Publications

2017

Gellad, Walid F, Francesca E Cunningham, Chester B Good, Joshua M Thorpe, Carolyn T Thorpe, Brandi Bair, KatieLynn Roman, and Susan L Zickmund. (2017) 2017. “Pharmacy Use in the First Year of the Veterans Choice Program: A Mixed-Methods Evaluation.”. Medical Care 55 Suppl 7 Suppl 1: S26-S32. https://doi.org/10.1097/MLR.0000000000000661.
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BACKGROUND: The Veterans Choice Program (VCP) was created to ensure timely access to health care in the Department of Veterans Affairs (VA). Under this program, medications may be ordered by select non-VA clinicians to be dispensed by VA pharmacies, creating new challenges in ensuring medication safety.

OBJECTIVES: To examine pharmaceutical use during the first year of the VCP and to understand barriers and facilitators for VA pharmacists to dispensing medications under the VCP.

STUDY DESIGN: Mixed-methods evaluation.

METHODS: We captured all prescriptions dispensed through the VCP and described the demographics of VCP users and their medications. We also conducted semistructured interviews of VA pharmacists, focusing on VA formulary management and experiences dispensing opioid and hepatitis C (HCV) medications. Codebook development and coding followed iterative qualitative methods.

RESULTS: Overall, 17,346 Veterans received 56,426 VCP prescriptions from November 7, 2014 through November 7, 2015. The total medication cost was $27 million, 90% of which was for only 2772 HCV prescriptions. Topical eye drops and opioids represented the most commonly dispensed prescriptions (15.6% and 9.2% of all prescriptions, respectively). Pharmacists reported numerous challenges to dispensing VCP medications, including time required to contact non-VA clinicians about formulary issues, requiring controlled substance prescriptions to be hand delivered to VA pharmacies, and lack of access to laboratory data required to safely dispense medications.

CONCLUSIONS: HCV-related medication costs predominated the first year of VCP, but this is likely to change going forward. The safe use of opioids, efficient management of nonformulary medications, and unintended new barriers to access created by the VCP must be addressed.

Tang, Yan, Marcela Horvitz-Lennon, Walid F Gellad, Judith R Lave, Chung-Chou H Chang, Sharon-Lise Normand, and Julie M Donohue. (2017) 2017. “Prescribing of Clozapine and Antipsychotic Polypharmacy for Schizophrenia in a Large Medicaid Program.”. Psychiatric Services (Washington, D.C.) 68 (6): 579-86. https://doi.org/10.1176/appi.ps.201600041.
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OBJECTIVE: Underuse of clozapine and overuse of antipsychotic polypharmacy are both indicators of poor quality of care. This study examined variation in prescribing clozapine and antipsychotic polypharmacy across providers, as well as factors associated with these practices.

METHODS: Using 2010-2012 Pennsylvania Medicaid data, prescribers were identified if they wrote antipsychotic prescriptions for ten or more nonelderly adult patients with schizophrenia annually. Generalized linear mixed models with a binomial distribution and a logit link were used to examine prescriber-level annual percentages of patients with clozapine use and with long-term (≥90 days) antipsychotic polypharmacy and associated characteristics of prescribers' patient caseloads, prescriber characteristics, and Medicaid payer (fee-for-service versus managed care plans).

RESULTS: The study cohort included 645 prescribers in 2010, 632 in 2011, and 650 in 2012. In 2012, the mean prescriber-level annual percentage of patients with any clozapine use was 7% (range 0%-89%), and the mean percentage of patients with any long-term antipsychotic polypharmacy was 7% (range 0%-45%) (similar rates were found during 2010-2012). Prescribers with high prescription volume, a smaller percentage of patients from racial or ethnic minority groups, and a larger percentage of patients eligible for Supplemental Security Income were more likely to use both clozapine and antipsychotic polypharmacy for treating schizophrenia. Prescriber specialty and Medicaid payer were also associated with prescribers' practices.

CONCLUSIONS: Considerable variation was found in clozapine and antipsychotic polypharmacy practices across prescribers in their treatment of schizophrenia. Targeting efforts to selected prescribers holds promise as an approach to promote evidence-based antipsychotic prescribing.

Cochran, Gerald, Adam J Gordon, Walid F Gellad, Chung-Chou H Chang, Wei-Hsuan Lo-Ciganic, Carroline Lobo, Evan Cole, et al. (2017) 2017. “Medicaid Prior Authorization and Opioid Medication Abuse and Overdose.”. The American Journal of Managed Care 23 (5): e164-e171.
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OBJECTIVES: The US opioid medication epidemic has resulted in serious health consequences for patients. Formulary management tools adopted by payers, specifically prior authorization (PA) policies, may lower the rates of opioid medication abuse and overdose. We compared rates of opioid abuse and overdose among enrollees in plans that varied in their use of PA from "High PA" (ie, required PA for 17 to 74 opioids), with "Low PA" (ie, required PA for 1 opioid), and "No PA" policies for opioid medications.

STUDY DESIGN: Retrospective cohort study of patients initiating opioid treatment in Pennsylvania Medicaid from 2010 to 2012.

METHODS: Generalized linear models with generalized estimating equations were employed to assess the relationships between the presence of PA policies and opioid medication abuse and overdose, as measured in Medicaid claims data, adjusting for demographics, comorbid health conditions, benzodiazepine/muscle relaxant use, and emergency department use.

RESULTS: The study cohort included 297,634 enrollees with a total of 382,828 opioid treatment episodes. Compared with plans with No PA, enrollees in High PA (adjusted rate ratio [ARR], 0.89; 95% confidence interval [CI], 0.85-0.93; P <.001) and Low PA plans (ARR, 0.93; 95% CI, 0.87-1.00; P = .04) had lower rates of abuse. Enrollees in the Low PA plan had a lower rate of overdose than those within plans with No PA (ARR, 0.75; 95% CI, 0.59-0.95; P = .02). High PA plan enrollees were also less likely than No PA enrollees to experience an overdose, but this association was not statistically significant (ARR, 0.88; 95% CI, 0.76-1.02; P = .08).

CONCLUSIONS: Enrollees within Medicaid plans that utilize PA policies appear to have lower rates of abuse and overdose following initiation of opioid medication treatment.

Cochran, Gerald, Adam J Gordon, Wei-Hsuan Lo-Ciganic, Walid F Gellad, Winfred Frazier, Carroline Lobo, Chung-Chou H Chang, Ping Zheng, and Julie M Donohue. (2017) 2017. “An Examination of Claims-Based Predictors of Overdose from a Large Medicaid Program.”. Medical Care 55 (3): 291-98. https://doi.org/10.1097/MLR.0000000000000676.
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BACKGROUND: Health systems may play an important role in identification of patients at-risk of opioid medication overdose. However, standard measures for identifying overdose risk in administrative data do not exist.

OBJECTIVE: Examine the association between opioid medication overdose and 2 validated measures of nonmedical use of prescription opioids within claims data.

RESEARCH DESIGN: A longitudinal retrospective cohort study that estimated associations between overdose and nonmedical use.

SUBJECTS: Adult Pennsylvania Medicaid program 2007-2012 patients initiating opioid treatment who were: nondual eligible, without cancer diagnosis, and not in long-term care facilities or receiving hospice.

MEASURES: Overdose (International Classification of Disease, ninth edition, prescription opioid poisonings codes), opioid abuse (opioid use disorder diagnosis while possessing an opioid prescription), opioid misuse (a composite indicator of number of opioid prescribers, number of pharmacies, and days supplied), and dose exposure during opioid treatment episodes.

RESULTS: A total of 372,347 Medicaid enrollees with 583,013 new opioid treatment episodes were included in the cohort. Opioid overdose was higher among those with abuse (1.5%) compared with those without (0.2%, P<0.001). Overdose was higher among those with probable (1.8%) and possible (0.9%) misuse compared with those without (0.2%, P<0.001). Abuse [adjusted rate ratio (ARR), 1.52; 95% confidence interval (CI), 1.10-2.10), probable misuse (ARR, 1.98; 95% CI, 1.46-2.67), and possible misuse (ARR, 1.76; 95% CI, 1.48-2.09) were associated with significantly more events of opioid medication overdose compared with those without.

CONCLUSIONS: Claims-based measures can be used by health systems to identify individuals at-risk of overdose who can be targeted for restrictions on opioid prescribing, dispensing, or referral to treatment.

Kabiri, Mina, Jagpreet Chhatwal, Julie M Donohue, Mark S Roberts, Everette James, Michael A Dunn, and Walid F Gellad. (2017) 2017. “Long-Term Disease and Economic Outcomes of Prior Authorization Criteria for Hepatitis C Treatment in Pennsylvania Medicaid.”. Healthcare (Amsterdam, Netherlands) 5 (3): 105-11. https://doi.org/10.1016/j.hjdsi.2016.11.001.
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BACKGROUND: Several highly effective but costly therapies for hepatitis C virus (HCV) are available. As a consequence of their high price, 36 state Medicaid programs limited treatment coverage to patients with more advanced HCV stages. States have only limited information available to predict the long-term impact of these decisions.

METHODS: We adapted a validated hepatitis C microsimulation model to the Pennsylvania Medicaid population to estimate the existing HCV prevalence in Pennsylvania Medicaid and estimate the impact of various HCV drug coverage policies on disease outcomes and costs. Outcome measures included rates of advanced-stage HCV outcomes and treatment and disease costs in both Medicaid and Medicare.

RESULTS: We estimated that 46,700 individuals in Pennsylvania Medicaid were infected with HCV in 2015, 33% of whom were still undiagnosed. By expanding treatment to include mild fibrosis stage (Metavir F2), Pennsylvania Medicaid will spend an additional $273 million on medications in the next decade with no substantial reduction in the incidence of liver cancer or liver-related death. Medicaid patients who are not eligible for treatment under restricted policies would get treatment once they transition to the Medicare program, which would incur 10% reduction in HCV-related costs due to early treatment in Medicaid. Further expanding treatment to patients with early fibrosis stages (F0 or F1) would cost Medicaid an additional $693 million during the next decade but would reduce the number of individuals in need of treatment in Medicare by 46% and decrease Medicare treatment costs by 23%. In some scenarios, outcomes could worsen with eligibility expansion if there is inadequate capacity to treat all patients.

CONCLUSIONS AND RELEVANCE: Expansion of HCV treatment coverage to less severe stages of liver disease may not substantially improve liver related outcomes for patients in Pennsylvania Medicaid in scenarios in which coverage through Medicare is widely available.

Stroupe, Kevin T, Bridget M Smith, Lauren Bailey, Jamal Adas, Walid F Gellad, Katie Suda, Zhiping Huo, Sean Tully, Muriel Burk, and Francesca Cunningham. (2017) 2017. “Medication Acquisition by Veterans Dually Eligible for Veterans Affairs and Medicare Part D Pharmacy Benefits.”. American Journal of Health-System Pharmacy : AJHP : Official Journal of the American Society of Health-System Pharmacists 74 (3): 140-50. https://doi.org/10.2146/ajhp150800.
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PURPOSE: The patterns of medication acquisition for veterans dually eligible for pharmacy benefits from the Department of Veterans Affairs (VA) and Medicare Part D-reimbursed pharmacies were examined.

METHODS: The characteristics of veterans who used pharmacies reimbursed by (1) VA only, (2) both VA and Part D-reimbursed, and (3) Part D-reimbursed only pharmacies in 2009 were compared and their medication types and sources examined. Pharmacy usage was measured as the number of 30-day medication supplies and the number of different drug classes that veterans received from VA and Part D-reimbursed pharmacies. Chi-square testing and analysis of variance were used to compare unadjusted patient characteristics and healthcare utilization.

RESULTS: A total of 145,899 veterans with any VA or Part D-reimbursed pharmacy use were included in the study: 69.6% used VA pharmacies only, 9.9% used VA and Part D-reimbursed pharmacies, and 20.5% used Part D-reimbursed pharmacies only. Veterans who lived in rural areas, were non-Black, had VA medication copayments, or were dual or Medicare-only outpatient users were more likely to be dual or Part D-reimbursed only pharmacy users (p < 0.001). Dual pharmacy users received more 30-day supplies than did the other two pharmacy-use groups (p < 0.001).

CONCLUSION: Nearly one third of VA users received medications from Part D-reimbursed pharmacies, either alone or together with VA pharmacies. Among dual pharmacy users, over half received medications from the same drug class from both VA and Part D-reimbursed pharmacies for which the days' supplies overlapped by more than seven days.

Radomski, Thomas R, Xinhua Zhao, Carolyn T Thorpe, Joshua M Thorpe, Jennifer G Naples, Maria K Mor, Chester B Good, Michael J Fine, and Walid F Gellad. (2017) 2017. “The Impact of Medication-Based Risk Adjustment on the Association Between Veteran Health Outcomes and Dual Health System Use.”. Journal of General Internal Medicine 32 (9): 967-73. https://doi.org/10.1007/s11606-017-4064-4.
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BACKGROUND: Veterans commonly receive care from both Veterans Health Administration (VA) and non-VA sources (i.e., dual use). A major challenge in comparing health outcomes between dual users and VA-predominant users is applying an accurate method of risk adjustment.

OBJECTIVE: To determine how different comorbidity indices affect the association between patterns of dual use and health outcomes.

DESIGN: Retrospective cohort.

PARTICIPANTS: A total of 316,775 community-dwelling Veterans (≥65 years) with type 2 diabetes who were enrolled in VA and fee-for-service Medicare from 2008 to 2010.

METHODS: We determined the associations between dual use and death or diabetes-related hospitalization in FY 2010 using multivariable models incorporating claims-based (Elixhauser) or medication-based (RxRisk-V) risk adjustment. Dual use was classified using four previously identified groups of health services users: 1) VA-predominant, 2) VA + Medicare visits and labs, 3) VA + Medicare test strips, and 4) VA + Medicare medications.

KEY RESULTS: Controlling for Elixhauser comorbidities, dual-use groups 2-4 had significantly decreased odds of death or hospitalization compared to VA-predominant users. Controlling for RxRisk-V comorbidities, groups 2-4 had increased odds of death compared to VA-predominant users, but variable odds of hospitalization, with group 2 having increased odds (OR 1.06, CI 1.04-1.09), while groups 3 (OR 0.96, CI 0.94-0.99) and 4 (OR 0.93, CI 0.89-0.97) had decreased odds.

CONCLUSIONS: The method of risk adjustment drastically influences the direction of effect in health outcomes among dual users of VA and Medicare. These findings underscore the need for standardized and reliable risk adjustment methods that are not susceptible to measurement differences across different health systems.