Pharmacy & Therapeutics - March 2008 - (Page 159) Compliance and Self-Monitoring of Blood Glucose chart to determine whether patients were using insulin or only oral agents. Patients using insulin were excluded, and the next name on the list was chosen. We followed this procedure in order to obtain a total of 20 patients from each site within the VISN 3 network. VISN 3 includes five sites: New York Harbor, Bronx, Hudson Valley, New Jersey, and Northport. Because we did not set out to evaluate the prescribing of test strips based on race or any other specific patient demographics, we made no attempt to obtain equal representation based on race. Every VA medical center has computerized provider order entry (CPOE) and pharmacy records that are integrated both locally and nationally. When we searched the database, we captured all of the test strips dispensed during the selected time period from each center. Because the report could not eliminate each patient who was receiving insulin by electronic means, we conducted a manual chart review to make that determination. We reviewed patients’ records to determine whether the local recommendation of 50 strips for the 90 days was being followed. At that time, the computer package did not allow for more precise compliance with the VHA/DoD guidelines. If the recommendation was not being followed, we reviewed the progress notes to decide whether there was a valid reason, according to the guidelines, for the extra strips. Acceptable reasons included the following: • if oral therapy was initiated • if therapy was adjusted or changed • if the health care provider decided that diabetes was not being well controlled (i.e., if patients were experiencing episodes of hypoglycemia or hyperglycemia). We calculated the number of excess strips dispensed per month for patients who did not have a valid reason for receiving them. On the basis of the number of extra strips dispensed, we calculated the potential cost savings. To avoid discrepancies among reviewers, only one person reviewed the charts; no repeated extraction of the records was conducted by the same individual. To determine the success of the new computer software package, we conducted another review of the test strips filled in January 2007. Once again, we performed a retrospective manual chart review of 100 randomly selected patients. We reviewed 20 charts from each of the five medical centers in VISN 3. This time, we examined the prescriptions to learn whether the new recommendation—50 strips for 180 days—was being followed. If not, we re-reviewed the progress notes to learn whether there was an acceptable reason for the extra strips. We evaluated only new or renewed prescriptions and excluded refills if the original prescription was written before November 1, 2006, the date on which the new computer software package was implemented. We then compared the August 2006 findings with the January 2007 reviews. After calculating the potential cost savings for each month and determining whether there were any differences between the two months, we extrapolated and calculated cost savings for all patients who were receiving test strips in VISN 3 and not using insulin. RESULTS Table 2 summarizes the results from the blood glucose test strip review of August 2006, prior to the cost savings initiative and the results of January 2007, after the cost-savings initiative was implemented. Of 100 patients, 17 non–insulin-using patients (17%) were found to have received an excess number of test strips based on the local VISN 3 recommendation of 50 strips for 90 days in August 2006. According to the data, VISN 3 could have saved $183.87 for the month of August 2006, with projected potential savings of $2,206.44 annually on the 17 prescriptions for which the recommendation was not followed. These dollar amounts were based only on the evaluation of 100 patients; if we had extrapolated them to include the entire population of non-insulin diabetic users of test strips in VISN 3 (13,740 patients), the potential projected annual savings would have been $303,191. We assumed that prescriptions were always refilled on their due date. Table 1 Management of Diabetes Mellitus Recommendations for Self-Monitoring of Blood Glucose Patients using oral agents For stable type-2 diabetes mellitus: no more than 50 strips per 150 days; this allows for twice-weekly testing. Additional strips may be needed for a limited time period for: • initiating therapy or adjusting oral agents, the meal plan, exercise, or activity. • detecting and preventing hypoglycemia if symptoms suggest its presence or if unawareness of hypoglycemia is documented. • detecting hyperglycemia if symptoms of urine glycosuria (in occasional patients using urine test strips) suggest its presence. • Frequency of monitoring should be individualized according to the frequency of insulin injections, hypoglycemic reactions, level of glycemic control, and the patient’s or health care provider’s use of the data to adjust therapy. • Preprandial and postprandial tests should be performed up to four times per day. Patients using insulin Adapted from Veterans Health Administration/Department of Defense, December 1999 (Update 2003).3 Vol. 33 No. 3 • March 2008 • P&T® 159
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