Drug Reduction in Older Patients: The DROP Trial

对退伍军人医疗保健的预期影响：多种药物，在已发表的研究中定义为五种以上 药物，和hyperpolypharmacy，定义为超过10种药物，都是常见的老年人， 患者出院至专业护理机构（SNF）。最近的几项研究表明， VA和非VA医疗机构中老年患者使用多种药物的潜在不适当性。 其他研究表明，多种药物治疗可能导致老年社区的多种有害后果- 居住和住院人群，包括药物依从性降低，不良药物 事件和增加的医疗保健利用率和成本。多种药物和各种药物指数， 此外，还发现定量药物负荷与以下发展相关 老年综合征：认知障碍、谵妄、福尔斯、尿失禁和意外体重减轻。 我们创新的、以患者为中心的老年患者药物减量（DROP）干预具有巨大的潜力 影响大量老年退伍军人的健康，他们容易受到健康状况不佳的影响。是 在住院和SNF护理期间，老年患者经常获得新的老年综合征和药物 因此，当取消处方行动应该由VA护理提供者发起。此外，临床 在住院和SNF住院期间提供的监督允许药物变化的影响更大， 密切监测退伍军人在家时的安全情况。 项目目的：拟开展的随机对照试验将评价干预措施对 减少出院接受专业护理的住院老年退伍军人的药物暴露（DROP） 使用有效性-实施混合设计的SNF设施，为未来的传播工作提供信息。 项目背景/依据：出院至SNF的患者代表了医疗保险的最大部分 受益人出院到急性后护理服务，是一个特别高风险的群体， 独立性和其他不良临床结果。这个调查小组最近完成了一个VA资助的 质量改进奖和医疗保险和医疗补助服务中心（CMS）创新奖， 其中提供了与多种药物的患病率以及与药物滥用之间的关系有关的强有力的初步数据。 在多种药物和老年综合征之间（例如，与福尔斯相关的药物） 人口基于这些数据，我们开发并试点测试了以患者为中心的取消处方干预措施 结合八种老年综合征的标准化筛查评估， 在SNF住院期间进行监测。 项目方法：我们提出了一个创新的有效性，实施混合设计研究，将 在一家VA医院进行。建议的DROP干预的目标是安全地取消处方 药物，定义为剂量减少和停药，基于临床 标准和退伍军人的偏好。这项为期三年的随机对照试验将评估 这种基于医院的干预对药物暴露、药物依从性、老年综合征 从医院到SNF再到家庭的退伍军人护理过渡期间的健康状况， SNF出院后的随访期。我们的总体假设是，减少老年人的药物治疗， 退伍军人将有利地影响老年综合征。此外，我们的目标是了解退伍军人，无论是VA和 促进或阻碍干预有效性的非VA提供者和系统级因素， 在VA中的临床吸收和传播。

Anticipated Impact on Veterans Healthcare: Polypharmacy, defined in published studies as more than five medications, and hyperpolypharmacy, defined as more than 10 medications, are both common in older patients discharged to skilled nursing facilities (SNFs). Several recent studies demonstrate the prevalence and potential inappropriateness of polypharmacy among older patients in both VA and non-VA healthcare settings. Other studies have shown that polypharmacy can lead to multiple harmful outcomes among older community- dwelling and hospitalized populations including decreased medication adherence, increased adverse drug events and increased health care utilization and costs. Polypharmacy and a variety of drug indices that quantify drug burden have additionally been found to be associated with the development of the following geriatric syndromes: cognitive impairment, delirium, falls, urinary incontinence and unintentional weight loss. Our innovative, patient-centered Drug Reduction in Older Patients (DROP) intervention has significant potential to impact the health of a large population of older Veterans who are vulnerable to poor health outcomes. It is during hospitalization and SNF care that older patients often acquire new geriatric syndromes and medications and, thus, when deprescribing actions should be initiated by VA care providers. In addition, the clinical oversight provided during the hospital and SNF stays allows the effects of medication changes to be more closely monitored for safety relative to when the Veteran is at home. Project Objectives: The proposed randomized, controlled trial will evaluate the effects of an intervention to reduce exposure to medications (DROP) among hospitalized older Veterans discharged to skilled nursing facilities (SNFs) using an effectiveness-implementation hybrid design to inform future dissemination efforts. Project Background/Rationale: Patients discharged to SNF represent the largest segment of Medicare beneficiaries discharged to post-acute care services and are a particularly high risk group for loss of independence and other poor clinical outcomes. This investigative team recently completed a VA-funded Quality Improvement Award and a Centers for Medicare and Medicaid Services (CMS) Innovation Award, both of which provide strong preliminary data related to the prevalence of polypharmacy and the relationship between polypharmacy and geriatric syndromes (e.g., medications associated with falls) in this patient population. Based on these data, we developed and pilot-tested a patient-centered deprescribing intervention combined with standardized screening assessments for eight geriatric syndromes to be implemented in the hospital and monitored during the SNF stay. Project Methods: We propose an innovative effectiveness-implementation hybrid design study that will be conducted in one VA hospital. The goal of the proposed DROP intervention is to safely deprescribe medications, as defined by dose reductions and stopped medications, based on a combination of clinical criteria and Veteran preferences. This randomized, controlled trial conducted over three years will evaluate the effects of this hospital-based intervention on medication exposure, medication adherence, geriatric syndromes, and health status across Veterans’ care transitions from the hospital to SNF to home to include a 90-day follow-up period after SNF discharge. Our overarching hypothesis is that reducing medications for older Veterans will favorably impact geriatric syndromes. Additionally, we aim to understand Veteran, both VA and non-VA provider and system-level factors that facilitate or impede intervention effectiveness to inform future clinical uptake and dissemination throughout the VA.