Addressing inappropriate benzodiazepine prescribing among older Veterans

解决老年退伍军人中不当使用苯二氮卓类药物的问题

• 批准号: 10186531
• 负责人: DONOVAN T MAUST
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-02-01 至 2022-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10186531
• 关键词: Academic Detailing; Acute; Address; Administrator; Age; Age-Years; Attention; Benzodiazepines; Cessation of life; Characteristics; Chronic; Chronic Obstructive Airway Disease; Cognition; Data; Distress; Dose; Elderly; Equipment and supply inventories; Fracture; Future; Goals; Health; Impaired cognition; Injury; Interruption; Intervention; Intervention Studies; Interview; Lead; Learning; Measures; Medical; Methods; Monitor; Opioid; Outcome; Overdose; Patient-Focused Outcomes; Patients; Pharmaceutical Preparations; Pharmacologic Substance; Physical Dependence; Policies; Professional Organizations; Provider; Psychological Dependence; Psychotropic Drugs; Recommendation; Research Personnel; Role; Services; Site; Site Visit; Structure; Telephone Interviews; Testing; Thinking; Time Series Analysis; Veterans; Work; adverse outcome; automobile accident; clinical care; dementia risk; effectiveness trial; experience; fall risk; falls; improved; interest; medication safety; member; mortality; mortality risk; pharmacy benefit; success; vehicular accident

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.

背景：苯二氮卓类药物 (BZD) 的使用是老年退伍军人中一个重大且持续存在的问题 BZD 与跌倒、骨折、机动车事故、受损等不良后果的关联 认知能力、痴呆风险增加和死亡率。 2015 财年，超过 82,000 名 75 岁以上的退伍军人接受了 尽管有大量证据表明急性和慢性使用的危害和建议，但还是开了 BZD 来自专业组织的限制使用。从 2013 财年开始，VA 的精神药物安全计划 (PDSI) 开始监测各种精神药物质量措施，包括 ≥75 岁退伍军人中 BZD 的使用情况 岁（以下简称“BZD≥75”）。在 52 家设施中（共 140 家）选择 BZD≥75 作为 作为优先事项，每个国家都制定了自己的本地战略来改进处方。为了使 VA 能够建立在 当地在解决 BZD 处方看似棘手的问题方面取得了成功，其目的 建议的目的是了解产生这些的当地设施策略和环境的组合 结果。此外，了解这些策略的患者体验也至关重要，因为 退伍军人可能会经历一些“成功”的策略，并感到极其痛苦。 这项工作可能会直接影响退伍军人的临床护理，并且具有极大的兴趣和直接的意义 与我们的运营合作伙伴的相关性，包括 PDSI、药品福利管理和学术机构 细节服务。 目标：目标 1：确定在急性和慢性 BZD 处方方面表现优异和表现不佳的机构 优先考虑 BZD≥75 措施的设施。目标 2：评估设施层面的策略和相关障碍 和促进者实现 BZD≥75 目标以及这些策略对老年人的可接受性 退伍军人。目标 3：确定并试点测试设施的环境敏感策略，以成功减少 老年退伍军人急性和慢性使用 BZD。 方法：我们将使用国家 VA 行政数据的间断时间序列分析来检验 BZD 在 BZD≥75 个优先设施中开处方 (n=52)。我们将具体衡量以下方面的变化：（1）急性发病率 使用（新的 BZD 起始）和（2）长期使用的强度（平均每日剂量[毫克/天]）。作为探索性子 目标，我们将按设施测量跌倒相关伤害的发生率，以确定 BZD 处方的变化是否 与相关不良后果的变化有关。在目标 2a 中，我们将进行半结构化电话 采访多达 16 名 PDSI 当地设施冠军以及来自表现最好和最差的其他员工 设施（目标 1 中确定的），然后与关键利益相关者进行最多 6 次的现场半结构化访谈 网站。我们将收集有关可能有助于或阻碍的设施级策略、障碍和促进因素的信息 设施努力。最后，我们将对服用慢性 BZD 的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感到这些设施策略感到痛苦。专家小组 临床医生、研究人员和管理人员将审查策略、当地情况、相关 BZD 处方结果和患者可接受性，以开发上下文敏感的最佳实践设施工具包 可以实施来解决 BZD 使用问题，然后我们将进行试点测试。