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

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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.