Optimizing Appropriate Use of Medications for Veterans

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We have selected optimization of medication use as the main theme of our QUERI Program with decision support and provider networks as foci of implementation. Our proposal will build upon existing strong relationships between the project leads (who have a long history of conducting successful QUERI projects), and our operations partners including Pharmacy Benefits Management (PBM), Primary Care (PC), and Specialty Care Services. Primary Program Goal: To optimize medication management in the VA general and Patient Aligned Care Teams in particular using pharmacy networks and decision support tools. While the VA has implemented many interventions to improve medication safety, medication management has significant room for improvement. Several recommendations by the Institute of Medicine, including the wide availability of decision support and more pharmacy involvement in prescribing have not been widely implemented in the VA. In 2011, 12% of Veterans were prescribed a potentially inappropriate medication with an incidence (new inappropriate medication) of 6% per year. A large variation in the quality of medication prescribing has been noted in the VA which is comparable to the general population. There is also variation in quality of prescribing across disease states in the VA. Associated Goal: Value: Our underlying principle is to promote high value clinical care with all medication related interventions. We will only recommend expansion of, or design interventions for, care strategies that are considered a “reasonable” value (ratio of benefit and cost). We plan to improve use of high value medications, decrease use of low-value medications and improve medication safety through: 1) Optimization and expansion of the Medication Use Evaluation Tracker (MUET) of PBM. (Project 1) 2) Implementation of Clinical Decision Support for medications commonly prescribed in PC. (Project 2) 3) Local One-Year Project: Determine optimal use of the VISN 21 Pharmacy Dashboard targeting Patient Aligned Care Teams. (Project 3) These projects include both innovation (clinical decision support, use of communities of practice, development of a new Medication Use Evaluation Tracker) and evaluation of existing implementation practices. By taking advantage of natural experiments that have occurred as different facilities implemented the MUET program and VISN 21 Pharmacy Dashboard differently, we will be able to examine effectiveness and value of a variety of implementation strategies. Implementation Science Focus: Our chosen area of focus for implementation is the use of provider networks. As described below in the Implementation Core Section, through our prior QUERI work we have shown (in a randomized trial) how QUERI facilitation of a provider network can be successful in rolling out a national initiative (Hospital to Home) in the VA health system. Our results demonstrate that Provider networks can complement top down implementation strategies to improve care for Veterans. Such networks are an unrealized opportunity to improve care, and the VA is uniquely positioned to develop and use them. A long-term goal of the QUERI Program is to optimize infrastructure and implementation strategies using local providers (pharmacists in Project 1), clinical decision support (Project 2) and, dashboard data (Project 3) that can be used for a variety of clinical decisions beyond medication management such as elicitation of patient goals of care or monitoring functional status in patients with multiple morbidities. Thus, while our program applies directly to medication management, the methods developed and tested apply broadly to VA health care and address VA's Blueprint for Excellence's focus on leveraging information technologies and analytics while fostering an environment of continuous learning.