Publications

de Boer and colleagues present a cost-effectiveness analysis based in the Netherlands of two vaccines available for the prevention of herpes zoster. Zostavax® was the first vaccine available for the prevention of herpes zoster in older adults. A live-attenuated vaccine, Zostavax is not free of limitations, which include a relatively low efficacy that wanes over time and its contraindication among immunocompromised individuals. The recently available adjuvanted herpes zoster subunit vaccine Shingrix® overcomes some of these limitations. The herpes zoster subunit vaccine is more efficacious than Zostavax, and it can be administered to immunosuppressed individuals. However, the herpes zoster subunit vaccine is considerably costlier and requires a booster injection. In order to clarify the value of each vaccine, de Boer and colleagues compare the cost-effectiveness of no vaccination, and of vaccination with Zostavax or the herpes zoster subunit vaccine in four cohorts of older adults from the perspective of the Netherlands. Whereas neither vaccine was cost-effective under the willingness-to-pay threshold of €20,000 per quality-adjusted life year, the authors find the herpes zoster subunit vaccine to be cost-effective in some scenarios under a €50,000 per quality-adjusted life year threshold.Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1213-5.

OBJECTIVE: To evaluate the effect of dual use of VA/Medicare Part D drug benefits on antihypertensive medication supply in older Veterans with dementia.

DATA SOURCES/STUDY SETTING: National, linked 2007-2010 Veterans Affairs (VA) and Medicare utilization and prescription records for 50,763 dementia patients with hypertension.

STUDY DESIGN: We used inverse probability of treatment (IPT)-weighted multinomial logistic regression to examine the association of dual prescription use with undersupply and oversupply of antihypertensives.

DATA COLLECTION/EXTRACTION METHODS: Veterans Affairs and Part D prescription records were used to classify patients as VA-only, Part D-only, or dual VA/Part D users of antihypertensives and summarize their antihypertensive medication supply in 2010: (1) appropriate supply of all prescribed antihypertensive classes, (2) undersupply of ≥1 class with no oversupply of another class, (3) oversupply of ≥1 class with no undersupply, or (4) both undersupply and oversupply.

PRINCIPAL FINDINGS: Dual prescription users were more likely than VA-only users to have undersupply only (aOR = 1.28; 95 percent CI = 1.18-1.39), oversupply only (aOR = 2.38; 95 percent CI = 2.15-2.64), and concurrent under- and oversupply (aOR = 2.89; 95 percent CI = 2.53-3.29), versus appropriate supply of all classes.

CONCLUSIONS: Obtaining antihypertensives through both VA and Part D was associated with increased antihypertensive under- and oversupply. Efforts to understand how best to coordinate dual-system prescription use are critically needed.

[This corrects the article DOI: 10.1371/journal.pone.0158017.].

OBJECTIVES: To describe the prevalence and incidence of opioid and nonsteroidal anti-inflammatory drug (NSAID) use before and since the start of the Veterans Health Administration (VHA) Opioid Safety Initiative (OSI) and to assess rates of adverse events (AEs).

STUDY DESIGN: Historical cohort study.

METHODS: The OSI began in August 2012 and was fully implemented by the end of fiscal year (FY) 2013. The study timeframe was categorized into baseline (FY 2011-2012), transition (FY 2013), and postimplementation (FY 2014-2015) phases. Prevalence and incidence rates were calculated for opioid and NSAID users by quarter between FY 2011 and FY 2015. For AEs among new users of an NSAID or opioid, Cox proportional hazards models with inverse probability weighting were used to adjust for potential confounding.

RESULTS: There were 3,315,846 regular users of VHA care with at least 1 opioid and/or NSAID outpatient prescription between FYs 2011 and 2015. The quarterly opioid prevalence rate was approximately 21% during the baseline and transition phases, then decreased to 17.3% in the postimplementation phase. NSAID prevalence remained constant at about 16%. Opioid incidence rates gradually decreased (2.7% to 2.2%) during the study, whereas NSAID incidence rates remained about 2.2%. After inverse probability weighting, patients receiving opioids had a greater risk of cardiovascular events (hazard ratio [HR], 1.41; 95% CI, 1.36-1.47), acute kidney injury (HR, 2.60; 95% CI, 2.51-2.68), gastrointestinal bleeding (HR, 1.68; 95% CI, 1.56-1.81), and all-cause mortality (HR, 3.73; 95% CI, 3.60-3.87) than NSAID users.

CONCLUSIONS: Opioid use declined following implementation of the OSI, whereas NSAID use remained constant. Rates of AEs were higher among opioid users, which provides additional rationale for efforts to use NSAIDs for pain management when appropriate.

RATIONALE AND OBJECTIVES: One way to understand medical overuse at the clinician level is in terms of clinical decision-making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision-making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De-implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition.

RESULTS: We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as "the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines." We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience "reactance," ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together.

CONCLUSIONS: By taking into account the dual process model of cognition, we may be able to design de-implementation strategies matched to clinicians' decision-making processes and avoid unintended consequence.

OBJECTIVES: To estimate the prevalence and consequences of receiving prescription opioids from both the Department of Veterans Affairs (VA) and Medicare Part D.

METHODS: Among US veterans enrolled in both VA and Part D filling 1 or more opioid prescriptions in 2012 (n = 539 473), we calculated 3 opioid safety measures using morphine milligram equivalents (MME): (1) proportion receiving greater than 100 MME for 1 or more days, (2) mean days receiving greater than 100 MME, and (3) proportion receiving greater than 120 MME for 90 consecutive days. We compared these measures by opioid source.

RESULTS: Overall, 135 643 (25.1%) veterans received opioids from VA only, 332 630 (61.7%) from Part D only, and 71 200 (13.2%) from both. The dual-use group was more likely than the VA-only group to receive greater than 100 MME for 1 or more days (34.3% vs 10.9%; adjusted risk ratio [ARR] = 3.0; 95% confidence interval [CI] = 2.9, 3.1), have more days with greater than 100 MME (42.5 vs 16.9 days; adjusted difference = 16.4 days; 95% CI = 15.7, 17.2), and to receive greater than 120 MME for 90 consecutive days (7.8% vs 3.1%; ARR = 2.2; 95% CI = 2.1, 2.3).

CONCLUSIONS: Among veterans dually enrolled in VA and Medicare Part D, dual use of opioids was associated with more than 2 to 3 times the risk of high-dose opioid exposure.

BACKGROUND: Clinical Laboratory Improvement Amendments (CLIA)-waived tests allow for quick, accurate, and noninvasive laboratory testing. Community pharmacists utilize CLIA-waived tests to provide clinical services such as point-of-care (POC) testing to help manage chronic disease and acute illness.

OBJECTIVE: To identify key themes in the successful delivery of POC testing services by community pharmacists in Pennsylvania.

RESULTS: An initial search identified 51 Pennsylvania pharmacies with a CLIA waiver. Of these, five independent pharmacies met inclusion criteria, three of which completed interviews. The remaining 38 chain pharmacies were represented by three interviews. In total, five key themes were identified as essential to POC testing services: (1) utilize state resources and professional connections to navigate federal and state regulations, (2) establish relationships with physician partners (3) offer tests that are meaningful to patients and their physicians, (4) evaluate financial impact, workflow adaptations, and marketing approaches when implementing POC testing services, and (5) focus on individualized attention and convenience of community pharmacy-based POC testing to improve patient satisfaction.

CONCLUSION: Successful POC testing services in community pharmacy practice rely on utilizing resources, partnering with known physicians, selecting meaningful tests for patients, and analyzing finances, workflow, and marketing to provide individualized attention and convenient care.