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Schleiden LJ, Thorpe CT, Cashy JP, Gellad WF, Good CB, Hanlon JT, Mor MK, Niznik JD, Pleis JR, Van Houtven CH, Thorpe JM. Characteristics of dual drug benefit use among veterans with dementia enrolled in the Veterans Health Administration and Medicare Part D. Res Social Adm Pharm 2018; 15:701-709. [PMID: 30236896 DOI: 10.1016/j.sapharm.2018.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/29/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Obtaining prescription medications from multiple health systems may complicate coordination of care. Older Veterans who obtain medications concurrently through Veterans Affairs (VA) benefits and Medicare Part D benefits (dual users) are at higher risk of unintended negative outcomes. OBJECTIVE To explore characteristics predicting dual drug benefit use from both VA and Medicare Part D in a national sample of older Veterans with dementia. METHODS Administrative data were obtained from the VA and Medicare for a national sample of 110,828 Veterans with dementia ages 68 and older in 2010. Veterans were classified into three drug benefit user groups based on the source of all prescription medications they obtained in 2010: VA-only, Part D-only, and Dual Use. Multinomial logistic regression was used to examine predictors of drug benefit user group. The source of prescriptions was described for each of the ten most frequently used drug classes and opioids. RESULTS Fifty-six percent of Veterans received all of their prescription medications from VA-only, 28% from Part D-only, and 16% from both VA and Part D. Veterans who were eligible for Medicaid or who had a priority group score conferring less generous drug benefits within the VA were more likely to be Part D-only or dual users. Nearly one fourth of Veterans taking opioids concurrently received opioid prescriptions from dual sources (24.7%). CONCLUSIONS Medicaid eligibility and Veteran priority group status, which largely decrease copayments for drugs obtained outside versus within the VA, respectively, were the main factors predicting drug user benefit group. Policies to encourage single-system prescribing and enhance communication across health systems are crucial to preventing negative health outcomes related to care fragmentation.
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Affiliation(s)
- Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, United States.
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, United States
| | - John P Cashy
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of General Internal Medicine, School of Medicine, University of Pittsburgh, University of Pittsburgh Medical Center Montefiore Hospital, Suite W933, Pittsburgh, PA, 5213, United States
| | - Chester B Good
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, United States; Division of General Internal Medicine, School of Medicine, University of Pittsburgh, University of Pittsburgh Medical Center Montefiore Hospital, Suite W933, Pittsburgh, PA, 5213, United States; Center for Value Based Pharmacy Initiatives, University of Pittsburgh Medical Center, 600 Grant St, Pittsburgh, PA, 15219, United States
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, 3471 Fifth Ave, Kaufmann Medical Building, Suite 500, Pittsburgh, PA, 15213, United States
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, 130 De Soto St, Pittsburgh, PA, 15261, United States
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, United States; Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, 3471 Fifth Ave, Kaufmann Medical Building, Suite 500, Pittsburgh, PA, 15213, United States
| | - John R Pleis
- National Center for Health Statistics, Centers for Disease Control and Prevention, Division of Research and Methodology, 3311 Toledo Road, Hyattsville, MD, 20782, United States
| | - Courtney H Van Houtven
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, VA Medical Center (152), 508 Fulton St., Durham, NC, 27705, United States; Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Imperial Center, Durham, NC, 27713, United States
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, United States; Veterans Experience Center, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Annex Suite 202, Philadelphia, PA, 19104, United States
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Gellad WF, Thorpe JM, Zhao X, Thorpe CT, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Hausmann LRM, Donohue JM, Gordon AJ, Suda KJ, Stroupe KT, Hanlon JT, Cunningham FE, Good CB, Fine MJ. Impact of Dual Use of Department of Veterans Affairs and Medicare Part D Drug Benefits on Potentially Unsafe Opioid Use. Am J Public Health 2017; 108:248-255. [PMID: 29267065 DOI: 10.2105/ajph.2017.304174] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To estimate the prevalence and consequences of receiving prescription opioids from both the Department of Veterans Affairs (VA) and Medicare Part D. METHODS Among US veterans enrolled in both VA and Part D filling 1 or more opioid prescriptions in 2012 (n = 539 473), we calculated 3 opioid safety measures using morphine milligram equivalents (MME): (1) proportion receiving greater than 100 MME for 1 or more days, (2) mean days receiving greater than 100 MME, and (3) proportion receiving greater than 120 MME for 90 consecutive days. We compared these measures by opioid source. RESULTS Overall, 135 643 (25.1%) veterans received opioids from VA only, 332 630 (61.7%) from Part D only, and 71 200 (13.2%) from both. The dual-use group was more likely than the VA-only group to receive greater than 100 MME for 1 or more days (34.3% vs 10.9%; adjusted risk ratio [ARR] = 3.0; 95% confidence interval [CI] = 2.9, 3.1), have more days with greater than 100 MME (42.5 vs 16.9 days; adjusted difference = 16.4 days; 95% CI = 15.7, 17.2), and to receive greater than 120 MME for 90 consecutive days (7.8% vs 3.1%; ARR = 2.2; 95% CI = 2.1, 2.3). CONCLUSIONS Among veterans dually enrolled in VA and Medicare Part D, dual use of opioids was associated with more than 2 to 3 times the risk of high-dose opioid exposure.
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Affiliation(s)
- Walid F Gellad
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Joshua M Thorpe
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Xinhua Zhao
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Carolyn T Thorpe
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Florentina E Sileanu
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - John P Cashy
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Jennifer A Hale
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Maria K Mor
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Thomas R Radomski
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Leslie R M Hausmann
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Julie M Donohue
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Adam J Gordon
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Katie J Suda
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Kevin T Stroupe
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Joseph T Hanlon
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Francesca E Cunningham
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Chester B Good
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Michael J Fine
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
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