QUERI – Quality Enhancement Research Initiative

Evaluating the Impact of the Veterans Choice Act on Appropriateness of Opioid Therapy

West Haven, CT

Overview:

Under the Veterans Choice Act, the Veterans Choice Program (VCP) provides primary care, inpatient and outpatient specialty care, and mental healthcare for eligible Veterans when, for various reasons (e.g., long wait times), their local VAMC cannot provide those services. The VCA also will cover indicated Veterans' visits to private pain management providers and the accompanying prescriptions written, with most of these prescriptions filled in VA pharmacies, but some outside VA. Chronic pain is highly prevalent in Veterans and one of the most common reasons they seek medical care. Despite increasing rates of opioid prescribing, evidence supporting its use for chronic pain is modest, and serious safety and addiction issues appear to be increasing. Regarding unsafe medication combinations, benzodiazepines increase the sedative properties of opioids and are listed as co-ingestions in a large proportion of opioid overdose deaths. Given these potential harms, experts have called for restraint in opioid use, targeting de-implementation of high-dose therapy, avoidance of opioid-benzodiazepine co-prescribing, and promotion of non-pharmacological treatment, to which VA has responded with a proactive, multi-pronged approach. One major component of VA's effort is requiring VA healthcare facilities to contribute VA controlled substance prescribing data to state prescription drug-monitoring programs (PDMPs), which have provider-searchable databases that contain prescription data, listed by patient, of all controlled substance prescriptions listed in the state.

Objectives:

This QUERI evaluation project will work to decrease participants' risk of unsafe opioid receipt, defined as rapid dose escalation, exceeding a high-dose threshold, and/or co-receipt of benzodiazepine therapy. As part of this effort, project investigators will develop strategies for linking state PDMP to VA electronic health record data. These data will greatly impact this evaluation, and also can be used in future system-wide evaluations. In addition, investigators will pilot an application of this process to evaluate the Choice Program's impact on the appropriateness of opioid therapy, and will conduct a preliminary analysis of relevant provider behavior regarding opioid prescribing.

Methodology:

The only method for reliably capturing prescriptions filled by Veterans, in and outside the VA healthcare system, is to link with state prescription drug-monitoring programs (PDMPs) datasets. The fact that some VA pharmacies are already reporting to PDMP—indeed in some states all VHA pharmacies—will strengthen the accuracy of data capture.

Early Impacts:

Three state PDMPs have partnered with the investigators in this project to run queries of participants in the Veterans Choice Act in their datasets.

Operations Partner: VA Pharmacy Benefits Management (PBM) Services.

Principal Investigator: William Becker, MD; contact at William.Becker4@va.gov .