title: Outcomes of Pharmacy-Led Hepatitis C Direct-Acting Antiviral Utilization Management at a Veterans Affairs Medical Center.
abstract: BACKGROUND
  The Veterans Affairs Health (VA) Administration has reported hepatitis C virus (HCV) infection rates among veterans to be twice that of the general U.S population. New HCV direct-acting antiviral (DAA) treatment options offer superior sustained virologic response (SVR) rates, improved side-effect profiles, and shortened treatment courses; yet, these new HCV DAAs are expensive, and utilization management strategies are needed to optimize use and improve clinical outcomes. A VA medical center uses pharmacist-led HCV DAA utilization management strategies that includes clinical guidance, optimizing operational flow, budget tracking and forecasting, and patient outcomes tracking.
  
  
  OBJECTIVE
  To assess the economic and clinical outcomes of pharmacy-led HCV DAA utilization management in a VA medical center.
  
  
  METHODS
  This was a single-center, retrospective cohort study. Patient electronic health records and the hepatitis C DAA outcomes tracking database were reviewed at a VA medical center. Patients with an HCV DAA prior authorization drug request and therapy initiated between October 1, 2014, and September 30, 2015, were included. The primary endpoint was the ratio of drug spend to cure rate calculated as the total dollars spent to the number of patients achieving SVR at least 12 weeks from end of treatment. Secondary endpoints included economic, clinical, and safety outcomes.
  
  
  RESULTS
  A total of 372 patients were included in the study. The overall cost ratio of total drug spend to cure rate was $40,135.22. The overall cure rate was 94.1%, with no discontinuations due to treatment failure. The ratio of drug spend to cure rate was $41,907.35 and $38,430.77 in cirrhotic and noncirrhotic patients, respectively, and $39,481.62 and $39,178.74 in treatment-experienced and naive patients, respectively. Ten patients discontinued therapy because of the adverse effects of anemia, nausea, vomiting, and anxiety. The medication possession ratio was 98.7% (± 0.13) for all patients included in the study.
  
  
  CONCLUSIONS
  This study suggests that pharmacist-led HCV DAA utilization management is an important factor in costs and cure rates. Utilization management strategies are valuable to help adequately manage patients with chronic hepatitis C (CHC) and may allow practitioners to maximize available funding for CHC, while maintaining high efficacy and safety.
  
  
  BACKGROUND
  No outside funding supported this research. The authors have no conflicts of interest to report. Study concept and design were contributed primarily by Britt, along with Hashem, Brown, and Yang. Yang took the lead in data collection, along with Britt, and data interpretation was performed by all the authors. The manuscript was written and revised by Yang, Britt, Brown, and Hashem.
authors.affiliation: 1 Durham VA Health Care System, Durham, North Carolina.
authors.forename: Sendra
authors.initials: S
authors.lastname: Yang
authors.affiliation: 1 Durham VA Health Care System, Durham, North Carolina.
authors.forename: Rachel B
authors.initials: RB
authors.lastname: Britt
authors.affiliation: 1 Durham VA Health Care System, Durham, North Carolina.
authors.forename: Mohamed G
authors.initials: MG
authors.lastname: Hashem
authors.affiliation: 1 Durham VA Health Care System, Durham, North Carolina.
authors.forename: Jamie N
authors.initials: JN
authors.lastname: Brown
mesh_terms: D000998:Antiviral Agents / Q000191:economics / Q000627:therapeutic use*; D005260:Female; D016174:Hepacivirus / Q000187:drug effects*; D006526:Hepatitis C / Q000188:drug therapy* / Q000191:economics; D006801:Humans; D008297:Male; D008875:Middle Aged; D010593:Pharmaceutical Services; D010604:Pharmacy / Q000379:methods; D012189:Retrospective Studies; D017211:Treatment Failure; D016896:Treatment Outcome; D014728:Veterans
chemical_list: D000998:Antiviral Agents