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

老年退伍军人是药物不良反应（ADE）的高危人群， 当他们从急诊室（艾德）出院时。超过一半的老年人出院 从艾德那里拿到了一个新的处方药多项研究表明，5.6%-13%的 在艾德出院时为老年人开的处方代表潜在的不适当药物（PIM）。 在初级保健环境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），这两个都是重复艾德访视的主要原因， 住院或死亡。为了告知退伍军人事务部（VA）全系统的方法，以改善 规定安全的老年退伍军人，我们提出了一项研究，以确定最佳做法，影响供应商 处方行为，以减少老年退伍军人在艾德出院时的PIM处方。 提高退伍老兵处方实践的质量（Enhancing Quality of Prescribing Practices for Older Veterans Discharged from 急诊科）最初是作为一项创新的质量改进举措而设立的， 减少65岁及以上成人的PIM处方。该计划提供了初步的 支持本提案的数据是为了响应学习型医疗系统提供者行为变化而编写的 射频消融最初由老年病和延伸护理办公室资助， 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人药房订单集提供决策支持;以及c）学术 包括审计和反馈以及同行基准。Beers Criteria是Beers Criteria的缩写， 这表明老年人应该避免使用药物，因为增加了ADE的风险。啤酒 标准被政府机构广泛使用，并得到各种环境中研究的支持，作为 处方质量。 已在10个VA ED中实施了RIPPED QI干预。结果从4的初始 具有亲自学术详细说明的经认证的PED网站证明了持续的事前改进（减少） 在6个月时，PIM处方率接近50%，这表明在以下方面可能发生文化变化： 提供者处方行为。一般而言，经认证的合格中介人干预涉及亲自进行学术详细说明 使用审计和反馈，并采用同行基准，这需要更多的资源。VA已经使用 被动反馈（即，用于报告社区生活中心中精神药物使用的仪表板 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ED中最有效的指导很少。 为改善供应商对老年退伍军人在艾德处方行为的策略，我们提出了一个 试验比较BMPED与积极的提供者反馈，包括学术细节BMPED与 通过临床仪表板使用个人电子报告的被动提供者反馈。 在一项平行分组随机试验中，我们将随机分配8家VA机构， 被动提供者反馈或主动提供者反馈。具体而言，所有研究中心都将实施EMPED 组件包括：关于比尔斯标准的教学教育;订单集的决策支持;以及 每月提供处方反馈。但是，被动提供商反馈网站将每月实施 通过使用具有审计的新颖临床仪表板的个人处方报告的电子提供者反馈， 反馈和同行基准，而积极的供应商反馈网站将实施一对一（1：1）在- 个人学术细节，包括亲自审核、反馈以及同行基准和参与 现场冠军为了告知最终的传播战略，我们还将包括形成性的 评估和微观成本的两种方法，实施供应商反馈的一部分，可持续发展。

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.