Veterans Health Administration Pharmacy Benefits Management Academic Detailing Services

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1 Veterans Health Administration Pharmacy Benefits Management Academic Detailing Services Melissa Christopher, Pharm.D. National Director, Academic Detailing Services VACO PBM San Diego, California USA Academic Detailing Service is a PBM program under the direction of Dr. Virginia Torrise, Deputy Chief Consultant, Professional Practice. Support is provided by Mr. Michael Valentino, Chief Consultant, PBM.

2 Disclosure and Disclaimers The authors have no relevant financial or nonfinancial relationships to disclose. During the development, analysis, and preparation of this presentation, the authors were employees of the US Veterans Health Administration, Department of Veterans Affairs. The views and opinions expressed in this presentation are those of the authors and do not necessarily reflect the official policy or position of any agency of the US government. Assumptions made within the analysis are not reflective of the position of any US government entity.

3 Designing and Implementing a National Academic Detailing Program Overview: VHA facility and regional implementation and penetration of AD program on safety initiatives targeting the opioid crisis psychotropic prescribing. Review of preliminary analysis after implementation, analyzing impact by AD on campaign measures. ADS centralized services have increased service to more VISNs, delivered educational products, provided data resources, evaluation and technical support for consultation to field level academic detailers.

4 Opioid Prescribing: Challenges and Next Steps VA is successfully reducing unsafe opioid prescribing- Since Q4 of FY2012, VHA has: Reduced the # of patients receiving opioids by 27% Reduced the # of patient receiving >/= 100 mg MEDD by 40% Dispensed over 52,000 naloxone rescue kits. Increased the % of patients with OUD receiving MAT to over 34%. In Substance Use Disorder (SUD) Specialty Care it s over 41%. 4

resources Increase the use of evidencebased treatments to Veterans Identify barriers to

6 VA Academic Detailing Vision Demonstrate the impact of the Clinical Pharmacy Specialist delivery of Academic Detailing Develop and disseminate clinician level education and resources Increase the use of evidencebased treatments to Veterans Identify barriers to prescribing and delivery of evidence-based treatments Deliver tools to identify actionable patients 6

Delivery of Patient Centered Interdisciplinary Team Based Care with CPS Clinical Pharmacy Specialist (CPS) Providers with Independent Medication Prescriptive Authority Highly trained Clinical

7 Delivery of Patient Centered Interdisciplinary Team Based Care with CPS Clinical Pharmacy Specialist (CPS) Providers with Independent Medication Prescriptive Authority Highly trained Clinical Workforce that is poised to assume more direct patient care duties. Panel and Population Management Comprehensive Medication Management services to allowing other providers to see more urgent/acute patients Bridging the gap to specialty care Part of VA s solution to Access and same day services. Clinical Pharmacy Specialists (CPS) are the Team s Medication Experts Optimize roles of CPS to provide Essential Chronic Disease and Medication Management Services

8 Type of Visits by CPS Provider by Practice Area FY 2016

9 Academic Detailing Services Implementation Status across VHA FY17 In FY16, 113 Clinical Pharmacist ADs recorded educational outreach visits roughly 53 FTEE 6 12 Baseline FY15: Five VISNs were implemented with AD services 9

10 AD Implementation Guide Includes the following sections: Code of Conduct Overview of AD Developing an AD Program Setting goals and expectations Rolling out an AD program Workload documentation Evaluations Glossary, References, Appendices

11 VISN Programs Are In Different Stages of Implementation Complexity of the interventions ranges from use of the audit/feedback tools, along with system process improvement programming (order sets; policy changes; practice facilitation) Range of topics regional AD programs cover in a year range from 1 campaign topic to 12 Different models include VISN centralized positions, facility CPSs and combination of both

12 AD Expansion Reached More Providers

13 AD Expansion Reached More Providers Geographical Reach of Outreach Visits Increased from FY15 to FY % increase 100% increase # of VISNs # of Facilities FY15 FY16

14 Increased Distribution of Educational Resources for Providers and Veterans

15 ADS Training Services Expanded in FY2016 Basic Skill Training fold increase in number of trained staff compared with FY15 VISNs 5, 7, 19 and 20 deployed new campaigns and included provider champions Four VISN Regional Trainings 60 AD Program Manager Training 33 New Training Resource for managers on how to operate AD program, measure progress, quality and drive results 15

Academic Detailing Educational Tools FY2016 24 new educational documents developed to support patients and providers Direct to Consumer Tools Incorporates processes on how to deploy direct to Veteran

16 Academic Detailing Educational Tools FY new educational documents developed to support patients and providers Direct to Consumer Tools Incorporates processes on how to deploy direct to Veteran campaigns to increase shared decision making Online catalog now contains 80 resources: ADS Educational Resources Catalog 2017 Online repository allows for more collaborative sharing of VISN developed AD tools 16

Quick Reference Guide OUD Provider Guide OUD dashboard and reports

17 Patient Tools to Influence the Provider and Patient Discussion Educational Resources OUD Direct-to-Consumer Patient Brochure OUD Quick Reference Guide OUD Provider Guide OUD dashboard and reports OEND Direct to Consumer Brochure Marijuana Patient Discussion Tool 17

18 Partners in Academic Detailing Provider Champions at each VA facility Academic Detailer Pain Champions Leveraging Pain Champions for Expert Consultation Identifying Gaps to Transform Pain Care for VA Location Mental Health Champions Leveraging Mental Health Champion for co-managed patients in specialty services with co-mh Diagnosis Identifying Gaps to Transform Care Primary Care Champions Models of transformed practices and peer to peer consultation Breaking down barriers for veterans accessing evidence based treatment 18

New Horizon Academic Detailers are well positioned to be the Catalyst to turn the tide on opioids - Helping to deliver better pain care reduce risk of OUD - Identifying patients

19 New Horizon Academic Detailers are well positioned to be the Catalyst to turn the tide on opioids - Helping to deliver better pain care reduce risk of OUD - Identifying patients with DSM-V criteria for substance use disorder through screening and leveraging population management tools - Increasing capacity for services for medication assisted treatment (MAT) 19

20 20

21 ADS Population Management Data Resources Available 21

22 Decision-support Tools: Academic Detailing s OUD Campaign Scores and links to actionable patients Available at VISN, Station, or Provider (MH or PC) level

23 Provider Level Dashboard: Patients with OUD

24 Patient Details

Comparison evaluations with providers who do not receive educational

25 Monitors Following Detailing Visits Providing evaluation tools that give real time monitors along with trend data to reinforce progress over time Comparison evaluations with providers who do not receive educational outreach allow system to measure impact and success of strategies deployed 25

26 Audit and Feedback Helps Detailers Self Monitor Progress Melissa Christopher s 26

27 Summary of preliminary analyses of Academic Detailing in the Opioid Safety, Opioid Overdose Education and Naloxone Distribution, and Psychotropic Drug Safety Initiatives

28 AD Impact on OSI Results: Baseline demographics comparisons Table 1. Baseline demographic between providers who were exposed and not exposed to academic detailing. Variables AD-exposed (N=1813) AD-unexposed (N=14,180) P-value Age (years), mean (SD) 50.8 (9.7) 49.6 (10.9) < Male, n (%) 917 (50.6%) 7,568 (53.4%) FTEE, mean (SD) 0.96 (0.15) 0.85 (0.30) < Prior months worked, mean (SD) 33.6 (118.0) 47.1 (133.0) <0.0001

29 AD OSI Results: Proportion of Veterans on High Dose (>100 mg MEDD) Figure 1. The changes in proportion of high dose opioids per month per provider from October 2013 to September 2016 were evaluated using best fit lines. AD-exposed providers had a statistically greater rate of reduction in the proportion of Veterans on high dose opioids compared to ADexposed VETERANS providers HEALTH (58% ADMINISTRATION versus 34%, respective; p=0.013).

30 AD OSI Results: Average MEDD Figure 2. The changes in the average morphine equivalent daily dose (MEDD) per month per provider from October 2015 to September 2016 were evaluated using best linear fits. AD-exposed providers had a significantly greater rate of reduction in MEDD from baseline compared to ADunexposed providers (59% versus 31%, respectively; p<0.0001).

31 Opioid Overdose Education and Naloxone Trends in Prescribing Increases FY15 vs FY16 Through the end of FY2016 Number of Naloxone Prescription Fills 45,185 Number of Veterans Receiving Naloxone 39,331 Number Provider Issuing Naloxone 5,694 % of VA stations that have dispensed Naloxone 100% # Naloxone Prescriptions Released OEND Implementation by Fiscal Quarter # New Prescribers # Naloxone Prescriptions Released Academic Detailing Service initiates OEND involvement Fiscal Quarter # New Prescribers 31

OEND Catalyzed Academic Detailing Services resulted in 7 times greater prescribing rate of Naloxone to Veterans at risk of overdose at 24 months From October 2014 to Sept 2016, detailed providers had

32 OEND Catalyzed Academic Detailing Services resulted in 7 times greater prescribing rate of Naloxone to Veterans at risk of overdose at 24 months From October 2014 to Sept 2016, detailed providers had prescribing rate of naloxone >3 times higher than non detailed providers 1 year after first OEND-related AD visit, and >7 times greater at 2 years. Moreover, the average rate of increase in naloxone prescribing was 7.1% greater in the ADexposed versus the ADunexposed providers (95% CI: 2.0%, 12.5%)

33 AD PDSI: Baseline demographics comparisons Table 2. Baseline demographic between providers who were exposed and not exposed to academic detailing. Variables AD-exposed (N=274) AD-unexposed (N=1,424) P-value Age (years), mean (SD) 54.8 (9.3) 53.8 (10.1) Male, n (%) 182 (66.4%) 905 (63.6%) FTEE, mean (SD) 0.97 (0.15) 0.94 (0.19) Prior months worked, mean (SD) (103.4) (104.6) 0.559

AD Impact on PDSI Measure: Proportion with BZD and PTSD diagnosis 7% reduction in

The changes in the proportion of Veterans on BZD with a PTSD diagnosis per month per

AD-exposed provider have a significantly greater rate of reduction in the proportion

34 AD Impact on PDSI Measure: Proportion with BZD and PTSD diagnosis 7% reduction in unexposed to AD Figure 3. The changes in the proportion of Veterans on BZD with a PTSD diagnosis per month per provider from October 2015 to September 2016 were evaluated using best fit lines. AD-exposed provider have a significantly greater rate of reduction in the proportion of Veterans with BZD and PTSD VETERANS diagnosis HEALTH from ADMINISTRATION baseline compared to AD-unexposed providers (14% versus 7%, respectively; p=0.045).

35 Summary The results from these analyses provide the first empirical evidence of academic detailing s impact on OSI and PDSI outcomes. Academic detailing was associated with beneficial improvement in OSI and PDSI-related outcomes. The reduction in the proportion of Veterans with high dose opioids and the average MEDD were significantly associated with providers exposed to academic detailing adjusting for provider s baseline characteristics. Similarly, academic detailing was significantly associated with a decline in the proportion of Veterans on BZD with a PTSD diagnosis. These outcomes are part of a multifaceted approach by the VA to improve the overall health of the Veteran population. Academic detailing is a vital part of these campaigns by proactively engaging providers to align their prescribing with best practices.

36 Questions?

37 CONTACT VACO PBM Academic Detailing Service Us VA PBM Academic Detailing Website: ome.asp Melissa Christopher VA Cell

Evaluation of National Academic Detailing Service on Naloxone Kit Prescription Rates in the Veterans Health Administration

Evaluation of National Academic Detailing Service on Naloxone Kit Prescription Rates in the Veterans Health Administration Melissa LD Christopher, PharmD National Director Academic Detailing Program Office