Development of a decision aid to help dually enrolled veterans make informed choices on medication sourcing

Veterans enrolled in both Veterans Affairs (VA) health care and Medicare Part D can choose to obtain medications through the VA, Medicare Part D, or both, with each option differing in cost, coverage, and coordination of care. Poorly informed choices can lead to veteran frustration when their expectations are not met, delays in medication access, and increased risks. This study aimed to develop a decision aid (DA) to help veterans with diabetes make informed choices about medication sourcing (ie, whether to fill medications through VA health care only, Part D only, or both).

DA development was guided by the International Patient DA Standards and the Ottawa Decision Support Framework. Interviews with veterans and care partners informed the prototype design. Alpha testing with 18 end users (mostly veterans) and 12 stakeholders (pharmacists, doctors, payers, Medicare counselors, and others) assessed comprehensibility, usability, and acceptability. During beta testing, the feasibility of the revised DA was assessed during interviews with 20 end users and 8 stakeholders. For end-user interviews, a survey assessing decisional conflict, satisfaction, and knowledge was provided before and after respondents filled out the DA.

Alpha testing feedback led to simplifying the cost and formulary comparison chart and expanding the medication list template to include more medications, fill location, and prescriber contact information. Based on beta testing responses (n = 16), the mean system usability scale score for the DA was 77.5 (SD = 14.4), suggesting usability. Beta testers also reported the DA to be acceptable in length (94%), balance (88%), and amount of information (81%). Based on pre- vs post-DA survey responses, decisional conflict was reduced, as indicated by an increase in the mean Sure of myself; Understand information; Risk-benefit ratio; Encouragement (SURE) score (pre-DA: 3.1, SD = 1.4 to all 16 respondents reporting a maximum SURE score of 4.0). Knowledge about VA and Medicare coverage of diabetes medications also improved: the proportion who answered all 5 comprehension questions correctly increased from 57% to 81%. Last, the proportion of respondents who reported being "very satisfied" with how they were currently filling their diabetes medicines (VA only, Part D only, or both) improved from 64% pre-DA to 81% post-DA.

The DA developed iteratively was usable and acceptable and showed potential in reducing decisional conflict, increasing knowledge, and increasing satisfaction, so it may help Part D-enrolled veterans with decisions about medication sourcing.