VHA INNOVATION PROGRAM Innovation #554 Insulin Pen Project VHA ISB Business Case September 25, 2013.

VHA INNOVATION PROGRAMInnovation #554 Insulin Pen ProjectVHA ISB Business Case

September 25, 2013

VETERANS HEALTH ADMINISTRATION

Project Background

• Problem Statement – The traditional vial and syringe method of administering insulin is complex, involving over 15 separate steps. Many patients find the process daunting and are reluctant to start insulin therapy, increasing their risk for diabetes-related complications. Insulin pens offer an easier method for patients to administer insulin injections. Previous research has shown that patients prefer insulin pens and report significantly less fear of self-injecting. They also report improved ease of use/handling with insulin pens, a factor that is particularly important for patients with poor manual dexterity or vision. As a result, many studies have shown improved adherence to recommended insulin regimens with insulin pens as compared to traditional vial and syringe (1,2). The goal of this project is to offer insulin pens in lieu of insulin vials and syringes to Veterans at the VA Montana Health Care System. The anticipated benefits include improvements in clinical outcomes as measured by hemoglobin A1c (HbA1c) levels, reductions in the amount of time clinicians spend training patients to administer insulin therapy, decreased adverse events related to insulin misuse and improvements in patient satisfaction.

• Description of Proposed Solution – Begin offering insulin pens in lieu of vial and syringes in inpatient settings– Expand use of insulin pen in outpatient settings in select patient populations– Provide training to nursing staff, physicians, pharmacists, and diabetes educators on

insulin pen use– Collect outcomes data to evaluate the impact of providing insulin pens as opposed to

traditional vial and syringe 2


Execution Status

• Local deployment in the VA Montana Healthcare System• Pharmacy staff was not supportive due to cost concerns

– The pharmacy staff was not supportive because cost-effectiveness data are lacking– Previous studies highlight that the overall health care costs are similar or lower with

insulin pen as compared to vial and syringe (1-2)• The modest increase in the cost of pens versus syringe and vials is usually more than

compensated for in cost-savings from reduced utilization of inpatient and outpatient services as a result of better medication adherence and disease management

• High level, project specific, tasks required for enterprise deployment:– In depth data gathering completed to identify specific number of Veterans currently receiving syringe

and vial treatment– Six (6) month pilot at approximately six (6) sites and Class III to Class I verification performed prior to

national release

3


ISB Selection Criteria

4

Criteria See… Self-Assigned Score

Compliance Slide 4 1

Five-Year Net Operational Cost Change Slide 5 0

Implementation Cost Slide 6 -6

Clinical Impact (Broadness) Slide 7 10

Clinical Impact (Degree) Slide 7 10

Business Impact (Broadness) Slide 8 10

Business Impact (Degree) Slide 8 10

Patient Safety Slide 9 7

Patient Value Slide 10 10

Healthcare Disparity Slide 11 1

Summary Value = 1 * (14+38) = 52

Business Value = 0 + (-6) + 10 + 10 = 14

Clinical Value = 10 + 10 + 10 + 1 + 7 = 38


Business Case – Compliance

• The solution is compliant with regulations, including patient safety

5

Self Assigned Score: 1


Business Case – 5 Year Net Operational Cost Change

6


While the pharmacy costs associated with the insulin pen are greater than with a vial & syringe, reviews of the literature suggesting that replacing traditional vial and syringes with insulin pens is cost-neutral due to reduced utilization of inpatient, outpatient, and ER resources (improved adherence)

Cost Element Cost Difference

Pharmacy cost differences between insulin pen vs. vial & syringe (anti-hyperglycemic therapy HTs and self –monitoring blood glucose supplies)

+ $293

Total diabetes-related costs (pharmacy, outpatient, inpatient, and ER)

- $296

Cost Element Cost Difference

Annual diabetes-related healthcare costs with vial and syringe vs. insulin pens

$3970 vs. $4838

Total annual healthcare related costs with vial and syringe vs. insulin pends $13,214 vs. $13212

Authors reported there were no significant changes in health care costs

Authors reported there were no significant changes in health care costs

Lee et al., 2011 Baser et al., 2010


Business Case - Implementation Costs

7

Year 1 Year 2 Year 3 Year 4 Year 5

Pilot Phase $250,000 $0 $0 $0 $0

Deployment Phase $0 $125,000 $125,000 $125,000 $125,000

Annual Total $250,000 $125,000 $125,000 $125,000 $125,000

Cumulative Costs $250,000 $375,000 $500,000 $625,000 $750,000

Self Assigned Score: -6

• Identified cost based on oversight of deployment at facilities• Initiating insulin therapy with a pen device was associated with

comparable medication adherence and significant reductions in health care resource utilization and associated costs compared with vial/syringe insulin(3).


Business Case – Clinical Impact

• Broadness: This solution positively impacts three clinical performance metrics

8

Self Assigned Score, Broadness: 10Self Assigned Score, Degree: 10

Clinical Performance Metric Degree of Impact

Communication about medications 20% improvement

Discharge information 15% improvement

DM, HbA1 GT9 or not done, poor control (OP)

• Degree: This solution positively impacts these metrics in the following ways

- Improves communication of staff by simplifying process for educating patients- Improves quality of care by preventing medication errors- Improves accuracy of medication profiles - Eliminates Veteran confusion associated with administration of new medication- Limits adverse drug events and decreases patient misuse- Improves hospital admission/discharge communication on medications


Business Case – Business Impact

• Broadness: This solution positively impacts five business performance metrics

9

Self Assigned Score, Broadness: 10Self Assigned Score, Degree: 10

• Degree: This solution positively impacts these metrics in the following ways- Improves accuracy of medication profiles (medication reconciliation) for clinical decision making- Standardizes and streamlines process for patient instruction- Reduces amount of time clinicians spend providing training to patients on administering self-

injections- Reduces Patient confusion/intimidation of new prescription

Business Performance Metric Degree of Impact

Improved accuracy of decision making (quality of work) 25% improvement

Standardization of best practices (quality of work) 10% improvement

Reduces program or organizational risk (quality of work) 25% improvement

Reduces costs (VA staff efficiency or workflow) 5% improvement

Improves the environment of care (Veteran/beneficiary’s experience) 15% improvement


Business Case - Patient Safety

• This solution demonstratively improves patient safety

- Improves accuracy of medication administered by patients due to visual impairment

- Improves quality of care by preventing medication errors

- Limits adverse drug events and decreases patient misuse

- Eliminates Veteran confusion due to ease of use of pens vs. vial and syringe and dosage requirements

Evaluation CriteriaScored -10 to 10 where -10 is severe decrease in patient safety, 0 is no change in patient safety and +10 is very strong impact in patient safety

1. Demonstratively reduces preventative harm in this population: 62. Reduces mortality and morbidity in this population: 53. Improves patient safety by demonstratively reducing the chance of human error: 9

10



Business Case – Patient Value

• This solution significantly increases patient satisfaction

– Decreases Veterans risk of needle stick injuries with the pens as compared to vial and syringe creates a safer environment for clinicians and patients

– Improves patient satisfaction with ease of use of pens

– Improves training for patients by simplifying process to administer medication

– Improves availability/portability of prescriptions

– Improves Veteran Satisfaction by reducing needs of refrigeration of vial

11



Business Case – Healthcare Disparity

• This solution does not address a healthcare disparity

12



References

1. Baser, O., Bouchard, J., DeLuzio, T., Henk, H., & Aagren, M. (2010). Assessment of adherence and healthcare costs of insulin device (FlexPen) versus conventional vial/syringe. Advances in therapy, 27(2), 94–104.

2. Lee, L. J., Li, Q., Reynolds, M. W., Pawaskar, M. D., & Corrigan, S. M. (2011). Comparison of utilization, cost, adherence, and hypoglycemia in patients with type 2 diabetes initiating rapid-acting insulin analog with prefilled pen versus vial/syringe. Journal of medical economics, 14(1), 75–86.

3. Pawaskar MD, Camacho FT, Anderson RT, Cobden D, Joshi AV, Balkrishnan R. (2007)Health care costs and medication adherence associated with initiation of insulin pen therapy in medicaid-enrolled patients with type 2 diabetes: a retrospective database analysis.

13

http://www.ncbi.nlm.nih.gov/pubmed/18046929





Back Up Slides

14


Other Considerations – Environmental Impact

• Insulin Pen Project will:

- Reduce hazardous waste reaching landfills and major water sources- Discarded syringes- Unusable/expired vials on insulin

- Decrease availability and misuse of insulin therapy syringes for illegal drug use

15

VHA INNOVATION PROGRAM Innovation #554 Insulin Pen Project VHA ISB Business Case September 25, 2013.

Documents

Transcript of VHA INNOVATION PROGRAM Innovation #554 Insulin Pen Project VHA ISB Business Case September 25, 2013.