Reducing Potentially Inappropriate Medication Prescribing for Older Patients: Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUIPPED)

减少老年患者可能不适当的药物处方：提高急诊科老年人的医疗服务质量（EQUIPPED）

• 批准号: 10216350
• 负责人: George L. Jackson
• 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: 2018-10-01 至 2022-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10216350
• 关键词: Academic Detailing; Accident and Emergency department; Adult; Adverse drug event; Beer; Behavior; Benchmarking; Cessation of life; Clinical; Cluster randomized trial; Data; Drug Prescriptions; Education; Elderly; Emergency department visit; Feedback; Funding; Geriatrics; Government Agencies; Health system; Hospitalization; Individual; Intervention; Learning; Long-Term Care; Methods; Persons; Pharmaceutical Preparations; Pharmacy facility; Program Effectiveness; Provider; Qi; Randomized; Randomized Controlled Trials; Reporting; Research Support; Resources; Risk; Safety; Site; Structure; Surveys; System; Telephone Interviews; Time; United States Department of Veterans Affairs; Veterans; Visit; Vulnerable Populations; aged; arm; behavior change; clinical decision support; community living; compare effectiveness; comparison intervention; cost; dashboard; design; didactic education; dissemination strategy; effectiveness evaluation; formative assessment; high risk; improved; innovation; microcosting; novel; older patient; outreach; peer; primary care setting; primary outcome; programs; provider behavior; response; trial comparing

Older Veterans are a vulnerable population at high risk of medication adverse drug events (ADE) especially when they are discharged from the Emergency Department (ED). More than half of older adults discharged from the ED leave with a new prescription medication. Multiple studies show that between 5.6%-13% of prescriptions written for older adults at ED discharge represent a potentially inappropriate medication (PIM). Prescribing new medications for older Veterans outside the setting of primary care increases the opportunity for suboptimal prescribing as well as adverse drug events (ADEs), both major reasons for repeat ED visits, hospitalization or death. In order to inform a Veterans Affairs (VA) system-wide approach to improve prescribing safety for older Veterans, we propose a study to determine best practices for influencing provider prescribing behavior in order to decrease PIMs prescribed for older Veterans at the time of ED discharge. EQUIPPED (Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department) was initially established as an innovative quality improvement initiative designed to reduce PIM prescribing for adults aged 65 years and older. The EQUIPPED QI initiative provides preliminary data supporting this proposal written in response to the Learning Health System Provider Behavior Change RFA. Initially funded by the Office of Geriatrics and Extended Care, the EQUIPPED QI intervention has three components aimed at influencing provider prescribing behavior: a) provider education; b) electronic clinical decision support via specialized geriatric pharmacy order sets at the point of prescribing; and c) academic detailing including audit and feedback and peer benchmarking. EQUIPPED is informed by the Beers Criteria, which indicate drugs that should be avoided in older adults because of the increased risk of ADEs. The Beers Criteria are widely used by government agencies and supported by research in various settings as a marker of prescribing quality. The EQUIPPED QI intervention has been implemented in 10 VA EDs. Results from 4 of the initial EQUIPPED sites with in-person academic detailing demonstrated sustained pre-post improvement (reduction) in PIM prescribing rates by nearly 50% at 6 months, suggesting the possibility of culture change with regard to provider prescribing behavior. The EQUIPPED QI intervention typically involves in-person academic detailing using audit and feedback with peer benchmarking, which is more resource intensive. The VA already uses both passive feedback (i.e. dashboards to report psychotropic medication use in community living center residents) and active feedback (i.e. implementation of a national academic detailing pharmacy program); however, there is little guidance on which strategy is most effective in the ED. In order to inform the optimal EQUIPPED strategy for improving provider prescribing behavior toward older Veterans in ED, we propose a trial comparing EQUIPPED with active provider feedback including academic detailing to EQUIPPED with passive provider feedback using individual electronic reports via a clinical dashboard. In a parallel cluster randomized trial, we will randomize 8 VA facilities to implement EQUIPPED with either passive provider feedback or active provider feedback. Specifically, all sites will implement EQUIPPED components including: didactic education concerning the Beers Criteria; decision support by order sets; and monthly provider prescribing feedback. However, passive provider feedback sites will implement monthly electronic provider feedback via individual prescribing reports using a novel clinical dashboard with audit, feedback and peer benchmarking, while active provider feedback sites will implement one-to-one (1:1) in- person academic detailing that includes in-person audit, feedback, and peer benchmarking and engagement with an on-site champion. In order to inform the eventual dissemination strategy, we will also include formative evaluation and micro-costing of the two methods of implementing provider feedback as part of EQUIPPED.

老年退伍军人是药物不良反应(ADE)的高危人群，尤其是 当他们从急诊科出院时。超过一半的老年人出院 从急诊室带着新的处方药离开。多项研究表明，5.6%-13%的 在ED出院时为老年人开出的处方代表一种潜在的不适当药物(PIM)。 在初级保健之外为老年退伍军人开新药增加了机会 对于次优处方和不良药物事件(ADE)，这两个重复急诊室就诊的主要原因， 住院或死亡。为了向退伍军人事务部(退伍军人事务部)提供信息，以改善 为了给老年退伍军人开出安全处方，我们提议进行一项研究，以确定影响提供者的最佳实践 处方行为，以减少老年退伍军人在ED出院时开出的PIM。 装备(提高从退伍军人中退伍的老年退伍军人的护理质量 急诊部)最初是作为一项创新的质量改进计划设立的，旨在 减少65岁及以上成年人的PIM处方。装备QI计划提供了初步的 支持这项建议的数据是为回应学习健康系统提供者的行为变化而编写的 RFA。最初由老年医学和长期护理办公室资助，装备的QI干预有三个 旨在影响提供者处方行为的组件：a)提供者教育；b)电子临床 在开处方时通过专门的老年药房订单集提供决策支持；以及c)学术 详细说明，包括审计和反馈以及同行基准。装备符合比尔斯标准， 这表明老年人应该避免服用药物，因为ADE的风险增加了。《啤酒》 标准被政府机构广泛使用，并得到各种环境研究的支持，作为 处方质量。 装备QI干预已在10个VA急诊室实施。结果来自4个初始的 配备面对面学术细节的网站显示出岗位前的持续改善(减少) 在6个月时，PIM的处方率下降了近50%，这表明关于以下方面的文化改变的可能性 提供者开处方的行为。装备齐全的QI干预通常包括面对面的学术细节 将审计和反馈与同行基准结合使用，这会更加耗费资源。退伍军人管理局已经在使用 两种被动反馈(即报告社区生活中心精神药物使用情况的仪表板 (居民)和积极反馈(即实施国家学术详细药房计划)； 然而，关于哪种策略在教育署最有效，几乎没有指导意见。为了通知最优的 装备战略，以改善医疗服务提供者对急诊科老年退伍军人的处方行为，我们建议 配备了包括学术详细信息在内的主动提供者反馈的试验比较 通过临床仪表板使用单独的电子报告进行被动提供者反馈。 在一项平行的群组随机试验中，我们将随机选择8个退伍军人管理局设施，以实施配备 被动提供者反馈或主动提供者反馈。具体地说，所有地点都将实施配备 内容包括：关于啤酒标准的教学教育；通过订单集提供决策支持；以及 月度提供者开出反馈。但是，被动提供商反馈网站将按月实施 电子提供者通过使用带有审计的新型临床仪表板的个人处方报告进行反馈， 反馈和同行基准，而主动提供商反馈站点将在以下方面实施一对一(1：1)- 个人学术细节，包括面对面审计、反馈以及同行基准和参与 有一位现场冠军。为了通知最终的传播策略，我们还将包括形成性 作为装备的一部分，对实施提供者反馈的两种方法进行评价和微观成本计算。