VIReC Database and Metho

Cyber Seminar Series

RESEARCHERS’ GUIDE TO VA DATA
VIReC Database and Methods Cyber Seminar S

Measuring Outpatient Pharmac

in the VA Using VA Pharmacy 

October 4, 2010

Presented by:

Todd A. Lee, PharmD, PhD

RESEARCHERS’ GUIDE TO VA DATA
Audience Poll

Have you ever used VA Pharmacy D

– Yes–

N

o

RESEARCHERS’ GUIDE TO VA DATA
Audience Poll

How would you rate your overall knowledge of VA Pharmacy Data?

– 1 (Never Used)– 2–

3

– 4– 5 (Used Frequently Very familiar) 5 (Used Frequently, Very familiar)

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

H h t ti t h tili How has ou

tpatient 

p

harmacy

utili

been measured in VA studies?Overview of VA Pharmacy databasFinding information in the VA PhardatabasesExamples of VA studies that have uthe VA Pharmacy databasesWh f hl ere to go 

for more 

h

elp

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

H h t ti t h tili How has ou

tpatient 

p

harmacy

utiliz

been measured in VA studies?Overview of VA Pharmacy databaseFinding information in the VA PhardatabasesExamples of VA studies that have uthe VA Pharmacy databasesWh f hl ere to go 

for more 

h

elp

RESEARCHERS’ GUIDE TO VA DATA
How has outpatient pharmacy utilization 

measured in VA studies?: 

Ch i M di ti U Chronic M

edication Use

S S ih troupe KT, S

mith BM,

et al. Effect of Increased Copayments on Pharmacy Use in the Department of Veterans Affairs. MedCare 2007; 45:1090 2007; 45:1090-

1097

How was pharmacy data utilized?

RESEARCHERS’ GUIDE TO VA DATA
How has outpatient pharmacy utilization 

measured in VA studies?: 

Quality of Care

Ti i A Tiwari A, R j a

jan M Mill D M, Miller D,

Pogach L, Pogach L, Olfson M, 

Sambamoorthi U. 

Guideline

-consistent 

antidepressant treatment patterns among veterans with diabetes and major depressive disorder. Psych Serv 2008; 59: 1139 2008; 59: 1139-1147.Ho as pha mac data Ho

w was phar

macy d

a

t

a

utilized?

RESEARCHERS’ GUIDE TO VA DATA
How has outpatient healthcare utilization 

measured in VA studies?: 

M di ti Adh M

edication Adherence

B CL A DH Bryson CL, A

u DH, 

McDonnell MB, McDonnell MB, Fihn 

Refill Adherence Al

Multiple Short InteEstimate Refill Com(ReComp). Med Ca497

-504.

How was 

p 

harmac

utilized?

RESEARCHERS’ GUIDE TO VA DATA
How has outpatient pharmacy utilization 

measured in VA studies?: 

Medication Use / Exposure

L TA Pi k d AS A DH Lee TA, Pi

c

kard AS, A

u DH,

Bartle B, Weiss KB. (2008). Risk for death associated with medications for recently diagnosed chronic obstructive pulmonary disease. Ann Intern Med., 149, 380-390.How was pharmacy data utilized?

RESEARCHERS’ GUIDE TO VA DATA
How has outpatient healthcare utilization 

measured in VA studies?:

Ri k dj s

k Adjustment

S l AE Li CH SS

ales AE, Li

u CH, S

al. Predicting costs using a pharmacy using a pharmacy-measure risk adjusveteran population2003; 41: 753 2003; 41: 753-760How was pharmacutilized?

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

H h t ti t h tili How has ou

tpatient 

p

harmacy

utili

been measured in VA studies?Overview of VA Pharmacy databasFinding information in the VA PhardatabasesExamples of VA studies that have uthe VA Pharmacy databasesWh f hl ere to go 

for more 

h

elp

RESEARCHERS’ GUIDE TO VA DATA
Pharmacy Pharmacy Data Sources Data Sources

Local Databases

– VistA– VISN Warehouses

National Data Sources

– PBM– DSS NDE Pharmacy SASR Datasets

Other Key Pharmacy Data Sources

– DSS Product Table– National Drug File

RESEARCHERS’ GUIDE TO VA DATA
Audience Poll

Which national sources of VA pharmdata have you used in the past?

– DSS NDE Pharmacy Data– PBM Pharmacy Data– Both– Neither

RESEARCHERS’ GUIDE TO VA DATA
VA Pharmacy Data Sources

VA Decision Support System (DSS) National Data Extract (NDE) PharmaDatasets

– Became available in 2003– Data from FY2002 to present– P i f d t i Vi tA P

rimary source

of d

a

t

a i

s Vi

stA

– All inpatient and outpatient prescriptions 

dis

p y ensed b

y a VAMC or VA Consolidated 

Outpatient Pharmacy (CMOP)

– Housed at Austin Information Technology 

(AITC) and directly accessible

RESEARCHERS’ GUIDE TO VA DATA
VA Pharmacy Data Sourc

VA Pharmacy Benefits Management (Database

– Available since 2000– Data from FY1999 to present– Primary source of data is VistA– Contains both inpatient and outpatient 

prescriptions

RESEARCHERS’ GUIDE TO VA DATA
PBM vs. DSS

PBM DS

Cost Drug supply cost Actual cost (ACT

Dispensing cost Supply cost (VS_

Access Researcher requested extract Direct accessD t il bilit Data availability FY1998 (O t ti t) FY1998 (Outpatient) FY2002 (O t ti 

FY2006 (Inpatient)

FY2002 (Outpati

Directions for Directions for SIG available

use

SIG available

RESEARCHERS’ GUIDE TO VA DATA
How Similar are PBM and DSS 

CSP 456 Hernia StudyP l ti opulation

– 1,591 Patients

Prescriptions

– Outpatient– FY2002– Fill d fill Fill

s and refill

s

– 42,469 prescriptions

Results

– High match rate between data sources– Discrepancy in only 1.7% of prescriptions 

R t A il bl t Report Avail

abl

e

a

t:

– http://www.virec.research.va.gov/Ref http://www.virec.research.va.gov/References/TechnicalRe

TechnicalReport1.pdf

RESEARCHERS’ GUIDE TO VA DATA
How Similar are PBM and DSS 

Limitations

– Outpatient only– Cohort not representative of whole populati

Conclusions

– DSS and PBM Pharmacy extracts capture sa

prescriptions

– DSS or PBM?

Future Com

parisons

– Inpatient data?– Representative Cohort

A d t l id f th 

Anec

d

o

t

al evidence

of 

other examp

where match is not as good

RESEARCHERS’ GUIDE TO VA DATA
Other Pharmacy Data Sour

DSS Product Table

– Key Variables

• IPNum, F d K D i ti ( h t 

Fee

der Key, Description (

s

hort a

Drug Class

• Feeder Ke

y => 1st 5 characters are VA 

p

file IEN; last 12 characters are NDC

– Available on DSS website

National Drug File

– Key Variables

• VA PRODUCT FEEDER NDF NDC VA C

VA

_

PRODUCT, FEEDER, NDF

_

NDC, VA

_

C

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

H h t ti t h tili How has ou

tpatient 

p

harmacy

utili

been measured in VA studies?Overview of VA Pharmacy databasFinding information in the VA PhardatabasesExamples of VA studies that have uthe VA Pharmacy databasesWh f hl ere to go 

for more 

h

elp

RESEARCHERS’ GUIDE TO VA DATA
Key Pharmacy Variables

Variable DSS PBMDays Supply X XDrug Description X XQuantity X XNDC X XMedication class X X

RESEARCHERS’ GUIDE TO VA DATA
Assessing Outpatient Pharmacy U

Finding info in VA Pharmacy Dataset

Where can I find cost variables?DSS and PBM contain different cost va

– PBM t f th d d t f th 

PBM: cost 

of th

e drug pro

duct from th

e sup

– DSS: 

1

) Dis

pg ( ) ensin

g Cost 

(DISPCOST

): direct 

pha

labor for dispensing the prescription and mailing costs

2) Supply Cost (VS_COST): Dru ) pp y ( )

g p roduct c

cost of supplies used in preparing the presuch as bottles and labels

3) Actual Cost (ACT_COST): Drug product c

of supplies such as bottles and labels to the prescription, indirect costs, and over

RESEARCHERS’ GUIDE TO VA DATA
Assessing Outpatient Pharmacy 

Finding info in VA Pharmacy Dataset

Why is the NDC for the same prescdifferent on the PBM record than oDSS record?The NDC’s are obtained from different sourcesDifferences can result if Local Drug File has not updated to reflect supply that was stocked whemedication was dis

pensed

Different NDC’s will refer to the same drug, dosage, and strength, but may indicate a different manufacturer and/or package size

RESEARCHERS’ GUIDE TO VA DATA
Assessing Outpatient Pharmacy 

Examples of Types of Questions Addressed wit

Data

Cohort identification

– Can pharmacy data be used to identify specific gro

patients?

Medication utilization

– Recent year? Longer historical view? Does policy ch

impact medication use?

Healthcare Quality

– Are patients being prescribed medications in accord

quality measures?

M di ti dh M

edication

adherence

– How much of a prescribed medication are patients 

Exposure to specific medications or medicatclasses

– Are specific drugs associated with better/worse out

Combining outpatient and pharmacy data to events

– Can we identify acute exacerbations of COPD with o

and prescription data?

Assessing comorbidity or case Assessing comorbidity or case-mix with med

mix with med

data

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

H h t ti t h tili How has ou

tpatient 

p

harmacy

utili

been measured in VA studies?Overview of VA Pharmacy databasFinding information in the VA PhardatabasesExamples of VA studies that have uthe VA Pharmacy databasesWh f hl ere to go 

for more 

h

elp

RESEARCHERS’ GUIDE TO VA DATA
How has outpatient pharmacy utilization 

measured in VA studies?: 

Ch i M di ti U Chronic M

edication Use

S S ih troupe KT, S

mith BM,

et al. Effect of Increased Copayments on Pharmacy Use in the Department of Veterans Affairs. MedCare 2007; 45:1090 2007; 45:1090-

1097

Objective: Evaluate the impact of copayment change for prescri ti d iption drugs onmedication use

RESEARCHERS’ GUIDE TO VA DATA
Chronic Medication Use:

Strou

pe et al. Med Care 2007

Chronic Medication 

Use

Chronic Medica

Use

• Number of 30-day equivalents dispensed over 12 month p• Days supply variable is key to analysis• Focused on “chronic” medications, excluded medications fp y atient did not receive an

y 30-da

y pp y su l

• Dispensing with less than 30-day supply was counted as 1 equivalent

RESEARCHERS’ GUIDE TO VA DATA
Chronic Medication Use:

Strou

pe et al. Med Care 2007

RESEARCHERS’ GUIDE TO VA DATA Adapted from Stroupe et al. 

Med Care 2007 Table 3
How has outpatient pharmacy utilization 

measured in VA studies?: 

Quality of Care

Ti i A Tiwari A, R j a

jan M Mill D M, Miller D,

Pogach L, Olfson M, Sambamoorthi U. Guidelineconsistent antidepressant treatment patterns among veterans with diabetes and major depressive disorder. P h S Psych Serv 2008 59 1139 2008; 59: 1139

-

1147.

Obj ti Objective: E ti t id li E

stima

t

e guid

elineconsistent antidepressant 

treatment of new episodes of 

depression in veterans with diabetes

RESEARCHERS’ GUIDE TO VA DATA
Quality of Care:

Tiwari et al Psych Services 2Tiwari et al. Psych Services 2

Cohort of patients with diabetes anepisode of major depressive episodG id li G

uid

eline-consi t t d i is

tent depression

treatment

– Antidepressant medication for at least 3 

within 6 months of initial diagnosis

Evaluated two outcomes

– Received antidepressant – Guideline-consistent antide

pressant use

RESEARCHERS’ GUIDE TO VA DATA
Quality of Care:

Tiwari et al Psych Services 2Tiwari et al. Psych Services 2

How was pharmacy data used?

Initial Antidepressant Rx

180 day follow-up period

Depression 120 days with no Follow-up Measures:

1 A A id

Date

antidepressant Rx 

from initial Rx 

following depression 

1. A

n

y

Antidepressant

2. Total days of therapy

Identify all antidepress

dia

gnosis d i f ll dur

i

n

g

follow-up (

(

Product name)

Sum days supply

RESEARCHERS’ GUIDE TO VA DATA
Quality of Care:

Tiwari et al Psych Services 2Tiwari et al. Psych Services 2

Received Antidepressant during follow Received Antidepressant during follow-up:

51%

Guideline Guideline-consistent depression: consistent depression:

31 4%.(62% of those with any antidepressant)

RESEARCHERS’ GUIDE TO VA DATA

Adapted from Tiwari et al 

Psych Serv 2008
Quality of Care:

Tiwari et al Psych Services 2Tiwari et al. Psych Services 2

RESEARCHERS’ GUIDE TO VA DATA

Adapted from Tiwari et al 

Psych Serv 2008
Quality of Care:

Tiwari et al Psych Services 2Tiwari et al. Psych Services 2

RESEARCHERS’ GUIDE TO VA DATA

Adapted from Tiwari et al 

Psych Serv 2008
How has outpatient healthcare utilization 

measured in VA studies?: 

M di ti Adh M

edication Adherence

B CL A DH Bryson CL, A

u DH, 

McDonnell MB, McDonnell MB, Fihn 

Refill Adherence Al

Multiple Short InteEstimate Refill Com(ReComp). Med Ca497

-504.

Ob

jective: Desi

gn 

based algorithm omedication use thused for short obsperiods

RESEARCHERS’ GUIDE TO VA DATA
Medication Adherence:

Bryson et al Med Care 200Bryson et al. Med Care 200

U d t f ACQUIP t 3 Use d

a

t

a from ACQUIP t ACQUIP t

o compare compare 3 m

of determining medication use

– MEDSUM – Dail

y yy p doses divided b

y da

ys in 

p

– MEDOUT – Number of medication gaps– ReComp – Algorithm for describing medicat

adherence

Evaluated the association between meadherence using the measures and ouf l t di ti for select medications

– Simvastatin and LDL– Antihypertensives and BP– Beta-blockers and heart rate

RESEARCHERS’ GUIDE TO VA DATA
Medication Adherence:

Bryson et al Med Care 200Bryson et al. Med Care 200

RESEARCHERS’ GUIDE TO VA DATA

From Bryson et al Med Care 2007
Medication Adherence:

Bryson et al Med Care 200Bryson et al. Med Care 200

From Bryson et al Med Care 2007

RESEARCHERS’ GUIDE TO VA DATA
Medication Adherence:

Bryson et al Med Care 200Bryson et al. Med Care 200

30-day 9

RESEARCHERS’ GUIDE TO VA DATA

Adapted from Bryson et al Med Care 2007
How has outpatient pharmacy utilization 

measured in VA studies?: 

Medication Use / Exposure

L TA Pi k d AS A DH Lee TA, Pi

c

kard AS, A

u DH,

Bartle B, Weiss KB. (2008). Risk for death associated with medications for recently diagnosed chronic obstructive pulmonary disease. Ann Intern Med., 149, 380-390.Objective: Examine association between COPD-related medication use and risk of death

RESEARCHERS’ GUIDE TO VA DATA
Medication Use / Exposur

Lee et al Ann Intern Med 2Lee et al. Ann Intern Med 2

Nested case Nested case-control study of patien

control study of patien

with newly diagnosed COPD

Id tifi d ll Identifi

ed 

all

-cause d i t and respira

tory

related and cardiovascular related and cardiovascular-related 

related 

Examined the association between respiratory medications and risk foevents

RESEARCHERS’ GUIDE TO VA DATA
Medication Use / Exposur

Lee et al Ann Intern Med 2Lee et al. Ann Intern Med 2

How was pharmacy data used?Pharmacy data was used to define medexposure in 6 months preceding an ind

– Medication use (yes / no)– Medication regimens– A i l d i / Actively treated patients / current users

– Amount of medication / dose

• Needed to 

q y uantify amount of use of inhaled 

• Pharmacy data not always easy to work with 

particularly true with regard to inhaled prod

– More straightforward to calculate cumul

exposure h d li i h bl / 

w

hen dealing

with tablets

/caps

with inhalers

RESEARCHERS’ GUIDE TO VA DATA
Medication Use / Expos

Lee et al Ann Intern Med Lee et al. Ann Intern Med 

RESEARCHERS’ GUIDE TO VA DATA
Medication Use / Exposur

Lee et al. Ann Intern Med 2

VA_PRODUCT

– Used to determine specific product– U d t d t i d t th Used t

o d

e

termine dose

s

trength

– Used to determine number of actuation

SIG

– Used to determine dosing frequency– Used to determine number of doses per 

RESEARCHERS’ GUIDE TO VA DATA
Medication Use / Exposur

Lee et al. Ann Intern Med 2

Calculation of cumulative ICS expos

– Determine strength for each prescription

• Fluticasone 220

μ

g

– C t t th t b l th i l 

Convert 

s

trength t

o beclomethasone equivale

• BDP_Equiv => 220*0.5 = 110

μg per dose

– Determine number of doses 

pp p er 

prescri

ption

• quantity dispensed * doses per product• 1 canister * 120 actuations/canister = 120 dos

– Calculate beclomethasone equivalents for eac

prescription and sum for cumulative exposure

RESEARCHERS’ GUIDE TO VA DATA
How has outpatient healthcare utilization 

measured in VA studies?:

Risk Adjustment

S l AE Li CH SS

ales AE, Li

u CH, S

al. Predicting costs using a pharmacy using a pharmacy-measure risk adjusveteran population2003; 41: 753 2003; 41: 753-760Objective: Compapharmacy based radjustment methoother methods in 

RESEARCHERS’ GUIDE TO VA DATA
Risk Adjustment:

Sales et al Med Care 200Sales et al. Med Care 200

Comparison of VA Comparison of VA-specific pharmac

specific pharmac

based risk adjustment model to othadjustment models (ACG HCC adjustment models (ACG, HCC, RxRDevelopment of a VA Development of a VA-based version 

based version 

RxRisk

( ) Chronic Disease Score

)

– Sloan KL, et al. Construction and characteri

RxRisk-V: a VA-adapted pharmacy-based ca

instrument. Med Care 2003; 41(6): 761

-74

– Includes 45 chronic disease categories iden

through Rx data

Potential value in using pharmacy

-

measures versus ICD measures versus ICD-based measu

based measu

RESEARCHERS’ GUIDE TO VA DATA
Risk Adjustment:

Sales et al Med Care 2003 Sales et al. Med Care 2003

RESEARCHERS’ GUIDE TO VA DATA

Adapted from Sales et al Med Care 2003
Session Objectives

H h t ti t h tili How has ou

tpatient 

p

harmacy

utili

been measured in VA studies?Overview of VA Pharmacy databasFinding information in the VA PhardatabasesExamples of VA studies that have uthe VA Pharmacy databasesWh f hl ere to go 

for more 

h

elp

RESEARCHERS’ GUIDE TO VA DATA
VIReC Help

VIReC Webpage

http://www.virec.research.va.gov

– Information on VA data sources and how 

access data

– Resource users guide for pharmacy data

• http://www virec research va gov/Referen

http://www.virec.research.va.gov/ReferenRUG-Pharmacy-2nd-Ed-er.pdf

RESEARCHERS’ GUIDE TO VA DATA
VIReC Help (cont’d)

HSRData Listserv

– Join at the VIReC Web site– Discussion amon

g 

 >400 data stewards

managers, and users

– Past messages in archive (on intranet)

VIReC Help Desk

– VIR Ce

C

st ff ill ti 

t

aff 

will answer your question a

direct you to available resources on to

– VIReC@va gov VIReC@va.gov

– (708) 202-2413

RESEARCHERS’ GUIDE TO VA DATA
Questions?

RESEARCHERS’ GUIDE TO VA DATA
Selected Recent References on 

VA Outpatient Pharmacy Use

Lee, T. A., Pickard, A. S., Au, D. H., Bartle, B., & Weiss, K. B. (2death associated with medications for recently diagnosed chropulmonary disease. Ann Intern Med., 149, 380-390.Sernyak, M. J. & Rosenheck, R. A. (2008). Antipsychotic use in of outpatients with schizophrenia in the VA from fiscal years 1Psychiatr Serv., 59, 567-569.Walbrown, M. A., Aspinall, S. L., Bayliss, N. K., Stone, R. A., CuSquier, C. L. et al. (2008). Evaluation of Clostridium difficile-asdiarrhea with a drug formulary change in preferred fluoroquinManag Care Pharm., 14, 34-40.Mortensen, E. M., Restrepo, M. I., Copeland, L. A., Pugh, J. A., ACornell, J. E. et al. (2007). Impact of previous statin and angioreceptor blocker use on mortality in patients hospitalized with 

patients hospitalized with 

Pharmacotherapy., 27, 1619-1626.Iqbal, S. U., Cunningham, F., Lee, A., Wang, S., Hamed, A., Mill(2007). Divalproex sodium vs. valproic acid: drug utilization ppersistence rates and predictors of hospitalization among VA pdi d ith bi l di d diagnosed 

with bipolar disor

der. J Cli n Pharm Th 32 er., 32, 625-6

Damush, T. M., Jia, H., Ried, L. D., Qin, H., Cameon, R., Plue, L. Case-finding algorithm for post-stroke depression in the veteradministration. Int J Geriatr Psychiatry., 23, 517-522..Frayne, S. M., Yu, W., Yano, E. M., Frayne, S. M., Yu, W., Yano, E. M., Ananth, L., Iqbal, S., Thrailk

Thrailk

(2007). Gender and use of care: planning for tomorrow's VeteAdministration. J Womens Health (Larchmt.)., 16, 1188-1199.

RESEARCHERS’ GUIDE TO VA DATA
Selected Recent References on 

VA Outpatient Pharmacy Use (co

Mahmood, M., Malone, D. C., Skrepnek, G. H., Abarca, J., ArmstrMurphy, J. E. et al. (2007). Potential drug-drug interactions witAffairs medical centers. Am J Health Syst Pharm., 64, 1500-150Davis, R. G., Hepfinger, C. A., Sauer, K. A., & Wilhardt, M. S. (20Retrospective evaluation of medication appropriateness and clinpharmacist drug therapy recommendations for home-based primveterans. Am J Geriat

r Pharmacothe

r., 5, 40-47.

Berlowitz, D. R. & Pugh, M. J. (2007). Pharmacoepidemiology in dwelling elderly taking antiepileptic drugs. Int Rev Neurobiol., 8153-163.Poon, I O . ., Lal, L Brown E N & Braun U K (2007) The imp

L., Brown, E. N., & Braun, U. K. (2007). The imp

pharmacist-managed oral anticoagulation therapy in older vetePharm Ther., 32, 21-29.Jia, H., Damush, T. M., Qin, H., Ried, L. D., Wang, X., Young, L. JThe impact of poststroke depression on healthcare use by veterstroke. Stroke., 37, 2796-2801.Fultz, S. L., Skanderson, M., Mole, L. A., Gandhi, N., Bryant, K., C(2006). Development and verification of a "virtual" cohortusing VA H l h I f i S VA Health I

n

formation System. M d C 44 M

ed Care., 44, S25-S30.

VIReC Technical Report: Comparison of VA Outpatient PrescriptDatasets and the PBM Databasehttp://vaww.virec.research.va.gov/References/TechnicalRepo

RESEARCHERS’ GUIDE TO VA DATA

icalReport1.pdf