A major role of the NPBM-CPPM group involves clinical document development, which is inclusive of the monograph-style documents used for formulary decision making. These clinical documents can be found stored on the PBM intranet sites, and most are under the Clinical Guidance subhead. Included among these documents are Drug Monographs used for formulary consideration, Criteria for Use (CFU), Abbreviated Reviews, Clinical Recommendations, and Drug Class Reviews. The various documents are designed to serve as resources for field practitioners to help optimize drug therapy for veterans.
The focus of the NPBM-CPPMs is to optimize pharmacotherapy from a population-based perspective. This focus is in contrast to the clinical pharmacy specialists who function at the facility level and focus primarily on patients in their particular geographic region. The NPBMCPPMs need to be familiar with the VA population as a whole. Although recognizing that every patient is different, NPBM-CPPMs develop clinical guidance documents that pertain to as many veterans as possible—typically about 80% of the population. About 20% of veterans may not possess the most common characteristics of an individual with a particular condition. If a common thread can be identified among this minority, then the focus of clinical guidance can expand to help improve the outcomes for this group, as well as educate VA providers.
Oncology NPBM-CPPMs
The field of oncology pharmacy has seen tremendous growth since it was originally recognized as a specialized field of pharmacy practice in 1998. At the same time, the FDA has approved many new drugs designated for oncologic conditions. 3 This expansion of drugs has led to an increase in the NPBM-CPPMs oncology workforce, allowing the CPPMs to “divide and conquer” their responsibilities with respect to the oncologic diseases and pharmacotherapeutic agents used to treat these specific conditions.
The FDA approval of an oncology drug means that an NPBM-CPPM needs to first determine the role and value of this drug to the veteran population. Knowing the most common oncologic conditions that afflict veterans helps to understand a drug’s importance to the VA. A number of common cancers among veterans include conditions associated with exposure to Agent Orange or other herbicides during military service and include chronic B-cell leukemias, Hodgkin lymphoma, non-Hodgkin lymphoma, multiple myeloma, and prostate cancer. 4 Aside from exposures related to military service, demographic and personal characteristics of the veteran population help determine the malignancies that put veterans at risk (eg, age and smoking history). It is apparent that colorectal cancer and lung cancer are among the most frequent tumor types detected among veterans.
Malignancies that are seen with less frequency in the VA are still important to the NPBM-CPPM. Breast cancer, for example, is a malignancy that afflicts a relatively small proportion of veterans, yet FDA-approved breast cancer drugs are reviewed for formulary consideration under the same national process.
Evidence-Based Determinations
The evidence-based drug monographs prepared for formulary consideration are approached in a consistent manner that takes into account clinical trial data published in peer-reviewed journals. In situations when peer-reviewed evidence is lacking, as in FDA-approval of a drug given Breakthrough Therapy designation, FDA Medical Review transcripts and abstracts from major meetings, such as the American Society of Clinical Oncology (ASCO), may be considered until published evidence is available.
