $44,086, and $52,663 per successfully treated patient, respectively. Linezolid and daptomycin were dominant strategies compared to vancomycin. However, linezolid was dominant when compared to daptomycin. The model was sensitive to the duration of daptomycin and linezolid treatment., Conclusion: Linezolid and daptomycin are potentially cost-effective based on the assumptions of the DA model; however, linezolid appears to be more cost-effective compared to daptomycin and vancomycin for MRSA cSSSIs., (Copyright © 2011 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Objective: To describe the development and assessment of monographs as an assignment to incorporate evidence-based medicine (EBM) and pharmacoeconomic principles into a third-year pharmacoeconomic course., Design: Eight newly FDA-approved drugs were assigned to 16 teams of students, where each drug was assigned to 2 teams. Teams had to research their drug, write a professional monograph, deliver an oral presentation, and answer questions posed by faculty judges. One team was asked to present evidence for inclusion of the drug into a formulary, while another team presented evidence against inclusion., Assessment: The teams' average score on the written report was 99.1%; on the oral presentation, 92.5%, and on the online quiz given at the end of the presentations, 77%., Conclusions: Monographs are a successful method of incorporating and integrating learning across different concepts, as well as increasing relevance of pharmacoeconomics in the PharmD curriculum.

Objective: The aim was to measure patient satisfaction with the Pharmacy Specialty Immunization Clinic (PSIC), a pharmacist-run vaccination clinic., Methods: Patient satisfaction was measured using a non-validated instrument containing 10 items with a five-point Likert scale (strongly agree, agree, not sure, disagree and strongly disagree). Patients who were seen at the PSIC and who received at least one vaccination were eligible to take part in the patient satisfaction survey. Priority index, a method used to identify areas where limited resources can be used to maximize patient satisfaction, was calculated for the different items of the instrument to determine areas for quality improvement. This study was conducted at the Veterans Affairs San Diego Healthcare System (VASDHS)., Key Findings: A total of 188 (55.1%) out of 341 patients who received at least one vaccine in the PSIC completed the survey. Prior to any encounter with the PSIC, patients perceived that the VASDHS was doing a good job providing vaccinations (92.5% answered agree or strongly agree). This perception continued when asked about overall satisfaction after receiving vaccination through the PSIC (86.9% answered agree or strongly agree). When asked about the time the pharmacist spent with the patient, nearly all answered that the pharmacist spent as much time as necessary (97.8% answered agree or strongly agree). Patient satisfaction with pharmacist counselling was equally well received and reflected good communication between patient and pharmacist (97.8% answered agree or strongly agree). In regard to pharmacist competency, 98.9% (n = 184) of patients agreed that pharmacists in the PSIC administered vaccinations appropriately. Priority index identified access to the vaccine as an area where performance-improvement efforts should be committed to improve patient satisfaction., Conclusions: Patients perceived good overall satisfaction with the pharmacist-run immunization clinic in terms of professionalism and access to vaccination. Priority index identified access to vaccination as a focus for future quality improvement.

Objective: There has been growing interest in newer anti-epileptic drugs (AEDs) for seizure prophylaxis in the intensive care setting because of safety and monitoring issues associated with conventional AEDs like phenytoin. This analysis assessed the cost-effectiveness of levetiracetam versus phenytoin for early onset seizure prophylaxis after neurosurgery and traumatic brain injury (TBI)., Methods: A cost-effectiveness analysis was conducted from the US hospital perspective using a decision analysis model. Probabilities of the model were taken from three studies comparing levetiracetam and phenytoin in post neurosurgery or TBI patients. The outcome measure was successful seizure prophylaxis regimen (SSPR) within 7 days, which was defined as patients who did not seize or require discontinuation of the AED due to adverse drug reactions (ADRs). One-way sensitivity analyses and probabilistic sensitivity analysis were conducted to test robustness of the base-case results., Results: The total direct costs for seizure prophylaxis were $8,784.63 and $8,743.78 for levetiracetam and phenytoin, respectively. The cost-effectiveness ratio of levetiracetam was $10,044.91 per SSPR compared to $11,525.63 per SSPR with phenytoin. The effectiveness probability (patients with no seizures and no ADR requiring change in therapy) was higher in the levetiracetam group (87.5%) versus the phenytoin group (75.9%). The incremental cost effectiveness ratio for levetiracetam versus phenytoin was $360.82 per additional SSPR gained., Conclusions: Levetiracetam has the potential to be more cost-effective than phenytoin for early onset seizure prophylaxis after neurosurgery if the payer's willingness-to-pay is greater than $360.82 per additional SSPR gained.

Purpose: The implementation of a comprehensive, 24-hour emergency department pharmacy program (EDPP) is described., Summary: An EDPP was created at the Veterans Affairs San Diego Healthcare System to address deficiencies identified by the pharmacy service within the ED, including medication tracking, documentation of doses administered, and formulary management. The documentation system used in the EDPP, including a computerized spreadsheet and documentation cards, allowed the activities of the ED pharmacists to be tracked on a 24-hour basis. This type of data collection allowed us to evaluate the impact of the program based on the quality of patient care delivered as well as cost. During the initial six-month implementation period, the ED pharmacists recorded 9,568 interventions. The information from these interventions was used to assess the safety components and to estimate the cost avoidance of their activities. A staff satisfaction survey was also created to assess the pharmacist's impact on providers and nurses, as well as its effect on workflow within the ED. Among the many benefits realized, the EDPP improved the quality of patient care, decreased medication errors and patient wait times, improved the medication reconciliation process, enhanced formulary management, ensured prospective medication order review, and increased overall patient safety, as evidenced by the documented interventions and staff satisfaction survey. The projected cost savings for the medical center during the first year of EDPP implementation was calculated as $1,691,185., Conclusion: A tertiary care teaching hospital successfully implemented a 24-hour, comprehensive ED pharmacy service that enhanced the efficiency and delivery of patient care and resulted in significant cost savings.

Objective: To examine patient and provider perspectives about the impact of having diabetes, hypertension and/or dyslipidemia (DHD) on health-related quality of life (HRQL) in order to identify domains for an HRQL instrument focusing on specific chronic diseases (DHD)., Study Design: Exploratory qualitative design was used to elicit patient and provider responses. Patient survey contained 11 demographic and nine content questions inquiring how the disease(s) affected patient HRQL. Provider survey examined how the disease(s) affected their patient's HRQL and crucial factors for improvement. Patients were included if they had DHD and spoke English. Providers working with DHD patients were identified among university faculty and community practitioners., Results: Thirty-eight patients (24.7%) completed the interviews. Three judges content analysed patient responses and proposed seven categories (patients ranked physical functioning first followed by diet, emotional well-being (E), general well-being, social functioning (S), 'no change in HRQL' and medications). One question about medications had four categories (medication inconvenience, medication side effects, forgetfulness and general well-being). Index for reliability was greater than 80% for all categories. Providers ranked lifestyle modification (LM), first followed by complications, medication, self-care, E, education, S, physical activity and resources (ability to pay) as components that impact HRQL., Conclusions: Patient and provider perspectives were similar in four areas (E, S, medication and diet); however, the differences were in how these impacted HRQL - patients focused on activities relevant to daily life that were affected, while providers based it on processes of therapy management and self-care (education and implementation of LM).

Purpose: To evaluate the cost-effectiveness of three antipsychotic medications (olanzapine, risperidone and haloperidol) in the treatment of schizophrenia using the Positive and Negative Symptom Scale., Study Design and Methods: A decision analysis model was created to evaluate the cost-effectiveness of two atypical antipsychotics (risperidone and olanzapine) and haloperidol. Outcome probabilities were determined from published clinical trials. The main dependent variable of interest was to compare the incremental cost-effectiveness ratios (ICER) of the atypical antipsychotic with haloperidol, and also to compare the ICER of olanzapine and risperidone. Sensitivity analyses were conducted for olanzapine and risperidone to determine the effects of altering drug cost, efficacy and re-hospitalization rate on total costs., Results: Risperidone and olanzapine were dominant strategies compared with haloperidol (less costly and more effective). Risperidone was also dominant when compared with olanzapine. A one-way sensitivity analysis for efficacy indicated that the efficacy of risperidone would need to decrease by approximately 3% from the base-case in order for olanzapine and risperidone to have equal total costs. In a two-way sensitivity analysis varying both the cost of olanzapine and risperidone, the difference in drug costs between them would have to increase from $2.12 per day to $4.12 per day in order to have equal total costs. In terms of varying re-hospitalization rates, the re-hospitalization rate for risperidone would have to increase from 3% to 33% greater than the re-hospitalization rate for olanzapine in order to have equal total direct costs., Conclusion: Based on this decision model, atypical antipsychotics were a dominant strategy over haloperidol primarily because of increased efficacy and lower re-hospitalizations. The ICER indicated that risperidone was dominant over olanzapine because of lower drug costs and increased number of responders, which leads to decreased total costs.