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The American Journal of Managed Care August 2018
Impact of a Medical Home Model on Costs and Utilization Among Comorbid HIV-Positive Medicaid Patients
Paul Crits-Christoph, PhD; Robert Gallop, PhD; Elizabeth Noll, PhD; Aileen Rothbard, ScD; Caroline K. Diehl, BS; Mary Beth Connolly Gibbons, PhD; Robert Gross, MD, MSCE; and Karin V. Rhodes, MD, MS
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Andrew M. Heekin, PhD; John Kontor, MD; Harry C. Sax, MD; Michelle S. Keller, MPH; Anne Wellington, BA; and Scott Weingarten, MD
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Levers to Reduce Use of Unnecessary Services: Creating Needed Headroom to Enhance Spending on Evidence-Based Care
Michael Budros, MPH, MPP, and A. Mark Fendrick, MD
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Michael E. Chernew, PhD
Optimizing Number and Timing of Appointment Reminders: A Randomized Trial
John F. Steiner, MD, MPH; Michael R. Shainline, MS, MBA; Jennifer Z. Dahlgren, MS; Alan Kroll, MSPT, MBA; and Stan Xu, PhD
Impact of After-Hours Telemedicine on Hospitalizations in a Skilled Nursing Facility
David Chess, MD; John J. Whitman, MBA; Diane Croll, DNP; and Richard Stefanacci, DO
Baseline and Postfusion Opioid Burden for Patients With Low Back Pain
Kevin L. Ong, PhD; Kirsten E. Stoner, PhD; B. Min Yun, PhD; Edmund Lau, MS; and Avram A. Edidin, PhD
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Reducing Coprescriptions of Benzodiazepines and Opioids in a Veteran Population
Ramona Shayegani, PharmD; Mary Jo Pugh, PhD; William Kazanis, MS; and G. Lucy Wilkening, PharmD

Reducing Coprescriptions of Benzodiazepines and Opioids in a Veteran Population

Ramona Shayegani, PharmD; Mary Jo Pugh, PhD; William Kazanis, MS; and G. Lucy Wilkening, PharmD
This study evaluated a passive clinical pharmacist intervention to reduce the coprescribing of benzodiazepines and opioid analgesics by using chart review notes to alert providers.
For each identified patient, the psychiatric pharmacist reviewed the EHR and submitted a 1-time patient-specific chart review note in VA’s Computerized Patient Record System (CPRS). Each chart review note followed a template that included a list of patients’ underlying overdose risk factors, documented prior medication trials for the indication for which the BZD was prescribed (ie, anxiety, insomnia), recommended alternative treatment options to BZDs, and provided BZD stepwise tapering regimens. Opioid dosages were calculated as daily morphine milligram equivalents (MME) at baseline using a standard opioid conversion table, with high doses defined as 100 MME or higher.14 Other overdose risk factors assessed for each patient included being older than 55 years; history of airway abnormalities, such as asthma and chronic obstructive pulmonary disease; sleep apnea; renal and/or hepatic insufficiencies; substance use disorder; and concomitant use of alcohol.3,11 Diagnoses of PTSD were also included, given the increased risk of adverse treatment outcomes with combination therapy in this population.4,15 Urine drug screenings (UDSs) were considered timely if they were completed at least once within the past year from the date of chart review note entry, as indicated in the patients’ charts. Finally, current VA guideline recommendations for BZD tapering schedules were included as a reference for providers.16

Once the chart review notes were completed and submitted into the CPRS, the psychiatric pharmacist requested that the respective BZD prescriber also provide their signature, known as the additional signature, to the chart review note to confirm acknowledgment of the recommendation. The additional signature did not complete the note but simply indicated that the chart review note had been acknowledged. Also, prescribers were asked to indicate their intervention plans by creating an addendum to the original note. Prescribers had to log into the CPRS and check the View Alerts inbox feature, similar to an email inbox, to see the request for their additional signature pending for the completed chart review note.


After a 30-day period following entry of the chart review notes, data were collected regarding the number of providers who (1) acknowledged the chart review notes by providing their additional signature and (2) committed to the recommended interventions by initiating taper schedules.

Data Analysis

Descriptive statistics were used to report demographics and other patient-specific characteristics. Due to small sample sizes, both Pearson χ2 and Fisher exact tests were used to evaluate any significant differences in response rates to chart review notes between provider types (mental health vs primary care). All analyses were performed using SAS version 9.4 statistical software (SAS; Cary, North Carolina), and findings were considered significant if P <.05.


A total of 134 patients were identified as receiving both opioid and BZD prescriptions. After being reviewed for QIA criteria, 61 patients were included in the final analysis (Figure). The majority of patients were white (n = 48; 79%), male (n = 55; 90%), and at least 55 years old (n = 48; 79%; mean [SD] age = 61 [9] years). The primary indication for BZDs was anxiety (n = 40; 66%), followed by insomnia (n = 17; 28%) and then combined insomnia and anxiety (n = 4; 7%). All opioids in this analysis were prescribed for chronic noncancer pain; however, specific indications are not reported in this QIA. The MME calculated for 11 patients (18%) resulted in 100 mg or higher per day. About one-third of patients (n = 23; 38%) had a missing UDS within the past year, and 11 of these patients had never completed a UDS within this particular healthcare system (Table 1). Unique prescribers of BZDs within our cohort included 7 mental health practitioners and 14 primary care providers (PCPs). Among the 7 mental health practitioners, 57% (n = 4) were individually responsible for 5 or more coprescriptions, whereas 57% (n = 8) of PCPs were individually responsible for just 1 coprescription (Table 2).

During the 30-day follow-up period, 48% (n = 29) of chart review notes were acknowledged and 11% (n = 7) of prescriptions were tapered by providers. Mental health providers were less likely to provide their additional signature (χ2 = 4.62, df = 1, P = .0316; Fisher exact test, P = .0215) and initiate taper schedules (χ2 = 5.51, df = 1, = .0189; Fisher exact test, P = .0410) compared with PCPs (Table 3). Of the recommendations enacted by providers, taper schedules were initiated for BZDs (n = 3), opioids (n = 2), and both BZDs and opioids (n = 2). Providers reported future plans to discuss BZD taper initiation for 7 patients during their next clinic visits.

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