Evaluating the Use of Medicare Part D in the Veteran Population With Spinal Cord Injury/Disorder

Published:February 06, 2018DOI:



      To examine the different sources of medications, the most common drug classes filled, and the characteristics associated with Medicare Part D pharmacy use in veterans with spinal cord injury/disorder (SCI/D).


      Retrospective, cross-sectional, observational study.


      Outpatient clinics and pharmacies.


      Veterans (N=13,442) with SCI/D using Medicare or Veteran Affairs pharmacy benefits.


      Not applicable.

      Main Outcome Measures

      Characteristics and top 10 most common drug classes were examined in veterans who (1) used VA pharmacies only; (2) used both VA and Medicare Part D pharmacies; or (3) used Part D pharmacies only. Chi-square tests and multinomial logistic regression analyses were used to determine associations between various patient variables and source of medications. Patient level frequencies were used to determine the most common drug classes.


      A total of 13,442 veterans with SCI/D were analyzed in this study: 11,788 (87.7%) used VA pharmacies only, 1281 (9.5%) used both VA and Part D pharmacies, and 373 (2.8%) used Part D pharmacies only. Veterans older than 50 years were more likely to use Part D pharmacies, whereas those with traumatic injury, or secondary conditions, were less associated with the use of Part D pharmacies. Opioids were the most frequently filled drug class across all groups. Other frequently used drug classes included skeletal muscle relaxants, gastric medications, antidepressants (other category), anticonvulsants, and antilipemics.


      Approximately 12% of veterans with SCI/D are receiving medication outside the VA system. Polypharmacy in this population of veterans is relatively high, emphasizing the importance of health information exchange between systems for improved care for this medically complex population.


      List of abbreviations:

      Dual (Medicare Part D and VA pharmacy), HIE (health information exchange), Part D only (Medicare Part D pharmacy only), SCI/D (spinal cord injury/disorder), SCIDO (Spinal Cord Injury and Disorders Outcomes), UTI (urinary tract infection), VA (Department of Veterans Affairs), Veterans Affairs Only (Veterans Affairs pharmacy only)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Christopher & Dana Reeve Foundation. One degree of separation. Available at: Accessed March 14, 2018.

      2. National Spinal Cord Injury Statistical Center (NSCISC). 2015 SCI data sheet: spinal cord injury (SCI) facts and figures at a glance. Available at: Accessed March 7, 2016.

      3. Department of Veterans Affairs, Office of Public Affairs Media Relations. Fact sheet: VA and spinal cord injury. Available at: Accessed February 15, 2017.

        • Petersen L.A.
        • Byrne M.M.
        • Daw C.N.
        • Hasche J.
        • Reis B.
        • Pietz K.
        Relationship between clinical conditions and use of Veterans Affairs health care among Medicare-enrolled veterans.
        Health Serv Res. 2010; 45: 762-791
      4. Antos J, Helms R, McClellan M. The facts: Medicare Part D and prescription drug prices. Available at: Accessed March 15, 2018.

        • Stroupe K.T.
        • Smith B.M.
        • Bailey L.
        • et al.
        Medication acquisition by veterans dually eligible for Veterans Affairs and Medicare Part D pharmacy benefits.
        Am J Health Syst Pharm. 2017; 74: 140-150
        • Stroupe K.T.
        • Smith B.M.
        • Hogan T.P.
        • et al.
        Medication acquisition across systems of care and patient-provider communication among older veterans.
        Am J Health Syst Pharm. 2013; 70: 804-813
        • Rupper R.W.
        • Bair B.D.
        • Sauer B.C.
        • Nebeker J.R.
        • Shinogle J.
        • Samore M.
        Out-of-pocket pharmacy expenditures for veterans under Medicare Part D.
        Med Care. 2007; 45: S77-S80
        • Desai R.A.
        • Rosenheck R.A.
        The impact of managed care on cross-system use of mental health services by veterans in Colorado.
        Psychiatr Serv. 2002; 53: 1599-1604
        • Hynes D.M.
        • Koelling K.
        • Stroupe K.
        • et al.
        Veterans’ access to and use of Medicare and Veterans Affairs health care.
        Med Care. 2007; 45: 214-223
        • Trivedi A.N.
        • Grebla R.C.
        • Jiang L.
        • Yoon J.
        • Mor V.
        • Kizer K.W.
        Duplicate federal payments for dual enrollees in Medicare Advantage Plans and the Veterans Affairs health care system.
        JAMA. 2012; 308: 67-72
        • Wolinsky F.D.
        • Miller T.R.
        • An H.
        • Brezinski P.R.
        • Vaughn T.E.
        • Rosenthal G.E.
        Dual use of Medicare and the Veterans Health Administration: are there adverse health outcomes?.
        BMC Health Serv Res. 2006; 6: 131
        • Wolinsky F.D.
        • An H.
        • Liu L.
        • Miller T.R.
        • Rosenthal G.E.
        Exploring the association of dual use of the VHA and Medicare with mortality: separating the contributions of inpatient and outpatient services.
        BMC Health Serv Res. 2007; 7: 70
        • West A.N.
        • Charlton M.E.
        • Vaughan-Sarrazin M.
        Dual use of VA and non-VA hospitals by Veterans with multiple hospitalizations.
        BMC Health Serv Res. 2015; 15: 431
        • Pizer S.D.
        • Gardner J.A.
        Is fragmented financing bad for your health?.
        Inquiry. 2011; 48: 109-122
        • Nayar P.
        • Nguyen A.T.
        • Ojha D.
        • Schmid K.K.
        • Apenteng B.
        • Woodbridge P.
        Transitions in dual care for veterans: non-federal physician perspectives.
        J Community Health. 2013; 38: 225-237
        • Maher R.L.
        • Hanlon J.
        • Hajjar E.R.
        Clinical consequences of polypharmacy in elderly.
        Expert Opin Drug Saf. 2014; 13: 57-65
        • Akazawa M.
        • Imai H.
        • Igarashi A.
        • Tsutani K.
        Potentially inappropriate medication use in elderly Japanese patients.
        Am J Geriatr Pharmacother. 2010; 8: 146-160
        • Hovstadius B.
        • Petersson G.
        The impact of increasing polypharmacy on prescribed drug expenditure—a register-based study in Sweden 2005-2009.
        Health Policy Amst Neth. 2013; 109: 166-174
        • Leelakanok N.
        • Holcombe A.L.
        • Lund B.C.
        • Gu X.
        • Schweizer M.L.
        Association between polypharmacy and death: a systematic review and meta-analysis.
        J Am Pharm Assoc (2003). 2017; 57: 729-738.e10
        • Mallet L.
        • Spinewine A.
        • Huang A.
        The challenge of managing drug interactions in elderly people.
        Lancet. 2007; 370: 185-191
        • Lindblad C.I.
        • Artz M.B.
        • Pieper C.F.
        • et al.
        Potential drug-disease interactions in frail, hospitalized elderly veterans.
        Ann Pharmacother. 2005; 39: 412-417
        • Lindblad C.I.
        • Hanlon J.T.
        • Gross C.R.
        • et al.
        Clinically important drug-disease interactions and their prevalence in older adults.
        Clin Ther. 2006; 28: 1133-1143
        • Bourgeois F.T.
        • Shannon M.W.
        • Valim C.
        • Mandl K.D.
        Adverse drug events in the outpatient setting: an 11-year national analysis.
        Pharmacoepidemiol Drug Saf. 2010; 19: 901-910
        • Marcum Z.A.
        • Amuan M.E.
        • Hanlon J.T.
        • et al.
        Prevalence of unplanned hospitalizations caused by adverse drug reactions in older veterans.
        J Am Geriatr Soc. 2012; 60: 34-41
        • Hohl C.M.
        • Dankoff J.
        • Colacone A.
        • Afilalo M.
        Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department.
        Ann Emerg Med. 2001; 38: 666-671
        • Gurwitz J.H.
        • Field T.S.
        • Harrold L.R.
        • et al.
        Incidence and preventability of adverse drug events among older persons in the ambulatory setting.
        JAMA. 2003; 289: 1107-1116
        • VA Information Resource Center
        VIReC research user guide: fiscal year 2009 VHA medical SAS inpatient datasets.
        Department of Veterans Affairs, Health Services Research & Development Service, VA Information Resource Center, Hines2011
        • VA Information Resource Center
        VIReC research user guide: fiscal year 2009 VHA medical SAS outpatient datasets.
        Department of Veterans Affairs, Health Services Research & Development Service, VA Information Resource Center, Hines2011
        • Abrams T.E.
        • Vaughan-Sarrazin M.
        • Kaboli P.J.
        Mortality and revascularization following admission for acute myocardial infarction: implication for rural veterans.
        J Rural Health. 2010; 26: 310-317
        • Morgan R.O.
        • Petersen L.A.
        • Hasche J.C.
        • et al.
        VHA pharmacy use in veterans with Medicare drug coverage.
        Am J Manag Care. 2009; 15: e1-e8
        • Kripalani S.
        • LeFevre F.
        • Phillips C.O.
        • Williams M.V.
        • Basaviah P.
        • Baker D.W.
        Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.
        JAMA. 2007; 297: 831-841
        • Granfors M.T.
        • Backman J.T.
        • Neuvonen M.
        • Neuvonen P.J.
        Ciprofloxacin greatly increases concentrations and hypotensive effect of tizanidine by inhibiting its cytochrome P450 1A2-mediated presystemic metabolism.
        Clin Pharmacol Ther. 2004; 76: 598-606
        • Macey T.A.
        • Weimer M.B.
        • Grimaldi E.M.
        • Dobscha S.K.
        • Morasco B.J.
        Patterns of care and side effects for patients prescribed methadone for treatment of chronic pain.
        J Opioid Manag. 2013; 9: 325-333
        • French D.D.
        • Siddharthan K.
        • Bass E.
        • Campbell R.R.
        Benchmark data on the utilization and acquisition costs of central nervous system and muscular skeletal drugs among veterans with combat-related injuries.
        Mil Med. 2008; 173: 626-628
        • Suda K.J.
        • Smith B.M.
        • Bailey L.
        • et al.
        Opioid dispensing and overlap in veterans with non-cancer pain eligible for Medicare Part D.
        J Am Pharm Assoc (2003). 2017; 57: 333-340.e3
        • Gellad W.F.
        • Good C.B.
        • Shulkin D.J.
        Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs.
        JAMA Intern Med. 2017; 177: 611-612
        • Buscaglia A.
        • Paik M.C.
        • Lewis E.
        • Trafton J.A.
        Baseline variation in use of VA/DOD clinical practice guideline recommended opioid prescribing practice across VA health care systems.
        Clin J Pain. 2015; 31: 803-812
      5. National Center for Patient Safety. Opioid Therapy Guideline Adherence Report.

        • Byrne C.M.
        • Mercincavage L.M.
        • Bouhaddou O.
        • et al.
        The Department of Veterans Affairs’ (VA) implementation of the Virtual Lifetime Electronic Record (VLER): findings and lessons learned from health information exchange at 12 sites.
        Int J Med Inform. 2014; 83: 537-547
        • Hill J.N.
        • Smith B.M.
        • Weaver F.M.
        • et al.
        Potential of personal health record portals in the care of individuals with spinal cord injuries and disorders: provider perspectives.
        J Spinal Cord Med. 2017; : 1-11
        • Ford E.W.
        • Hesse B.W.
        • Huerta T.R.
        Personal health record use in the United States: forecasting future adoption levels.
        J Med Internet Res. 2016; 18: e73
        • Klein D.M.
        • Fix G.M.
        • Hogan T.P.
        • Simon S.R.
        • Nazi K.M.
        • Turvey C.L.
        Use of the Blue Button online tool for sharing health information: qualitative interviews with patients and providers.
        J Med Internet Res. 2015; 17: e199