Addressing inappropriate benzodiazepine prescribing among older Veterans

背景：苯二氮卓类药物（BZD）的使用是老年退伍军人的一个重要和持续的问题， BZD与不良结局的相关性，包括福尔斯、骨折、机动车事故、受损 认知，痴呆症风险增加和死亡率。2015财年，超过82，000名75岁以上的退伍军人 尽管有大量证据表明急性和慢性使用的危害， 从专业组织到限制使用。从2013财年开始，VA的精神药物安全倡议 （PDSI）开始监测各种精神病质量指标，包括≥75岁的退伍军人使用BZD 岁（以下简称“BZD≥75”）。在选择BZD≥75作为 作为一个优先事项，每个人都制定了自己的当地战略，以改善处方。为了让退伍军人事务部 在解决看似棘手的BZD处方问题方面取得了当地的成功， 建议是了解当地设施战略和产生这些战略的背景的组合， 成果。此外，了解这些策略的患者体验至关重要，因为 退伍军人可能会经历一些“成功”的战略，作为极其痛苦的。 这项工作可能会直接影响退伍军人的临床护理，是既有极大的兴趣和紧迫的 与我们的运营合作伙伴的相关性，包括PDSI，药房福利管理和学术 详细服务。 目标：目标1：确定急性和慢性BZD处方的高绩效和低绩效设施 优先考虑BZD≥75措施的设施。目标2：评估设施一级的战略和相关障碍 和促进者，以解决BZD≥75的目标沿着这些策略的可接受性，以老年人 老兵目标3：确定和试点测试设施的上下文敏感的战略，以成功地减少 老年退伍军人中的急性和慢性BZD使用。 方法：我们将使用全国VA管理数据的中断时间序列分析来检查BZD 在BZD≥75家优先机构中开处方（n=52）。我们将具体衡量以下变化：（1）急性 使用（新BZD开始）和（2）长期使用强度（平均日剂量[mg/天]）。作为一个探索性的潜艇- 为了达到这个目的，我们将通过设施测量跌倒相关损伤的发生率，以确定BZD处方的变化是否 与相关不良结局的变化相关。在目标2a中，我们将进行半结构化电话 与最多16家PDSI当地设施冠军和来自表现最好和最差的其他员工进行访谈 设施（在目标1中确定），然后与关键利益相关者进行现场半结构化访谈， 网站.我们将收集有关设施级别的策略、障碍和可能帮助或阻碍的促进者的信息 设施的努力。最后，我们将对老年退伍军人进行电话采访， 尝试逐渐减少，以了解患者是否经历了这些设施的战略作为痛苦。一个专家小组 的临床医生，研究人员和管理人员将审查策略，当地背景，相关的BZD 处方结果和患者可接受性，以开发一个上下文敏感的最佳实践工具包 可以实施以解决BZD的使用，然后我们将进行试点测试。

Background: Benzodiazepine (BZD) use is a significant and persistent concern among older Veterans given the association of BZDs with adverse outcomes including falls, fractures, motor vehicle accidents, impaired cognition, increased risk of dementia, and mortality. In FY2015, over 82,000 Veterans ≥75 years of age were prescribed a BZD despite abundant evidence of harms from both acute and chronic use and recommendations from professional organizations to limit use. Beginning in FY2013, the VA's Psychotropic Drug Safety Initiative (PDSI) began monitoring a variety of psychotropic quality measures, including BZD use among Veterans ≥75 years of age (hereafter referred to as “BZD≥75”). Among the 52 facilities (out of 140) that selected BZD≥75 as a priority, each developed its own local strategy to improve prescribing. In order for the VA to build upon local successes at addressing the seemingly intractable problem of BZD prescribing, the aim of this proposal is to understand the combinations of local facility strategies and context that generate these outcomes. In addition, it is critical to understand the patient experience of these strategies, as Veterans may experience some “successful” strategies as extremely distressful. This work may directly influence the clinical care of Veterans and is of both great interest and immediate relevance to our operational partners, including PDSI, Pharmacy Benefits Management, and the Academic Detailing Service. Objectives: Aim 1: Identify high- and low-performing facilities on acute and chronic BZD prescribing among facilities that prioritized the BZD≥75 measure. Aim 2: Assess facility-level strategies and associated barriers and facilitators to addressing the BZD≥75 goal along with the acceptability of those strategies to older Veterans. Aim 3: Identify and pilot test context-sensitive strategies for facilities to successfully reduce both acute and chronic BZD use among older Veterans. Methods: We will use interrupted time-series analyses of national VA administrative data to examine BZD prescribing across BZD≥75 priority facilities (n=52). We will specifically measure change in: (1) rate of acute use (new BZD initiation) and (2) intensity of chronic use (average daily dose [mg/day]). As an exploratory sub- aim, we will measure the rate of fall-related injury by facility to determine whether change in BZD prescribing is associated with change in associated adverse outcomes. In Aim 2a we will conduct semi-structured telephone interviews with up to 16 PDSI local facility champions and additional staff from top- and bottom-performing facilities (identified in Aim 1), followed by on-site, semi-structured interviews with key stakeholders at up to 6 sites. We will gather information on facility-level strategies, barriers, and facilitators that may help or hinder facility efforts. Finally, we will conduct telephone interviews with older Veterans prescribed chronic BZDs that attempted a taper to learn whether patients experienced these facility strategies as distressful. An expert panel of clinicians, researchers, and administrators will review the strategies, local context, associated BZD prescribing outcomes, and patient acceptability to develop a toolkit of context-sensitive best practices facilities can implement to address BZD use, which we will then pilot test.