title: Variation in Formulary Management Practices Within the Department of Veterans Affairs Health Care System.
abstract: BACKGROUND
  All Department of Veterans Affairs Medical Centers (VAMCs) operate under a single national drug formulary, yet substantial variation in prescribing and spending exists across facilities. Local management of the national formulary may differ across VAMCs and may be one cause of this variation.
  
  
  OBJECTIVE
  To characterize variation in the management of nonformulary medication requests and pharmacy and therapeutics (P&T) committee member perceptions of the formulary environment at VAMCs nationwide.
  
  
  METHODS
  We performed an online survey of the chief of pharmacy and an additional staff pharmacist and physician on the P&T committee at all VAMCs. Respondents were asked questions regarding criteria for use for nonformulary medications, specific procedures for ordering nonformulary medications in general and specific lipid-lowering and diabetes agents, the appeals process, and the formulary environment at their VAMCs. We compared responses across facilities and between chiefs of pharmacy, pharmacists, and physicians.
  
  
  RESULTS
  A total of 212 chief pharmacists (n = 80), staff pharmacists (n = 78), and physicians (n = 54) responded, for an overall response rate of 49%. In total, 107/143 (75%) different VAMCs were represented. The majority of VAMCs reported adhering to national criteria for use, with 38 (36%) being very adherent and 69 (65%) being mostly adherent. There was substantial variation between VAMCs regarding how nonformulary drugs were ordered, evaluated, and appealed. The nonformulary lipid-lowering drugs ezetimibe, rosuvastatin, and atorvastatin were viewable to providers in the order entry screen at 67 (63%), 67 (63%), and 64 (60%) VAMCs, respectively. The nonformulary diabetes medication pioglitazone was only viewable at 58 (55%) VAMCs. In the remaining VAMCs, providers could not order these nonformulary drugs through the normal order-entry process. For questions about the formulary environment, physician respondent perceptions differed from those of staff pharmacists and chief pharmacists. Compared with pharmacy chiefs and staff pharmacists, physicians were less likely to agree that providers at their VAMC prescribed too many nonformulary medications (47% and 44% vs. 12%, P < 0.001), more likely to agree that providers must jump through too many hoops to prescribe nonformulary medication (5% and 3% vs. 25%, P < 0.001), and more likely to agree that providers make an effort to convert new patients from nonformulary to formulary lipid-lowering (65% and 73% vs. 94%, P <0.02) and diabetic medications (49% and 50% vs. 88%, P < 0.001).
  
  
  CONCLUSIONS
  Although the Department of Veterans Affairs (VA) operates under a single national formulary, we found significant differences among VAMCs regarding their management of nonformulary medication requests. We also found differences among formulary leaders regarding their perception of the environment in which their VAMC's formulary is managed. These findings have important implications not just for VA, but for any organization that develops, implements, and manages drug formularies across multiple facilities.
authors.affiliation: 1 Clinical Instructor, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, and Clinical Research Fellow, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Radomski
authors.affiliation: 2 Professor, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine; Professor, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy; Core Investigator, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; and Chair, Medical Advisory Panel, and Co-director, VA Center for Medication Safety, Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, Illinois.
authors.forename: Chester B
authors.initials: CB
authors.lastname: Good
authors.affiliation: 3 Core Investigator, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and Assistant Professor, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania.
authors.forename: Carolyn T
authors.initials: CT
authors.lastname: Thorpe
authors.affiliation: 4 Statistician, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
authors.forename: Xinhua
authors.initials: X
authors.lastname: Zhao
authors.affiliation: 5 Assistant Professor, Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
authors.forename: Zachary A
authors.initials: ZA
authors.lastname: Marcum
authors.affiliation: 6 Staff Physician, VA Greater Los Angeles Healthcare System; Professor of Clinical Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles; and Chair, Medical Advisory Panel, and Co-director, VA Center for Medication Safety, Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, Illinois.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Glassman
authors.affiliation: 7 Associate Chief Consultant, Pharmacy Compliance and Efficiency, Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, Illinois.
authors.forename: John
authors.initials: J
authors.lastname: Lowe
authors.affiliation: 8 Director, Biostatistics and Informatics Core, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and Research Assistant Professor, Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Maria K
authors.initials: MK
authors.lastname: Mor
authors.affiliation: 9 Professor, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, and Director, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Fine
authors.affiliation: 10 Associate Professor, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, and Core Investigator, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
authors.forename: Walid F
authors.initials: WF
authors.lastname: Gellad
mesh_terms: D003695:Delivery of Health Care / Q000379:methods*; D003920:Diabetes Mellitus / Q000188:drug therapy; D019468:Disease Management; D011307:Drug Prescriptions; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D010595:Pharmacists; D010604:Pharmacy; D010607:Pharmacy Service, Hospital / Q000379:methods; D010820:Physicians; D014728:Veterans
chemical_list: D007004:Hypoglycemic Agents