INNOVATIVE GERIATRIC PRACTICE MODELS: PRELIMINARY DATA
Enhancing the Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED): Preliminary Results from Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department, a Novel Multicomponent Interdisciplinary Quality Improvement Initiative Melissa B. Stevens, MD,a,b,c Susan Nicole Hastings, MD,d,e,f,g James Powers, MD,h,i,j Ann E. Vandenberg, PhD, MPH,c Katharina V. Echt, PhD,a,b,c William E. Bryan, III, PharmD,f Kiffany Peggs, MD,i,j Alayne D. Markland, DO, MSc,a,k Ula Hwang, MD, MPH,l,m,n William W. Hung, MD, MPH,l,n Anita J. Schmidt, RN, MEd,b Gerald McGwin, PhD,a,o Edidiong Ikpe-Ekpo, MD, MPH,b,p Carolyn Clevenger, RN, DNP,a,b,q Theodore M. Johnson, II, MD, MPH,a,b,c and Camille P. Vaughan, MD, MSa,b,c
Suboptimal medication prescribing for older adults has been described in a number of emergency department (ED) studies. Despite this, few studies have examined ED-targeted interventions aimed at reducing the use of potentially inappropriate medications (PIMs). Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the ED (EQUiPPED) is an ongoing multicomponent, interdisciplinary quality improvement initiative in eight Department of Veterans Affairs EDs. The project aims to decrease the use of PIMs, as identified by the Beers criteria, prescribed to veterans aged 65 and older at the time of ED discharge. Interventions include provider education; inforFrom the aDepartment of Veterans Affairs Birmingham, Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; b Atlanta Veterans Affairs Medical Center; cDepartment of Medicine, Emory University, Atlanta, Georgia; dDepartment of Veterans Affairs Geriatric Research, Education, and Clinical Center; eHealth Services Research and Development Center; fDurham Veterans Affairs Medical Center; gDepartment of Medicine, Duke University, Durham, North Carolina; hDepartment of Veterans Affairs Geriatric Research, Education, and Clinical Center; iTennessee Valley Veterans Affairs Health System; j Department of Medicine, Vanderbilt University, Nashville, Tennessee; k Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; lDepartment of Veterans Affairs, Geriatric Research, Education, and Clinical Center, Bronx, New York; m Departments of Emergency Medicine ; n Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; oDepartment of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama; pDepartment of Emergency Medicine; and qSchool of Nursing, Emory University, Atlanta, Georgia. Address correspondence to Melissa Stevens, Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA 30033. E-mail: [email protected] DOI: 10.1111/jgs.13404
JAGS 63:1025–1029, 2015 © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society
matics-based clinical decision support with electronic medical record–embedded geriatric pharmacy order sets and links to online geriatric content; and individual provider education including academic detailing, audit and feedback, and peer benchmarking. Poisson regression was used to compare the number of PIMs that staff providers prescribed to veterans aged 65 and older discharged from the ED before and after the initiation of the EQUiPPED intervention. Initial data from the first implementation site show that the average monthly proportion of PIMs that staff providers prescribed was 9.4 1.5% before the intervention and 4.6 1.0% after the initiation of EQUiPPED (relative risk = 0.48, 95% confidence interval = 0.40–0.59, P < .001). Preliminary evaluation demonstrated a significant and sustained reduction of ED-prescribed PIMs in older veterans after implementation of EQUiPPED. Longer follow-up and replication at collaborating sites would allow for an assessment of the effect on health outcomes and costs. J Am Geriatr Soc 63:1025–1029, 2015.
Key words: quality improvement; emergency department; inappropriate prescribing; aged 65 and older; veterans health
A
n increasing number of older adults are evaluated in emergency departments (EDs) annually.1 More than half are discharged without admission and receive a
0002-8614/15/$15.00
1026
STEVENS ET AL.
MAY 2015–VOL. 63, NO. 5
JAGS
improvement nurses, and clinical applications coordinators developed EQUiPPED using the Vision-Analysis-Team-AimMap-Measure-Change-Sustain model of process improvement, which was developed within the VA from Lean and Six Sigma principles.10 The primary goal of the project was to reduce ED prescribing of PIMs for veterans aged 65 and older at the time of ED discharge. PIMs were defined as American Geriatrics Society 2012 Beers Criteria Update11 Category 1 medications to avoid in all older adults. Chronic nonsteroidal anti-inflammatory drug (NSAID) prescriptions were defined as any dose for longer than 30 days. Research in various settings supports the Beers criteria, which are widely used as a marker of prescribing quality.12,13 Based on literature review and baseline data, the team set a goal of reducing PIM use to 5% or less.7
treatment plan, which frequently involves a new prescription medication.2 Suboptimal prescribing for older adults has been described in a number of ED-based studies over the past 3 decades.3,4 A study of veterans discharged from a Veterans Affairs (VA) Medical Center (VAMC) ED suggested that the use of potentially inappropriate medications (PIMs) was common and associated with a trend toward greater risk of repeat ED visits, hospitalization, or death.5 Newly released guidelines for geriatric ED care cite interventions to address prescribing quality as a specific goal for high-quality ED care.6 Previous studies in the ED and outpatient care settings suggest that electronic decision support and provider audit and feedback improve the quality of prescribing for specific high-risk medications.7,8 This article describes the design and implementation of Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED), a quality improvement initiative9 aimed at implementing evidence-based strategies to reduce prescribing of PIMs, and presents preliminary results from the first of eight sites to implement the model.
Intervention Components Provider Education A geriatrician presented a geriatric pharmacology lecture during three shifts over the course of a month for ED providers (November 2012, Figure 1). Twelve of 16 (75%) staff providers attended one of these sessions. ED staff also reviewed the 2012 Beers Criteria Update during a quarterly journal club held in January 2013. Finally, reminder cards identifying the top five most-frequently prescribed PIMs or PIM categories based on local prescribing trends were provided at computer stations in the ED.
METHODS Setting EQUiPPED is an ongoing quality improvement initiative in eight VA EDs. The design and implementation of EQUiPPED at the initial site, a large, urban VAMC with an average annual ED volume of 41,000 visits of which 40% represent veterans aged 65 and older are described. The ED employs a diverse group of staff providers, including board-certified physicians in emergency medicine (EM) (n = 7), internal medicine (IM) (n = 3), and family practice (n = 2); a dually board-certified EM/IM physician; advanced practice providers (n = 2); and a clinical pharmacist. The ED also uses more than 40 moonlighting physicians and midlevel providers who work from one to 20 shifts per month; these moonlighting providers did not participate in the initial phase of EQUiPPED.
Informatics-Based Clinical Decision Support Mapping the computerized provider order entry (CPOE) process identified multiple steps that could increase prescribing of PIMs in older veterans at the time of ED discharge. Existing discharge order sets consisted of an alphabetized list of commonly used medications without consideration of dosage adjustments for age or renal function. Interviews revealed that providers preferentially used the existing list for prescribing because it streamlined order entry and not because they necessarily felt the listed medications were superior choices. Subsequently, the EQUiPPED team developed geriatric outpatient pharmacy order sets grouped according to common discharge diagnoses with medication options
Program Development and Goals An interdisciplinary team comprising ED physicians, geriatricians, gerontologists, clinical pharmacists, quality
Timeline of EQUiPPED IntervenƟons
Provider EducaƟon Team Formed Concept Development
Order Sets
Journal Club
Academic Detailing
Reminder Cards
Beers Drug Messages
Figure 1. Timeline for Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED) implementation and evaluation.
JAGS
MAY 2015–VOL. 63, NO. 5
preferred for use in older adults. These templates were placed alongside existing order sets in the electronic medical record (EMR) order menu for all veterans checked into the ED. Dose adjustments for renal impairment, point-of-prescribing education regarding medications to avoid, and links to synthesized geriatric content were embedded within the order sets. When providers prescribed medications using the order sets, the order entry process was streamlined with prepopulated fields including: “days supply,” “number of pills,” and method for prescription pick-up. Pharmacists, ED providers, and the local VA pharmacy and therapeutics committee reviewed template logic that the group developed before implementation. In addition to expediting the order entry process, the order sets simultaneously encouraged providers to choose safer medications.14 The order sets were activated in February 2013.
Individual Provider Feedback
EQUIPPED: IMPROVING ED PRESCRIBING QUALITY
1027
Figure 2. Monthly percentage of potentially inappropriate medication (PIM) prescriptions by staff providers for veterans aged 65 years and older discharged from the emergency department (April 2012 to April 2014) (piecewise nonlinear regression).
All ED providers (n = 16) received at least one face-to-face feedback session using a process of individual practice pattern feedback (academic detailing), which has previously been demonstrated to be an effective method for changing provider prescribing practices alone or in combination with clinical decision support tools.8 Provider feedback included audit and feedback of individual prescribing patterns and peer benchmarking comparing individual performance with that of other ED providers at the same site.15,16 An ED staff physician colleague conducted feedback sessions over 3 months from February to April 2013. Each provider subsequently received standardized monthly reports that included total number of veterans aged 65 and older that they evaluated and discharged from the ED, total number of medications prescribed, and proportion of total medications that were PIMs. The reports also contained a breakdown of the drug classes for PIMs and peer benchmarking for the same time period.
tion of PIMs prescribed was 9.4 1.5%. This declined to 4.6 1.0% after the initiation of the EQUiPPED interventions (relative risk = 0.48, 95% confidence interval = 0.40–0.59, P < .001). Figure 2 shows the percentage of PIMs prescribed monthly from April 2012 through April 2014 with the results of a piecewise, nonlinear regression model. The model indicated that the inflection point occurred in April 2013 and that the observed change was sustained for the remainder of the evaluation period. At the facility, the top five most-frequently prescribed PIMs or categories as defined according to the Beers criteria were diphenhydramine, hydroxyzine, skeletal muscle relaxants, chronic NSAIDs, and promethazine. The proportion of prescriptions decreased for all of these except hydroxyzine and diphenhydramine. The greatest decrease occurred in the category of muscle relaxants, with a 60% relative reduction.
Program Evaluation
DISCUSSION
As a quality improvement project, the Department of Veterans Affairs Office of Geriatrics and Extended Care deemed the analysis of the EQUiPPED outcomes to be a nonresearch evaluation. The primary outcome of interest was the monthly number of PIMs as defined according to the Beers criteria that ED staff providers prescribed to veterans aged 65 and older at the time of discharge from the ED. Poisson regression was used to compare the number of PIMs prescribed in the 8 months before the first EQUiPPED intervention with 17 months of data from after the initial EQUiPPED intervention. The total number of prescriptions served as the offset term in the model, and a piecewise, nonlinear regression model was used to evaluate the pattern of PIMs prescriptions over time. Analyses were conducted using SAS version 9.2 (SAS Institute, Inc., Cary, NC).
The EQUiPPED program used provider education, clinical decision support for improved workflow in a CPOE or EMR, and provider feedback with audit and peer benchmarking in a busy urban VAMC. This intervention achieved the target reduction in the proportion of PIMs prescribed to older adults discharged from the ED (
Enhancing the Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED): Preliminary Results from Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department, a Novel Multicomponent Interdisciplinary Quality Improvement Initiative Melissa B. Stevens, MD,a,b,c Susan Nicole Hastings, MD,d,e,f,g James Powers, MD,h,i,j Ann E. Vandenberg, PhD, MPH,c Katharina V. Echt, PhD,a,b,c William E. Bryan, III, PharmD,f Kiffany Peggs, MD,i,j Alayne D. Markland, DO, MSc,a,k Ula Hwang, MD, MPH,l,m,n William W. Hung, MD, MPH,l,n Anita J. Schmidt, RN, MEd,b Gerald McGwin, PhD,a,o Edidiong Ikpe-Ekpo, MD, MPH,b,p Carolyn Clevenger, RN, DNP,a,b,q Theodore M. Johnson, II, MD, MPH,a,b,c and Camille P. Vaughan, MD, MSa,b,c
Suboptimal medication prescribing for older adults has been described in a number of emergency department (ED) studies. Despite this, few studies have examined ED-targeted interventions aimed at reducing the use of potentially inappropriate medications (PIMs). Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the ED (EQUiPPED) is an ongoing multicomponent, interdisciplinary quality improvement initiative in eight Department of Veterans Affairs EDs. The project aims to decrease the use of PIMs, as identified by the Beers criteria, prescribed to veterans aged 65 and older at the time of ED discharge. Interventions include provider education; inforFrom the aDepartment of Veterans Affairs Birmingham, Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; b Atlanta Veterans Affairs Medical Center; cDepartment of Medicine, Emory University, Atlanta, Georgia; dDepartment of Veterans Affairs Geriatric Research, Education, and Clinical Center; eHealth Services Research and Development Center; fDurham Veterans Affairs Medical Center; gDepartment of Medicine, Duke University, Durham, North Carolina; hDepartment of Veterans Affairs Geriatric Research, Education, and Clinical Center; iTennessee Valley Veterans Affairs Health System; j Department of Medicine, Vanderbilt University, Nashville, Tennessee; k Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; lDepartment of Veterans Affairs, Geriatric Research, Education, and Clinical Center, Bronx, New York; m Departments of Emergency Medicine ; n Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; oDepartment of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama; pDepartment of Emergency Medicine; and qSchool of Nursing, Emory University, Atlanta, Georgia. Address correspondence to Melissa Stevens, Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA 30033. E-mail: [email protected] DOI: 10.1111/jgs.13404
JAGS 63:1025–1029, 2015 © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society
matics-based clinical decision support with electronic medical record–embedded geriatric pharmacy order sets and links to online geriatric content; and individual provider education including academic detailing, audit and feedback, and peer benchmarking. Poisson regression was used to compare the number of PIMs that staff providers prescribed to veterans aged 65 and older discharged from the ED before and after the initiation of the EQUiPPED intervention. Initial data from the first implementation site show that the average monthly proportion of PIMs that staff providers prescribed was 9.4 1.5% before the intervention and 4.6 1.0% after the initiation of EQUiPPED (relative risk = 0.48, 95% confidence interval = 0.40–0.59, P < .001). Preliminary evaluation demonstrated a significant and sustained reduction of ED-prescribed PIMs in older veterans after implementation of EQUiPPED. Longer follow-up and replication at collaborating sites would allow for an assessment of the effect on health outcomes and costs. J Am Geriatr Soc 63:1025–1029, 2015.
Key words: quality improvement; emergency department; inappropriate prescribing; aged 65 and older; veterans health
A
n increasing number of older adults are evaluated in emergency departments (EDs) annually.1 More than half are discharged without admission and receive a
0002-8614/15/$15.00
1026
STEVENS ET AL.
MAY 2015–VOL. 63, NO. 5
JAGS
improvement nurses, and clinical applications coordinators developed EQUiPPED using the Vision-Analysis-Team-AimMap-Measure-Change-Sustain model of process improvement, which was developed within the VA from Lean and Six Sigma principles.10 The primary goal of the project was to reduce ED prescribing of PIMs for veterans aged 65 and older at the time of ED discharge. PIMs were defined as American Geriatrics Society 2012 Beers Criteria Update11 Category 1 medications to avoid in all older adults. Chronic nonsteroidal anti-inflammatory drug (NSAID) prescriptions were defined as any dose for longer than 30 days. Research in various settings supports the Beers criteria, which are widely used as a marker of prescribing quality.12,13 Based on literature review and baseline data, the team set a goal of reducing PIM use to 5% or less.7
treatment plan, which frequently involves a new prescription medication.2 Suboptimal prescribing for older adults has been described in a number of ED-based studies over the past 3 decades.3,4 A study of veterans discharged from a Veterans Affairs (VA) Medical Center (VAMC) ED suggested that the use of potentially inappropriate medications (PIMs) was common and associated with a trend toward greater risk of repeat ED visits, hospitalization, or death.5 Newly released guidelines for geriatric ED care cite interventions to address prescribing quality as a specific goal for high-quality ED care.6 Previous studies in the ED and outpatient care settings suggest that electronic decision support and provider audit and feedback improve the quality of prescribing for specific high-risk medications.7,8 This article describes the design and implementation of Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED), a quality improvement initiative9 aimed at implementing evidence-based strategies to reduce prescribing of PIMs, and presents preliminary results from the first of eight sites to implement the model.
Intervention Components Provider Education A geriatrician presented a geriatric pharmacology lecture during three shifts over the course of a month for ED providers (November 2012, Figure 1). Twelve of 16 (75%) staff providers attended one of these sessions. ED staff also reviewed the 2012 Beers Criteria Update during a quarterly journal club held in January 2013. Finally, reminder cards identifying the top five most-frequently prescribed PIMs or PIM categories based on local prescribing trends were provided at computer stations in the ED.
METHODS Setting EQUiPPED is an ongoing quality improvement initiative in eight VA EDs. The design and implementation of EQUiPPED at the initial site, a large, urban VAMC with an average annual ED volume of 41,000 visits of which 40% represent veterans aged 65 and older are described. The ED employs a diverse group of staff providers, including board-certified physicians in emergency medicine (EM) (n = 7), internal medicine (IM) (n = 3), and family practice (n = 2); a dually board-certified EM/IM physician; advanced practice providers (n = 2); and a clinical pharmacist. The ED also uses more than 40 moonlighting physicians and midlevel providers who work from one to 20 shifts per month; these moonlighting providers did not participate in the initial phase of EQUiPPED.
Informatics-Based Clinical Decision Support Mapping the computerized provider order entry (CPOE) process identified multiple steps that could increase prescribing of PIMs in older veterans at the time of ED discharge. Existing discharge order sets consisted of an alphabetized list of commonly used medications without consideration of dosage adjustments for age or renal function. Interviews revealed that providers preferentially used the existing list for prescribing because it streamlined order entry and not because they necessarily felt the listed medications were superior choices. Subsequently, the EQUiPPED team developed geriatric outpatient pharmacy order sets grouped according to common discharge diagnoses with medication options
Program Development and Goals An interdisciplinary team comprising ED physicians, geriatricians, gerontologists, clinical pharmacists, quality
Timeline of EQUiPPED IntervenƟons
Provider EducaƟon Team Formed Concept Development
Order Sets
Journal Club
Academic Detailing
Reminder Cards
Beers Drug Messages
Figure 1. Timeline for Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED) implementation and evaluation.
JAGS
MAY 2015–VOL. 63, NO. 5
preferred for use in older adults. These templates were placed alongside existing order sets in the electronic medical record (EMR) order menu for all veterans checked into the ED. Dose adjustments for renal impairment, point-of-prescribing education regarding medications to avoid, and links to synthesized geriatric content were embedded within the order sets. When providers prescribed medications using the order sets, the order entry process was streamlined with prepopulated fields including: “days supply,” “number of pills,” and method for prescription pick-up. Pharmacists, ED providers, and the local VA pharmacy and therapeutics committee reviewed template logic that the group developed before implementation. In addition to expediting the order entry process, the order sets simultaneously encouraged providers to choose safer medications.14 The order sets were activated in February 2013.
Individual Provider Feedback
EQUIPPED: IMPROVING ED PRESCRIBING QUALITY
1027
Figure 2. Monthly percentage of potentially inappropriate medication (PIM) prescriptions by staff providers for veterans aged 65 years and older discharged from the emergency department (April 2012 to April 2014) (piecewise nonlinear regression).
All ED providers (n = 16) received at least one face-to-face feedback session using a process of individual practice pattern feedback (academic detailing), which has previously been demonstrated to be an effective method for changing provider prescribing practices alone or in combination with clinical decision support tools.8 Provider feedback included audit and feedback of individual prescribing patterns and peer benchmarking comparing individual performance with that of other ED providers at the same site.15,16 An ED staff physician colleague conducted feedback sessions over 3 months from February to April 2013. Each provider subsequently received standardized monthly reports that included total number of veterans aged 65 and older that they evaluated and discharged from the ED, total number of medications prescribed, and proportion of total medications that were PIMs. The reports also contained a breakdown of the drug classes for PIMs and peer benchmarking for the same time period.
tion of PIMs prescribed was 9.4 1.5%. This declined to 4.6 1.0% after the initiation of the EQUiPPED interventions (relative risk = 0.48, 95% confidence interval = 0.40–0.59, P < .001). Figure 2 shows the percentage of PIMs prescribed monthly from April 2012 through April 2014 with the results of a piecewise, nonlinear regression model. The model indicated that the inflection point occurred in April 2013 and that the observed change was sustained for the remainder of the evaluation period. At the facility, the top five most-frequently prescribed PIMs or categories as defined according to the Beers criteria were diphenhydramine, hydroxyzine, skeletal muscle relaxants, chronic NSAIDs, and promethazine. The proportion of prescriptions decreased for all of these except hydroxyzine and diphenhydramine. The greatest decrease occurred in the category of muscle relaxants, with a 60% relative reduction.
Program Evaluation
DISCUSSION
As a quality improvement project, the Department of Veterans Affairs Office of Geriatrics and Extended Care deemed the analysis of the EQUiPPED outcomes to be a nonresearch evaluation. The primary outcome of interest was the monthly number of PIMs as defined according to the Beers criteria that ED staff providers prescribed to veterans aged 65 and older at the time of discharge from the ED. Poisson regression was used to compare the number of PIMs prescribed in the 8 months before the first EQUiPPED intervention with 17 months of data from after the initial EQUiPPED intervention. The total number of prescriptions served as the offset term in the model, and a piecewise, nonlinear regression model was used to evaluate the pattern of PIMs prescriptions over time. Analyses were conducted using SAS version 9.2 (SAS Institute, Inc., Cary, NC).
The EQUiPPED program used provider education, clinical decision support for improved workflow in a CPOE or EMR, and provider feedback with audit and peer benchmarking in a busy urban VAMC. This intervention achieved the target reduction in the proportion of PIMs prescribed to older adults discharged from the ED (
