ObjectivesThe effectiveness and costs associated with addition of pharmacist-led group medical visits to standard care for patients with Type-2 Diabetes Mellitus (T2DM) is unknown.MethodsRandomized-controlled-trial in three US Veteran Health Administration (VHA) Hospitals, where 250 patients with T2DM, HbA1c >7% and either hypertension, active smoking or hyperlipidemia were randomized to either (1) addition of pharmacist-led group-medical-visits or (2) standard care alone for 13 months. Group (4–6 patients) visits consisted of 2-hour, education and comprehensive medication management sessions once weekly for 4 weeks, followed by quarterly visits. Change from baseline in cardiovascular risk estimated by the UKPDS-risk-score, health-related quality-of-life (SF36v) and institutional healthcare costs were compared between study arms.ResultsAfter 13 months, both groups had similar and significant improvements from baseline in UKPDS-risk-score (-0.02 ±0.09 and -0.04 ±0.09, group visit and standard care respectively, adjusted p<0.05 for both); however, there was no significant difference between the study arms (adjusted p = 0.45). There were no significant differences on improvement from baseline in A1c, systolic-blood-pressure, and LDL as well as health-related quality-of-life measures between the study arms. Compared to 13 months prior, the increase in per-person outpatient expenditure from baseline was significantly lower in the group visit versus the standard care arm, both during the study intervention period and at 13-months after study interventions. The overall VHA healthcare costs/person were comparable between the study arms during the study period (p = 0.15); then decreased by 6% for the group visit but increased by 13% for the standard care arm 13 months post-study (p<0.01).ConclusionsAddition of pharmacist-led group medical visits in T2DM achieved similar improvements from baseline in cardiovascular risk factors than usual care, but with reduction in the healthcare costs in the group visit arm 13 months after completion compared to the steady rise in cost for the usual care arm.Trial registrationNCT00554671 ClinicalTrials.gov

Objective To determine the utility (i.e., positive predictive value [PPV] and time requirement) of an adverse drug event (ADE) trigger tool in Veterans Affairs (VA) nursing homes (NHs); and to describe the most common types of potential ADEs detected with the trigger tool. Design Retrospective chart review. Setting/Patients Veterans residing in three VA NHs between 09/29/2010 and 10/29/2010. Measurement We used the Institute for Healthcare Improvement (IHI)-endorsed NH ADE trigger tool, modified to enhance its clinical relevance to detect potential ADEs. Electronic medical records were screened to identify residents with ≥1 abnormal laboratory value specified in the trigger tool. Main Outcome Measures A potential ADE was defined as the concurrent administration of medication that could cause the abnormal laboratory value. An overall PPV, or proportion of residents with an abnormal laboratory value who had a potential ADE, and average time required to complete each trigger tool assessment were calculated. Results Among 321 Veterans, 50.5% (n=162) had at least one abnormal laboratory value contained in the trigger tool. Ninety-nine potential ADEs involving 146 medications were detected in 65 Veterans. The overall PPV of the ADE trigger tool was 40.1% (65/162), and the average time to complete resident assessments was 8.8 (sd ± 5.7) minutes. The most common potential ADEs were acute kidney injury (n=30 residents), hypokalemia (n=18), hypoglycemia (n=13), and hyperkalemia (n=10). Conclusions The modified NH trigger tool was shown to be an effective and efficient method for detecting potential ADEs.

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OBJECTIVES To describe the quality of warfarin prescribing and monitoring in Veterans Affairs (VA) nursing homes and to assess the factors associated with maintaining a therapeutic International Normalized Ratio (INR). DESIGN Retrospective cohort. SETTING Five VA nursing homes. PARTICIPANTS All Veterans who received warfarin between January 1 and June 30, 2008 at the nursing homes. MEASUREMENTS Using medical records, we estimated the percentage of person-time spent in the target INR range, the proportion of patients with INRs in the therapeutic range on ≥ 50% of their person-days and the frequency of INR monitoring. We used multivariable logistic regression to identify factors associated with maintaining a therapeutic INR ≥ 50% of the time. RESULTS Over six months, 160 patients received 10,380 person-days of warfarin. INRs were in the therapeutic range for a majority (55%) of the person-days, and 99% of the INR tests were repeated within four weeks of the previous result. On an individual level, 49% of patients had INRs in the target range for ≥ 50% of their person-days. Achieving this outcome was more likely in patients with prevalent warfarin use versus new use (Adjusted odds ratio [AOR]=2.86; 95% confidence interval [CI]=1.06, 7.72). Conversely, patients with a history of a stroke (AOR=0.38; 95% CI=0.18, 0.80) were less likely to have therapeutic INRs for ≥ 50% of their days. CONCLUSION Warfarin appears to be effectively prescribed and monitored in VA nursing home patients. Future studies should focus on increasing time in therapeutic range among patients with poor INR control.