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中一个重要且持续的问题 BZD与跌倒、骨折、机动车事故、损伤等不良后果的关系 认知、痴呆症风险增加和死亡率。在2015财年，超过82,000名75岁的退伍军人≥ 尽管有大量证据表明急性和慢性使用和建议使用BZD会造成危害，但仍需开出BZD 从专业组织到限制使用。从2013财年开始，退伍军人管理局的精神药物安全倡议 (PDSI)开始监测各种精神药物质量指标，包括在退伍军人中使用苯扎西林≥75 年(下称“bzd≥75”)。在52家选择必和必拓≥75作为 一个优先事项是，每个国家都制定了自己的地方战略，以改善处方。为了让退伍军人事务部建立在 当地在解决BZD处方这一看似棘手的问题上取得的成功，其目的是 建议是了解当地设施战略和环境的组合，从而产生这些 结果。此外，了解这些策略的耐心体验是至关重要的，因为 退伍军人可能会体验到一些非常痛苦的“成功”策略。 这项工作可能会直接影响退伍军人的临床护理，具有重大的意义和迫切性 与我们的运营合作伙伴相关，包括PDSI、药房福利管理和学术 详细服务。 目标：目标1：确定急、慢性BZD处方中的高绩效和低绩效机构 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 和推动者，以实现BZD≥75目标以及这些策略对较老的人的接受度 退伍军人。目标3：为设施确定并试行测试上下文相关策略，以成功地减少 老年退伍军人中急性和慢性BZD的使用。 方法：采用国家退伍军人管理局数据的中断时间序列分析方法对BZD进行检验 在必和必拓≥开出75个优先设施(n=52)。我们将具体衡量以下方面的变化：(1)急性 使用(新的BZD)和(2)长期使用的强度(平均每日剂量[毫克/天])。作为一名探索者- 目的，我们将测量跌倒相关伤害的比率，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 采访了多达16家PDSI本地设施冠军和来自业绩最好和最差的员工 设施(在目标1中确定)，随后与关键利益攸关方进行现场半结构化访谈，最多6次 网站。我们将收集有关设施级别的策略、障碍和促进者的信息，这些策略、障碍和促进者可能会帮助或阻碍 设施方面的努力。最后，我们将对开出慢性BZD的老年退伍军人进行电话采访， 试图了解患者是否经历了这些设施策略的痛苦。专家小组 临床医生、研究人员和管理人员将审查策略、当地背景、相关的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工具工具包 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.