A cost-effective approach to the use of selective serotonin reuptake inhibitors in a Veterans Affairs Medical Center.
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In light of the tremendous expansion in the number of selective serotonin reuptake inhibitors available to the clinician, the Pharmacy and Therapeutics Committee of the Denver Veterans Affairs Medical Center considered the advantages and disadvantages of fluoxethine, paroxetine, and sertraline, to determine which agent or agents would be carried on the formulary. The committed recommended sertraline as the preferred agent for the treatment of depression, panic disorders, and obsessive-compulsive disorders. The purpose of this retrospective study was to assess the economic outcome of that decision. The study population consisted of patients at the medical center who were receiving selective serotonin reuptake inhibitors during January through March of 1994 and those were receiving these agents between September 1995 and January 1996. The expanded collection period in 1995-96 was due to a relatively new medical center policy to offer 90-day fills on medication to reduce costs. The extended collection period assured a 100% sample of patients receiving these agents. The 1994 fluoxetine to sertraline dosage equivalency ratio was 20 mg:55.6 mg, based on average daily doses of fluoxetine and sertraline of 32.7 and 90.9 mg, respectively. The cost to the medical center for an average daily dose of fluoxetine was $1.86; sertraline cost $1.22 per day. The 1996 fluoxetine to sertraline dosage equivalency ratio (20 mg:51.3 mg) had not changed significantly since 1994, indicating that the dose of 20 mg of fluoxetine remained very close to a 50-mg dose of sertraline. The average daily doses of fluoxetine and sertraline (34.9 mg and 89.7 mg, respectively) were not significantly different than the 1994 doses. Only 33 patients had been prescribed paroxetine (average daily dose, 32.4 mg). On the basis of these values, the average daily cost of fluoxetine to the medical center was $2.01, compared with $1.18 for sertraline and $1.24 for paroxetine. This $0.83 per patient per day drug acquisition cost difference between fluoxetine and sertraline results in a drug cost reduction of $302,674 per year. (+info)
Postmarketing analysis of lovastatin use in the VA Northern California System of Clinics: a retrospective, computer-based study.
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Prevention of coronary heart disease is a major public health goal. The efficacy of lovastatin in lowering serum cholesterol has been proven in research studies, but its efficacy in practice is unclear. To evaluate our practice patterns and outcome in the Veterans Administration Northern California System of Clinics, we reviewed computer-based records of 203 unselected patients issued lovastatin; 193 (95%) were men, and the average patient age was 66 +/- 9 years. The average daily dose of lovastatin was 24 +/- 10 mg, and average duration of therapy was 22 +/- 11 months. Only 72 patients (35%) were instructed on the prescription to take their medication with the evening meal, and only 59 patients (29%) had seen a dietitian during the observed (1 to 3 years) treatment period. Nevertheless, among the 124 patients with pretreatment lipid data, total serum cholesterol decreased by 18% from 271 +/- 45 to 221 +/- 41 mg/dL (P < 0.001), and low density lipoprotein (LDL)-cholesterol decreased by 23% from 185 +/- 43 to 143 +/- 37 (P < 0.001) mg/dL. High density lipoprotein-cholesterol and triglycerides were unchanged. Of the 168 patients with LDL-cholesterol data during the treatment period, only 74 (44%) achieved an LDL-cholesterol level of less than 130 mg/dL, the minimum goal for a population of older males with a high incidence of other cardiac risk factors. Safety surveillance with liver function testing was performed at least once in 192 patients (95%), but with creatine phosphokinase (CPK) testing in only 123 patients (61%) during the survey period. Enzyme elevations were minor, but occurred at least intermittently in approximately one quarter of patients. Only 5.7% of patients on lovastatin manifested an increase in transaminases on therapy. Due to incomplete baseline data, it is unclear how many patients had elevated CPK as a result of lovastatin. We conclude that: (1) lovastatin is effective in lowering total and LDL-cholesterol in practice, but is often used in dosage insufficient to lower LDL-cholesterol to goal levels; (2) patients are not being adequately educated on dosing schedules; (3) toxicity may be underestimated by infrequent and inconsistent surveillance; and (4) nonpharmacologic therapy is underutilized. (+info)
Effect of home blood glucose monitoring on the management of patients with non-insulin dependent diabetes mellitus in the primary care setting.
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The purpose of the study was to determine whether blood glucose monitoring strips influence the management of patients with non-insulin dependent diabetes (NIDDM) in the primary care setting. The medical records of 115 patients with NIDDM taking a sulfonylurea drug (oral hypoglycemic agent) during the review period were randomly selected for review. Patients were divided into two groups: those who did not receive a prescription for blood glucose monitoring strips during 1995 and 1996 and those who did for the same 2 years. The main outcome measures were hemoglobin A1c, blood sugar, number of laboratory tests ordered, and number and type of treatment interventions. No statistically significant differences between groups were noted for any measured parameter. Glucose control was independent of number of strips dispensed. Home glucose monitoring strips did not affect the management of patients with NIDDM taking a sulfonylurea agent in the primary care setting. (+info)
Physician and dietitian prescribing of a commercially available oral nutritional supplement.
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We examined whether a policy change transferring prescribing privileges for oral nutritional supplements to dietitians resulted in fewer inappropriate outpatient prescriptions. This was a pre/post study design using a retrospective review of physician and dietitian prescribing for ambulatory patients during two separate time periods: physician prescribing, October to December, 1994; dietitian prescribing, April to June, 1995. Inappropriate prescriptions during each period were defined as those given to patients with normal nutritional status or with a contraindication to a high-energy, electrolyte-containing solution. The study was conducted in outpatient clinics at a Veterans Affairs teaching hospital. We found that dietitians gave fewer prescriptions to outpatients who were not malnourished or to outpatients who had a contraindication to receiving a supplement (11% vs 34%; P = 0.002). In addition, dietitians more often completed relevant laboratory assessments (75% vs 43%; P = 0.001) and more frequently arranged follow-up dietetic evaluations (84% vs 30%, P < 0.001) for ambulatory patients receiving supplements. We conclude that transferring nutritional supplement prescribing privileges to dietitians led to fewer inappropriate outpatient prescriptions and to more comprehensive nutritional assessments, as measured by relevant laboratory use and dietetic follow-up. Physicians more frequently prescribed supplements to outpatients who were not malnourished or who had contraindications to receiving supplements. Our results suggest that physicians would benefit from assistance with and/or education concerning oral nutritional supplements. (+info)
Improving access to disability benefits among homeless persons with mental illness: an agency-specific approach to services integration.
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OBJECTIVES: This study evaluated a joint initiative of the Social Security Administration (SSA) and the Department of Veterans Affairs (VA) to improve access to Social Security disability benefits among homeless veterans with mental illness. METHODS: Social Security personnel were colocated with VA clinical staff at 4 of the VA's Health Care for Homeless Veterans (HCHV) programs. Intake assessment data were merged with SSA administrative data to determine the proportion of veterans who filed applications and who received disability awards at the 4 SSA-VA Joint Outreach Initiative sites (n = 6709) and at 34 comparison HCHV sites (n = 27 722) during the 2 years before and after implementation of the program. RESULTS: During the 2 years after the initiative began, higher proportions of veterans applied for disability (18.9% vs 11.1%; P < .001) and were awarded benefits (11.4% vs 7.2%, P < .001) at SSA-VA Joint Initiative sites. CONCLUSION: A colocation approach to service system integration can improve access to disability entitlements among homeless persons with mental illness. Almost twice as many veterans were eligible for this entitlement as received it through a standard outreach program. (+info)
Amputation prevention by vascular surgery and podiatry collaboration in high-risk diabetic and nondiabetic patients. The Operation Desert Foot experience.
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OBJECTIVE: To describe a unique multidisciplinary outpatient intervention for patients at high risk for lower-extremity amputation. RESEARCH DESIGN AND METHODS: Patients with foot ulcers and considered to be high risk for lower-extremity amputation were referred to the High Risk Foot Clinic of Operation Desert Foot at the Carl T. Hayden Veterans Affairs' Medical Center in Phoenix, Arizona, where patients received simultaneous vascular surgery and podiatric triage and treatment. Some 124 patients, consisting of 90 diabetic patients and 34 nondiabetic patients, were initially seen between 1 October 1991 and 30 September 1992 and followed for subsequent rate of lower-extremity amputation. RESULTS: In a mean follow-up period of 55 months (range 3-77), only 18 of 124 patients (15%) required amputation at the level of the thigh or leg. Of the 18 amputees, 17 (94%) had type 2 diabetes. The rate of avoiding limb loss was 86.5% after 3 years and 83% after 5 years or more. Furthermore, of the 15 amputees surviving longer than 2 months, only one (7%) had to undergo amputation of the contralateral limb over the following 12-65 months (mean 35 months). Compared with nondiabetic patients, patients with diabetes had a 7.68 odds ratio for amputation (95% CI 5.63-9.74) (P < 0.01). CONCLUSIONS: A specialized clinic for prevention of lower-extremity amputation is described. Initial and contralateral amputation rates appear to be far lower in this population than in previously published reports for similar populations. Relative to patients without diabetes, patients with diabetes were more than seven times as likely to have a lower-extremity amputation. These data suggest that aggressive collaboration of vascular surgery and podiatry can be effective in preventing lower-extremity amputation in the high-risk population. (+info)
Dual use of VA and non-VA primary care.
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OBJECTIVE: To determine how frequently veterans use non-Department of Veterans Affairs (VA) sources of care in addition to primary care provided by the VA and to assess the association of this pattern of "dual use" to patient characteristics and satisfaction with VA care. DESIGN: Cross-sectional telephone survey of randomly selected patients from four VA medical centers. PARTICIPANTS: Of 1,240 eligible veterans, 830 (67%) participated in the survey. MEASUREMENTS AND MAIN RESULTS: Survey data were used to assess whether a veteran reported receiving primary care from both VA and non-VA sources of care, as well as the proportion of all primary care visits made to non-VA providers. Of 577 veterans who reported VA primary care visits, 159 (28%) also reported non-VA primary care visits. Among these dual users the mean proportion of non-VA primary care visits was 0.50. Multivariate analysis revealed that the odds of dual use were reduced for those without insurance (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.18, 0.66) and with less education (OR 0.60; 95% CI 0.38, 0.92), while increased for those not satisfied with VA care (OR 2.40; 95% CI 1.40, 4.13). Among primary care dual users, the proportion of primary care visits made to non-VA providers was decreased for patients with heart disease ( p <.05) and patients with alcohol or drug dependence ( p <.05). CONCLUSIONS: Primary care dual use was common among these veterans. Those with more education, those with any type of insurance, and those not satisfied with VA care were more likely to be dual users. Non-VA care accounted for approximately half of dual users' total primary care visits. (+info)
Safety and efficacy of metformin in a restricted formulary.
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OBJECTIVE: To assess the efficacy and safety of metformin (MET) in the Veterans' Administration Northern California Health Care System during the period from June 1995 through April 1996 when its use required approval by Endocrinology. STUDY DESIGN: A retrospective review of patient charts and computerized pharmacy and laboratory records. Patients served as their own historical controls. PATIENTS AND METHODS: Patients receiving MET (n = 251) were identified from the pharmacy database. On-line laboratory data, including the intermediate outcome variable HbA1c, were retrieved by computer for the interval 4 months prior to the initial prescription to May 1996. Clinical data including weight and blood pressure were obtained from chart review. RESULTS: Of 228 patients whose charts were available for review, 29 reported side effects, and 12 discontinued use due to these side effects. No patients were identified with lactic acidosis. Both baseline and treatment data on HbA1c were available on 164 patients. Mean HbA1c (%) data (unpaired), expressed as mean +/- SE, were as follows: between 4 months pretreatment and 1 month pretreatment, 9.41 +/- 0.19 (n = 103 tests); between 1 month pretreatment and baseline, 9.41 +/- 0.19 (n = 110 tests); 3 months of treatment, 8.79 +/- 0.16 (n = 157 tests, P < 0.05); 6 months of treatment, 8.30 +/- 0.17 (n = 79 tests, P < 0.0001); 9 months of treatment, 8.72 +/- 0.24 (n = 70 tests, P < 0.05), compared to pretreatment values. Similar analysis of unpaired weight and blood pressure data in 152 patients did not reveal any reduction in these clinical parameters over this treatment period. Serum lipids were unchanged on treatment (by paired analysis), but the number of tests was limited. CONCLUSION: In this setting, MET provided sustained beneficial effects on glycemic control and was well tolerated. Any effects on weight, blood pressure, and serum lipids were not demonstrable in this analysis. We conclude that MET can substantially improve outcome of diabetes care. (+info)