New Medication Review Method Cuts Veterans' Rx Load, Saves Millions

Clinical pharmacists in collaboration with primary care providers at Central Arkansas Veterans Healthcare System (CAVHS) have methodically “deprescribed” more than 20,000 medication regimens in 2 years, lessening patients’ pill burden and enabling the organization to reallocate resources, program leaders said in February.

Medical Center Director Margie A. Scott said deprescribing the medications led to about a $3.5 million annualized cost avoidance for CAVHS.

“It’s put back into the system to serve more veterans,” Scott said of the money, emphasizing that it is cost avoidance, not cost savings. “So not only is it good for the patient, but it’s good for other patients.”

With 24 months of data accumulated, program leaders reported an average of 3.15 fewer prescriptions per veteran.

Mnemonic guide

The program uses the deprescribing tool VIONE, which came to national attention through the Department of Veterans Affairs’ Diffusion of Excellence Initiative competition.

VIONE is a mnemonic to guide designated clinical staff members, said Sara Swathy Battar, who conceived the tool in early 2016.

At the time, Battar was the attending physician for the 15-bed short-stay inpatient geriatric evaluation and management unit on the North Little Rock campus.

Using the mneomic, she explained, clinical staff members evaluate each medication in the presence of the patient and categorize it as

• Vital (e.g., insulin),
• Important to quality of life (e.g., pain medication, stool softener),
• Optional (e.g., vitamin supplement),
• Not indicated (e.g., statin when the patient’s expected lifespan is short), or
• Every medication has a specific indication for use (e.g., proton pump inhibitor after the patient’s acute symptoms have ceased).

Any medication that is not vital or important is a candidate to pursue for discontinuation, Battar said.

And every evaluation occurs in consultation with the treatment team and, if the patient cannot fully participate, with the patient’s surrogate.

Pharmacy’s commitment

Chief of Pharmacy Services Timothy G. Cmelik said pharmacists started off targeting inpatients whose medication profile had more than 25 listings. The target now is patients with 8 listings or more.

The main reason for such a high initial trigger, he said, was the pharmacy’s staffing level in early 2016. Pharmacy managers had previously reported regularly to a committee regarding the number of patients using at least 8 drugs. But that was a large number of patients, Cmelik said, and the VIONE approach to deprescribing medications meant a new type of profile review.

“One of the focuses of VIONE is to engage the patient . . . in understanding their drug therapy and helping them be more engaged in making those decisions and knowing why they’re feeling better,” he said.

Through a different effort, Cmelik said, pharmacy services personnel had been discontinuing prescriptions not filled in at least 7 months for the roughly 50,000 veterans who receive medications directly from CAVHS, he said.

Battar, who is now associate chief of staff for the geriatrics and extended care service, said Cmelik enthusiastically supported the VIONE approach and dedicated pharmacy personnel to the program from the start.

The scope of practice for clinical pharmacy specialists allows them to deprescribe medications and add their physician collaborator as cosigner, she said. Similarly, physicians with a pharmacist collaborator add him or her as cosigner when deprescribing medications.

About 3 months in, however, with the deprescribing tool in use on 4 inpatient units, each with at least 1 pharmacist, the team realized the endeavor was “way more intensive” than had been anticipated, she said.

Help came in the form of Kimberly W. Dickerson, lead and academic detail pharmacist.

Dickerson, Battar said, had the technical expertise to create the data-capturing and data-mining processes necessary to propel and expand the project.

Since May 2016, pharmacists and primary care providers have been using a drop-down menu in the electronic medical record to record VIONE-related events, including the reason for a medication being discontinued, Battar said.

Dickerson also created a means for pharmacists to prepare for patients’ clinic visits.

“We are able to pull together patient-, provider-, and pharmacy-specific lists of patients who will be coming in for an appointment, and then those patients are reviewed for polypharmacy,” she said.

As of February, the tool is formally in use in the acute, primary, and inpatient and outpatient geriatric care areas and informally elsewhere at CAVHS, Battar said, but not all patients have been evaluated.

Success locally, nationally

Scott said her facility has received a lot of positive feedback from veterans on the VIONE approach to deprescribing.

“It’s not deprescribing in a void,” the medical center director said. “It’s letting the veterans take control of [a] part of their healthcare that is important to them day after day after day.”

The program was among 19 finalists selected from 356 applicants to the third Diffusion of Excellence Initiative competition, held on June 13, 2017.

In this competition, which the Department of Veterans Affairs has said is modeled after the ABC television series Shark Tank, each finalist’s spokesperson had 2 minutes to present his or her innovative program to medical center and integrated service network directors. These directors, known as sharks during the competition, had 2 minutes to ask questions and then 1 minute to bid resources on being the site where a facilitator helps to implement the program. In the end, 10 programs were deemed “Gold Status,” resulting in support for facilitated implementation.

Serving as the CAVHS team’s spokesperson, Battar told the sharks that the program yielded a $1.75 million net annual savings, according to twitter.com/vainnovation. The Twitter feed also reported that a 3-state integrated service network bid “staff to roll out throughout.”

Battar said the $1.75 million cost avoidance she mentioned in her pitch to the sharks reflected VIONE-related discontinuation of more than 11,000 prescriptions for just over 3,200 veterans.

CAVHS’s program achieved Gold Status. Iowa City VA Health Care System submitted the winning bid.

Battar said the Iowa City system’s version of the VIONE approach to deprescribing medications starts with the medical center’s nurses. They show a patient coming in for an appointment his or her medication list and ask whether there are any medications he or she does not take now.

Fifteen other Veterans Affairs medical centers have inquired about the program, received the CAVHS-prepared toolkit, and are customizing the VIONE approach to their facilities, she said.

Advice

Leaders of the program at CAVHS, Battar said, suggest that organizations wanting to use the VIONE approach assemble a “willing, capable, available” team of physicians, pharmacists, nurses, information technology personnel, change agents, and personnel who can support data capture and mining.

And for each patient care area targeted for implementation, she stated, identify a physician and a pharmacist with relevant expertise who will be champions of the program.

Cmelik said pharmacists on a Patient Aligned Care Team and clinical pharmacists who have completed a residency program already have the training to conduct the thorough review and evaluations necessary for the VIONE approach.

“The only further training they need is just orientation on what the project is about and then [instruction] to follow the template of VIONE,” he said.

[This news story appears in the April 15, 2018, issue of AJHP.]