2025 Southeastern Residency Conference

Title: Implementing a Population Management Tool for Specialty Gastrointestinal (GI) Medications in a Veterans Affairs Health Care System (VAHCS)
Authors: Alexandra Carlson, Azur Eckley

Background:
Pharmacologic therapy for moderate to severe Ulcerative Colitis (UC) and Crohn’s Disease (CD) includes high-cost, high-risk biologic agents such as infliximab, adalimumab, ustekinumab, vedolizumab, and risankizumab, as well as small molecule inhibitors such as upadacitinib and tofacitinib to induce and maintain remission. Barriers to success with these agents include adherence which can lead to the development of antidrug antibodies (ADAs) and can result in a loss of response or failure of therapy. With a limited number of medication options comes the need to ensure medication appropriateness, efficacy and adherence in our Veteran patients. This project aims to develop a population health management tool to assist pharmacists in making efficient and effective interventions to encourage improved clinical outcomes and patient adherence.
Methods:
In this prospective, quality improvement project, a population management tool, or “dashboard,” was created and implemented to make interventions at our local VAHCS from 11/14/24-3/14/25. Included were Veterans cared for by the Ralph H Johnson VAHCS and treated with one of either five biologic injectable agents or one oral small molecule inhibitor. Patients followed outside of our facility were excluded. Corporate Data Warehouse (CDW) program utilized to list patient name, medication, prescription details, lab values, appointment dates, and pertinent endpoint data to identify those overdue for next dose, without GI follow up and more. Our primary composite endpoint compared pre- and post-dashboard event rates of suboptimal response, which was defined by presence of >1 induction dose for select agents, short-term steroid prescriptions with UC/CD diagnosis, or admissions linked to diagnosis codes. The secondary outcome was to compare rates of nonadherence defined by patients having either delayed outpatient prescriptions based on proportion of days covered (PDC) <80%, or delayed infusion appointment if prescribed intravenous agent. The tertiary endpoint was to track the quantity and type of interventions made by a pharmacist. Clinical judgement was used to triage the urgency of interventions made and patients intervened on based on type of flag on the dashboard.
Results:
There were 110 total patients populated on the dashboard with UC or CD and prescribed one of the six select agents and this project compared event rates of both suboptimal response and nonadherence to biologics from pre- and post-dashboard periods. The primary endpoint showed a decrease in number of steroid prescriptions and re-induction doses but no improvement in number of admissions, with composite of 0.49 events per pt year in baseline period decreased to 0.25 in project period (p=0.107). Regarding the tertiary endpoint, the baseline time period reached 33 total patients, including 61 notes, and 62 interventions made while the project period reached 22 patients and included only 22 notes with a total of 139 interventions made. While there were differences in documentation of interventions, we found that overall notes per patient year decreased from 1.50 to 0.46 notes per patient year. With a statistically significant p-value of <0.001 our tertiary result highlights the utility in making efficient interventions.
Conclusion:
The Specialty GI dashboard proved to be an effective and efficient way to monitor patients on biologic agents or small molecule inhibitors for IBD showing a decrease in events rates of suboptimal response and nonadherence while increasing the amount of interventions made per patient. While only one endpoint proved to be statistically significant, this population management tool is easy to use and would benefit all members of the interdisciplinary healthcare team. Overall, increased use of this population health management tool will have a positive impact on patient-centered outcomes and encourage continued adherence to these specialty high-risk and high-cost agents.