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: 10305696
• 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/10305696
• 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事件 (ADE) 高风险的弱势群体，尤其是 当他们从急诊室 (ED) 出院时。一半以上老年人出院 从急诊室离开并服用新的处方药。多项研究表明，5.6%-13% 之间 急诊室出院时为老年人开出的处方可能是不适当的药物 (PIM)。 在初级保健之外为老年退伍军人开新药增加了机会 对于次优处方以及药物不良事件 (ADE)，这都是重复就诊的主要原因， 住院或死亡。为了告知退伍军人事务部（VA）全系统的方法来改进 为了确保老年退伍军人的安全，我们提出了一项研究，以确定影响提供者的最佳实践 规定行为，以减少老年退伍军人在急诊室出院时开出的 PIM。 装备（提高从退役老兵的处方质量 急诊科）最初是作为一项创新的质量改进举措而设立的，旨在 减少 65 岁及以上成年人的 PIM 处方。 EQUIPPED QI 倡议提供了初步的 支持此提案的数据是为了响应学习健康系统提供者行为变化而编写的 射频消融。 EQUIPPED QI 干预措施最初由老年病学和延伸护理办公室资助，包括三个项目： 旨在影响提供者处方行为的组成部分： 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医嘱集提供决策支持； c) 学术 详细信息包括审核和反馈以及同行基准测试。 EQUIPPED 遵循啤酒标准， 这表明老年人应避免使用药物，因为 ADE 的风险增加。啤酒 标准被政府机构广泛使用，并得到各种环境下研究的支持，作为 规定质量。 EQUIPPED QI 干预已在 10 个 VA 急诊室实施。最初的 4 个结果 配备有现场学术详细信息的网站显示出持续的前后改进（减少） PIM 处方率在 6 个月时增加了近 50%，这表明文化改变的可能性 提供者规定行为。 EQUIPPED QI 干预通常涉及面对面的学术细节 使用审计和反馈以及同行基准测试，这需要更多的资源。 VA 已经使用 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学计划）； 然而，对于哪种策略在急诊科最有效，几乎没有任何指导。为了告知最佳 为了改善医疗服务提供者对急诊室老年退伍军人的处方行为，我们提出了一项装备策略 试验将 EQUIPPED 与积极的提供者反馈进行比较，包括学术详细信息 通过临床仪表板使用个人电子报告进行被动提供者反馈。 在一项并行集群随机试验中，我们将随机分配 8 个 VA 设施来实施配备 被动提供者反馈或主动提供者反馈。具体来说，所有站点都将实施 EQUIPPED 组成部分包括：有关啤酒标准的教学教育；通过订单集进行决策支持；和 每月提供者处方反馈。然而，被动的提供商反馈网站将每月实施 使用带有审计功能的新型临床仪表板，通过个人处方报告提供电子提供者反馈， 反馈和同行基准测试，而活跃的提供商反馈网站将实施一对一 (1:1) 的一对一 (1:1) 反馈 个人学术详细信息，包括现场审核、反馈以及同行基准测试和参与 与现场冠军。为了告知最终的传播策略，我们还将包括形成性的 作为 EQUIPPED 的一部分，对实施提供商反馈的两种方法进行评估和微观成本核算。

项目成果

A cluster-randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program.

对两种实施策略进行整群随机试验，以在 EQUIPPED 药物安全计划中提供审核和反馈。

• DOI: 10.1111/acem.14697
• 发表时间: 2023
• 期刊: Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
• 作者: Vaughan,CamilleP;Burningham,Zach;Kelleher,JessicaL;McGwin,Gerald;Jasien,ChristineL;Hastings,SNicole;Stevens,MelissaB;Morris,Isis;Jackson,GeorgeL;The EQUIPPEDVAImplementationQIGroup
• 通讯作者: The EQUIPPEDVAImplementationQIGroup