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Vandenberg AE, Hwang U, Das S, Genes N, Nyamu S, Richardson L, Ezenkwele U, Legome E, Richardson C, Belachew A, Leong T, Kegler M, Vaughan CP. Scaling the EQUIPPED medication safety program: Traditional and hub-and-spoke implementation models. J Am Geriatr Soc 2024; 72:2184-2194. [PMID: 38259070 DOI: 10.1111/jgs.18746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/09/2023] [Accepted: 12/09/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND The EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) medication safety program is an evidence-informed quality improvement initiative to reduce potentially inappropriate medications (PIMs) prescribed by Emergency Department (ED) providers to adults aged 65 and older at discharge. We aimed to scale-up this successful program using (1) a traditional implementation model at an ED with a novel electronic medical record and (2) a new hub-and-spoke implementation model at three new EDs within a health system that had previously implemented EQUIPPED (hub). We hypothesized that implementation speed would increase under the hub-and-spoke model without cost to PIM reduction or site engagement. METHODS We evaluated the effect of the EQUIPPED program on PIMs for each ED, comparing their 12-month baseline to 12-month post-implementation period prescribing data, number of months to implement EQUIPPED, and facilitators and barriers to implementation. RESULTS The proportion of PIMs at all four sites declined significantly from pre- to post-EQUIPPED: at traditional site 1 from 8.9% (8.1-9.6) to 3.6% (3.6-9.6) (p < 0.001); at spread site 1 from 12.2% (11.2-13.2) to 7.1% (6.1-8.1) (p < 0.001); at spread site 2 from 11.3% (10.1-12.6) to 7.9% (6.4-8.8) (p = 0.045); and at spread site 3 from 16.2% (14.9-17.4) to 11.7% (10.3-13.0) (p < 0.001). Time to implement was equivalent at all sites across both models. Interview data, reflecting a wide scope of responsibilities for the champion at the traditional site and a narrow scope at the spoke sites, indicated disproportionate barriers to engagement at the spoke sites. CONCLUSIONS EQUIPPED was successfully implemented under both implementation models at four new sites during the COVID-19 pandemic, indicating the feasibility of adapting EQUIPPED to complex, real-world conditions. The hub-and-spoke model offers an effective way to scale-up EQUIPPED though a speed or quality advantage could not be shown.
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Affiliation(s)
- Ann E Vandenberg
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ula Hwang
- Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York, USA
- James J. Peters VA Medical Center GRECC, Bronx, New York, USA
| | - Shamie Das
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nicholas Genes
- Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Sylviah Nyamu
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lynne Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ugo Ezenkwele
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric Legome
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Adam Belachew
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Michelle Kegler
- Department of Behavioural, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Camille P Vaughan
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Birmingham/Atlanta VA GRECC, Atlanta, Georgia, USA
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Syed Q, McGwin G, Burningham Z, Kelleher JL, Mather J, Hastings SN, Stevens MB, Morris I, Jackson GL, Vaughan CP. Gabapentinoid prescribing in Veterans Administration emergency departments implementing EQUIPPED. J Am Geriatr Soc 2024; 72:1265-1268. [PMID: 38243674 DOI: 10.1111/jgs.18759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 11/22/2023] [Accepted: 12/03/2023] [Indexed: 01/21/2024]
Affiliation(s)
- Quratulain Syed
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Brookhaven, Georgia, USA
- Department of Medicine, Division of Geriatrics and Gerontology, Emory University, Atlanta, Georgia, USA
| | - Gerald McGwin
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Brookhaven, Georgia, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Zachary Burningham
- Decision-Enhancement and Analytic Sciences (IDEAS) Centers of Innovation (COIN), Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, USA
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Jessica L Kelleher
- VA Data Analytics Core (DAC), Atlanta VA Healthcare System, Atlanta, Georgia, USA
| | - Jennie Mather
- VA Data Analytics Core (DAC), Atlanta VA Healthcare System, Atlanta, Georgia, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
- Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina, USA
| | - Melissa B Stevens
- Department of Medicine, Division of General Internal Medicine, Emory University, Atlanta, Georgia, USA
| | - Isis Morris
- Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina, USA
| | - George L Jackson
- Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Department of Medicine, Division of General Internal Medicine, Duke University, Durham, North Carolina, USA
- Department of Family Medicine & Community Health, Duke University, Durham, North Carolina, USA
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Camille P Vaughan
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Brookhaven, Georgia, USA
- Department of Medicine, Division of Geriatrics and Gerontology, Emory University, Atlanta, Georgia, USA
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Goldberg EM, Dresden SM, Carpenter CR. Clin-STAR corner: Practice changing advances in prescribing for geriatric emergency department patients. J Am Geriatr Soc 2023; 71:3686-3691. [PMID: 37801018 DOI: 10.1111/jgs.18619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 10/07/2023]
Abstract
Reducing adverse drug events among older adults in heterogeneous and often chaotic emergency department (ED) settings requires a multidisciplinary approach. Recent research evaluates the impact of multicomponent protocols designed to reduce ED physician prescribing of potentially inappropriate medications (PIMs), including transdisciplinary training and leveraging electronic health records to provide real-time alternative safer pharmaceuticals while providing personalized feedback to prescribers. Most new research is not randomized trial data. Although this current research does not consistently demonstrate a reduction in the prescribing of PIMs, these studies provide a foundation for emergency medicine healthcare teams, geriatricians, and pharmacists to collaborate with health informatics to continue advancing the frontiers of safer medication prescribing during episodes of acute care.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Scott M Dresden
- School of Medicine Department of Emergency Medicine, Northwestern University, Chicago, Illinois, USA
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Burningham Z, Jackson GL, Kelleher JL, Morris I, Stevens MB, Cohen J, Maloney G, Sauer BC, Halwani AS, Chen W, Vaughan CP. Use of a Medication Safety Audit and Feedback Tool in the Emergency Department Is Affected by Prescribing Characteristics. Appl Clin Inform 2023; 14:684-692. [PMID: 37648222 PMCID: PMC10468720 DOI: 10.1055/s-0043-1771393] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/17/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND The Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUIPPED) program developed an audit and feedback health information technology (IT) solution with the intent to replace the in-person academic detailing service provided by the program. The EQUIPPED dashboard provides emergency department (ED) providers with a personalized view of their prescribing performance. OBJECTIVES Here, we analyze the association between ED provider characteristics and viewership of the EQUIPPED dashboard, adding insight into strategies for addressing barriers to initial use. METHODS We performed a retrospective analysis of EQUIPPED dashboard viewership among four Veterans Affairs (VA) EDs. We extracted quantitative data from user interaction logs to determine evidence of dashboard use. Provider characteristics and baseline potentially inappropriate medication (PIM) prescribing rate were extracted from the VA's Corporate Data Warehouse. Logistic regression was used to examine the association between dashboard use and provider characteristics. RESULTS A total of 82 providers were invited to receive audit and feedback via the EQUIPPED dashboard. Among invited providers, 40 (48.7%) had evidence of at least 1 dashboard view during the 1-year feedback period. Adjusted analyses suggest that providers with a higher baseline PIM prescribing rate were more likely to use the dashboard (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.01-1.47). Furthermore, providers at ED site D were more likely to use the dashboard in comparison to the other sites (OR: 9.99; 95% CI: 1.72-58.04) and reportedly had the highest site-level baseline PIM rate. CONCLUSION Providers with lower PIM prescribing rates (i.e., <5%) receive communication from an integrated dashboard reminder system that they are "optimal prescribers" which may have discouraged initial attempts to view the dashboard. Site D had the highest baseline PIM rate, but further qualitative investigation is warranted to better understand why site D had the greatest users of the dashboard.
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Affiliation(s)
- Zach Burningham
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, United States
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - George L. Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, United States
- Medicine (Division of General Internal Medicine), and Family Medicine & Community Health, Departments of Population Health Sciences, Duke University, Durham, North Carolina, United States
| | - Jessica L. Kelleher
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Decatur, Georgia, United States
| | - Isis Morris
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, United States
| | - Melissa B. Stevens
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Decatur, Georgia, United States
- Division of General Medicine and Division of Geriatrics and Gerontology, Department of Medicine, Emory University, Atlanta, Georgia, United States
| | - Joy Cohen
- Department of Emergency Medicine, New Orleans Veterans Affairs Medical Center, New Orleans, Louisiana, United States
| | - Gerald Maloney
- Department of Emergency Medicine, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States
| | - Brian C. Sauer
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Ahmad S. Halwani
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, United States
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Wei Chen
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Camille P. Vaughan
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Decatur, Georgia, United States
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Tungare S, Gantela S, Kookal KK, Yansane AI, Sedlock E, Jeske A, Johnson T, Walji M. Designing audit and feedback dashboards for dentists to monitor their opioid prescribing. Int J Med Inform 2023; 176:105092. [PMID: 37267811 DOI: 10.1016/j.ijmedinf.2023.105092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/28/2023] [Accepted: 05/06/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Prescription drug abuse is a major factor leading to drug overdose deaths in the US and dentists are one of the leading prescribers of opioid pain medication. Knowing that Audit & Feedback (A&F) dashboards are an effective tool and are used as quality improvement interventions, we aimed to develop such dashboards personalized for dental providers which could allow them to monitor their own opioid prescribing performance. METHODS In this paper we report on the process for designing the A&F dashboards for dentists which were developed by using an iterative human-centered design process. The results obtained from each iteration were used to enrich the information needs analyses, provide function testing, and guide the design decisions of the next iteration. RESULTS Engaging dentists in the development and refinement of the dashboards while using the think-aloud protocol for user-testing, provided rapid feedback and identified areas that were confusing and needed either a redesign or additional explanatory content. The final version of dashboards consisted of displaying necessary information through easy to interpret visualizations and interactive features. These included providing access to current national and organizational prescribing guidelines, displaying changes in individual prescribing behavior over time, comparing individual prescribing rate to peer group rate and target rate, displaying procedure specific prescribing, integrating patient reported post-operative dental pain experience and providing navigation and interpretation tips for users. The dashboards were easy to learn and understand for the dentists and were deemed as worth using often in dental practice. CONCLUSION Our research was able to demonstrate the creation of useful and usable A&F dashboards using data from electronic dental records and patient surveys, for dentists to effectively monitor their opioid prescribing behavior. Efficacy of the dashboards will be tested in future work.
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Affiliation(s)
- Sayali Tungare
- The University of Texas Health Science Center at Houston (UTHealth Houston) School of Dentistry, 7500 Cambridge St, Houston, TX 77054, United States
| | - Swaroop Gantela
- The University of Texas Health Science Center at Houston (UTHealth Houston) School of Biomedical Informatics, 7000 Fannin St Suite 600, Houston, TX 77030, United States
| | - Krishna Kumar Kookal
- The University of Texas Health Science Center at Houston (UTHealth Houston) School of Dentistry, 7500 Cambridge St, Houston, TX 77054, United States
| | - Alfa-Ibrahim Yansane
- The University of California San Francisco School of Dentistry, 707 Parnassus Ave, San Francisco, CA 94143, United States
| | - Emily Sedlock
- The University of Texas Health Science Center at Houston (UTHealth Houston) School of Dentistry, 7500 Cambridge St, Houston, TX 77054, United States
| | - Arthur Jeske
- The University of Texas Health Science Center at Houston (UTHealth Houston) School of Dentistry, 7500 Cambridge St, Houston, TX 77054, United States
| | - Todd Johnson
- The University of Texas Health Science Center at Houston (UTHealth Houston) School of Biomedical Informatics, 7000 Fannin St Suite 600, Houston, TX 77030, United States
| | - Muhammad Walji
- The University of Texas Health Science Center at Houston (UTHealth Houston) School of Dentistry, 7500 Cambridge St, Houston, TX 77054, United States.
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Montgomery A, Tarasovsky G, Izadi Z, Shiboski S, Whooley MA, Dana J, Ehiorobo I, Barton J, Bennett L, Chung L, Reiter K, Wahl E, Subash M, Schmajuk G. An Electronic Dashboard to Improve Dosing of Hydroxychloroquine Within the Veterans Health Care System: Time Series Analysis. JMIR Med Inform 2023; 11:e44455. [PMID: 37171858 PMCID: PMC10221491 DOI: 10.2196/44455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/03/2023] [Accepted: 03/19/2023] [Indexed: 03/21/2023] Open
Abstract
BACKGROUND Hydroxychloroquine (HCQ) is commonly used for patients with autoimmune conditions. Long-term use of HCQ can cause retinal toxicity, but this risk can be reduced if high doses are avoided. OBJECTIVE We developed and piloted an electronic health record-based dashboard to improve the safe prescribing of HCQ within the Veterans Health Administration (VHA). We observed pilot facilities over a 1-year period to determine whether they were able to improve the proportion of patients receiving inappropriate doses of HCQ. METHODS Patients receiving HCQ were identified from the VHA corporate data warehouse. Using PowerBI (Microsoft Corp), we constructed a dashboard to display patient identifiers and the most recent HCQ dose and weight (flagged if ≥5.2 mg/kg/day). Six VHA pilot facilities were enlisted to test the dashboard and invited to participate in monthly webinars. We performed an interrupted time series analysis using synthetic controls to assess changes in the proportion of patients receiving HCQ ≥5.2 mg/kg/day between October 2020 and November 2021. RESULTS At the start of the study period, we identified 18,525 total users of HCQ nationwide at 128 facilities in the VHA, including 1365 patients at the 6 pilot facilities. Nationwide, at baseline, 19.8% (3671/18,525) of patients were receiving high doses of HCQ. We observed significant improvements in the proportion of HCQ prescribed at doses ≥5.2 mg/kg/day among pilot facilities after the dashboard was deployed (-0.06; 95% CI -0.08 to -0.04). The difference in the postintervention linear trend for pilot versus synthetic controls was also significant (-0.06; 95% CI -0.08 to -0.05). CONCLUSIONS The use of an electronic health record-based dashboard reduced the proportion of patients receiving higher than recommended doses of HCQ and significantly improved performance at 6 VHA facilities. National roll-out of the dashboard will enable further improvements in the safe prescribing of HCQ.
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Affiliation(s)
- Anna Montgomery
- San Francisco VA Medical Center, San Francisco, CA, United States
| | - Gary Tarasovsky
- San Francisco VA Medical Center, San Francisco, CA, United States
- University of California San Francisco, San Francisco, CA, United States
| | - Zara Izadi
- University of California San Francisco, San Francisco, CA, United States
| | - Stephen Shiboski
- University of California San Francisco, San Francisco, CA, United States
| | - Mary A Whooley
- San Francisco VA Medical Center, San Francisco, CA, United States
- University of California San Francisco, San Francisco, CA, United States
- UCSF Philip R Lee Institute for Health Policy Studies, San Francisco, CA, United States
| | - Jo Dana
- San Francisco VA Medical Center, San Francisco, CA, United States
| | - Iziegbe Ehiorobo
- University of California San Francisco, San Francisco, CA, United States
| | | | - Lori Bennett
- Ralph H Johnson VA Medical Center, Charleston, SC, United States
| | - Lorinda Chung
- Palo Alto VA Medical Center, Palo Alto, CA, United States
- Stanford University, Palo Alto, CA, United States
| | - Kimberly Reiter
- Raymond G Murphy VA Medical Center, Albuquerque, AZ, United States
- University of New Mexico School of Medicine, Albuquerque, AZ, United States
| | - Elizabeth Wahl
- Seattle/Puget Sound VA Healthcare System, Seattle, WA, United States
| | - Meera Subash
- UT Physicians Center for Autoimmunity, Houston, TX, United States
| | - Gabriela Schmajuk
- San Francisco VA Medical Center, San Francisco, CA, United States
- University of California San Francisco, San Francisco, CA, United States
- UCSF Philip R Lee Institute for Health Policy Studies, San Francisco, CA, United States
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Vaughan CP, Burningham Z, Kelleher JL, McGwin G, Jasien CL, Hastings SN, Stevens MB, Morris I, Jackson GL. A cluster-randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program. Acad Emerg Med 2023; 30:340-348. [PMID: 36790188 DOI: 10.1111/acem.14697] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/09/2023] [Accepted: 02/12/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVES The Enhancing the Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) medication safety program involves three core components including provider education, clinical decision support, and audit and feedback using the American Geriatrics Society Beers Criteria to determine potentially inappropriate medications (PIMs). This study evaluated implementation of audit and feedback through a centralized informatics-based dashboard compared to academic detailing delivered one on one by an EQUIPPED champion. METHODS In a cluster-randomized study (October 2019-September 2021), eight VA emergency department (EDs) implemented either the academic detailing (n = 4) or the dashboard (n = 4) strategy for the audit and feedback component of EQUIPPED. The primary outcome was the monthly proportion of PIMs prescribed to Veterans 65 years or older at ED discharge. Poisson regression was used to evaluate the proportion of PIMs prescribed 6 months prior to EQUIPPED implementation compared to 12 months following implementation. RESULTS Eight VA ED sites successfully implemented the EQUIPPED program. During the 6-month baseline period, the academic detailing and dashboard sites had similar PIM prescribing rates of 8.01% for academic detailing versus 8.04% for dashboard (p = 0.90). Comparing 12 months of prescribing data after EQUIPPED implementation, the academic detailing group significantly improved PIM prescribing (7.07%) compared to the dashboard group (8.10%; odds ratio 1.14, 95% confidence interval 1.08-1.22, p ≤ 0.0001). Within the groups, two of the four academic detailing sites demonstrated statistically significant reductions in PIM prescribing. One of the four dashboard sites achieved nearly 50% relative reduction in PIM prescribing. CONCLUSIONS Eight VA EDs successfully implemented the core components of the EQUIPPED program amid the unprecedented challenges posed by the COVID-19 pandemic. While the academic detailing approach to EQUIPPED audit and feedback was more effective at the group level to improve safe prescribing for older Veterans discharged from the ED, the trial suggests that dashboard-based audit and feedback is a reasonable strategy in resource-limited settings.
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Affiliation(s)
- Camille P Vaughan
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Decatur, Georgia, USA.,Department of Medicine, Division of Geriatrics and Gerontology, Emory University, Atlanta, Georgia, USA
| | - Zach Burningham
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, USA.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | | | - Gerald McGwin
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Decatur, Georgia, USA.,Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Medicine (Division of Geriatrics), Duke University, Durham, North Carolina, USA
| | - Melissa B Stevens
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Decatur, Georgia, USA.,Department of Medicine, Division of General Internal Medicine, Emory University, Georgia, Atlanta, USA
| | - Isis Morris
- Department of Medicine (Division of Geriatrics), Duke University, Durham, North Carolina, USA
| | - George L Jackson
- Department of Medicine (Division of Geriatrics), Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, Medicine (Division of General Internal Medicine), and Family Medicine & Community Health, Duke University, Durham, North Carolina, USA.,Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Lee S, Bobb Swanson M, Fillman A, Carnahan RM, Seaman AT, Reisinger HS. Challenges and opportunities in creating a deprescribing program in the emergency department: A qualitative study. J Am Geriatr Soc 2023; 71:62-76. [PMID: 36258309 PMCID: PMC10092723 DOI: 10.1111/jgs.18047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND As the population of older adults increases, appropriate deprescribing becomes increasingly important for emergency geriatric care. Older adults represent the sickest patients with chronic medical conditions, and they are often exposed to high-risk medications. We need to provide an evidence-based, standardized deprescribing program in the acute care setting, yet the evidence base is lacking and standardized medication programs are needed. METHODS We conducted a qualitative study with the goal to understand the perspective of healthcare workers, patients, and caregivers on deprescribing high-risk medications in the context of emergency care practices, provider preferences, and practice variability, along with the facilitators and barriers to an effective deprescribing program in the emergency department (ED). To ensure rich, contextual data, the study utilized two qualitative methods: (1) a focus group with physicians, advanced practice providers, nurses, pharmacists, and geriatricians involved in care of older adults and their prescriptions in the acute care setting; (2) semi-structured interviews with patients and caregivers involved in treatment and emergency care. Transcriptions were coded using thematic content analysis, and the principal investigator (S.L.) and trained research staff categorized each code into themes. RESULTS Data collection from a focus group with healthcare workers (n = 8) and semi-structured interviews with patients and caregivers (n = 20) provided evidence of a potentially promising ED medication program, aligned with the vision of comprehensive care of older adults, that can be used to evaluate practices and develop interventions. We identified four themes: (1) Challenges in medication history taking, (2) missed opportunities in identifying high-risk medications, (3) facilitators and barriers to deprescribing recommendations, and (4) how to coordinate deprescribing recommendations. CONCLUSIONS Our focus group and semi-structured interviews resulted in a framework for an ED medication program to screen, identify, and deprescribe high-risk medications for older adults and coordinate their care with primary care providers.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Morgan Bobb Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Allison Fillman
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ryan M Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Aaron T Seaman
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Heather Schacht Reisinger
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Goldberg EM, Lin TR, Cunha CB, Mujahid N, Davoodi NM, Vaughan CP. Enhancing the quality of prescribing practices for older adults discharged from the emergency department in Rhode Island. J Am Geriatr Soc 2022; 70:2905-2914. [PMID: 35809226 PMCID: PMC9588533 DOI: 10.1111/jgs.17955] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/29/2022] [Accepted: 06/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND We sought to examine the effectiveness of the Enhancing the Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUiPPED) medication safety program in three emergency departments (EDs) within the largest health system in Rhode Island (RI) with funding through a quality incentive payment by a private insurance partner. METHODS This study utilized a quasi-experimental interrupted time series design to implement EQUiPPED, a three-prong intervention aimed at reducing potentially inappropriate medication (PIM) prescriptions to 5% or less per month. We included clinicians who prescribed medications to older ED patients during the pre-and post-intervention periods from July 2018 to January 2021. We determined the monthly rate of PIM prescribing among older adults discharged from the ED, according to the American Geriatrics Society Beers Criteria, using Poisson regression. RESULTS 247 ED clinicians (48% attendings [n = 119], 27% residents [n = 67], 25% advanced practice providers [n = 61]) were included in EQUiPPED, of which 92% prescribed a PIM during the study period. In the pre-implementation period (July 2018-July 2019) the average monthly rate of PIM prescribing was 9.30% (95% CI: 8.82%, 9.78%). In the post-implementation period (October 2019-January 2021) the PIM prescribing rate decreased significantly to 8.62% (95% CI: 8.14%, 9.10%, p < 0.01). During pre-implementation, 1325 of the 14,193 prescribed medications were considered inappropriate, while only 1108 of the 13,213 prescribed medications in post-implementation were considered inappropriate. The greatest reduction was observed among antihistamines, skeletal muscle relaxants, and benzodiazepines. CONCLUSIONS EQUiPPED contributed to a modest improvement in PIM prescribing to older adults among clinicians in these RI EDs even in the midst of the COVID-19 pandemic. The quality incentive funding model demonstrates a successful strategy for implementation and, with greater replication, could shape national policy regarding health care delivery and quality of care for older adults.
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Affiliation(s)
| | - Timmy R Lin
- Emergency Medicine, Brown University, Providence, Rhode Island, USA
| | - Cheston B Cunha
- Infectious Disease, Brown University, Providence, Rhode Island, USA
| | - Nadia Mujahid
- Division of Geriatric & Palliative Medicine, Brown University, Providence, Rhode Island, USA
| | | | - Camille P Vaughan
- Division of Geriatrics and Gerontology, Emory University, Birmingham/Atlanta VA GRECC, Atlanta, Georgia, USA
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10
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Burningham Z, Lagha RR, Duford-Hutchinson B, Callaway-Lane C, Sauer BC, Halwani AS, Bell J, Huynh T, Douglas JR, Kramer BJ. Developing the VA Geriatric Scholars Programs' Clinical Dashboards Using the PDSA Framework for Quality Improvement. Appl Clin Inform 2022; 13:961-970. [PMID: 36223868 PMCID: PMC9556171 DOI: 10.1055/s-0042-1757553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background
Involving clinician end users in the development process of clinical dashboards is important to ensure that user needs are adequately met prior to releasing the dashboard for use. The challenge with following this approach is that clinician end users can undergo periodic turnover, meaning, the clinicians that played a role in the initial development process may not be the same individuals that use the dashboard in future.
Objectives
Here, we summarize our Plan, Do, Study, Act (PDSA)-guided clinical dashboard development process for the VA Geriatric Scholars Program (GSP) and the value of continuous, iterative development. We summarize dashboard adaptations that resulted from two PDSA cycles of improvement for the potentially inappropriate medication dashboard (PIMD), one of many Geriatric Scholars clinical dashboards. We also present the evaluative performance of the PIMD.
Methods
Evaluation of the PIMD was performed using the system usability scale (SUS) and through review of user interaction logs. Routine end users that were Geriatric Scholars and had evidence of 5 or more dashboard views were invited to complete an electronic form that contained the 10-item SUS.
Results
The proportion of Geriatric Scholars that utilized the PIMD increased for each iterative dashboard version that was produced as a byproduct from feedback (31.0% in 2017 to 60.2% in 2019). The overall usability of the PIMD among routine users was found to be above average (SUS score: 75.2 [95% CI 70.5–79.8]) in comparison to the recommended standard of acceptability (SUS score: 68)
Conclusion
The solicitation of feedback during dashboard orientations led to iterative adaptations of the PIMD that broadened its intended use. The presented PDSA-guided process to clinical dashboard development for the VA GSP can serve as a valuable framework for development teams seeking to produce well-adopted and usable health information technology (IT) innovations.
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Affiliation(s)
- Zachary Burningham
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States.,Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Centers of Innovation (COIN), Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Regina Richter Lagha
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Greater Los Angeles Medical Center, Los Angeles, California, United States
| | - Brittany Duford-Hutchinson
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Centers of Innovation (COIN), Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Carol Callaway-Lane
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Health Care System, Murfreesboro, Tennessee, United States
| | - Brian C Sauer
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States.,Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Centers of Innovation (COIN), Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Ahmad S Halwani
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Centers of Innovation (COIN), Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, United States.,Department of Hematology, University of Utah, Salt Lake City, Utah, United States
| | - Jamie Bell
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States.,Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Centers of Innovation (COIN), Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Tina Huynh
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States.,Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Centers of Innovation (COIN), Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Joseph R Douglas
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Greater Los Angeles Medical Center, Los Angeles, California, United States
| | - B Josea Kramer
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Greater Los Angeles Medical Center, Los Angeles, California, United States.,Division of Geriatric Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, United States
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11
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Damschroder LJ, Sussman JB, Pfeiffer PN, Kurlander JE, Freitag MB, Robinson CH, Spoutz P, Christopher MLD, Battar S, Dickerson K, Sedgwick C, Wallace-Lacey AG, Barnes GD, Linsky AM, Ulmer CS, Lowery JC. Maintaining Implementation through Dynamic Adaptations (MIDAS): protocol for a cluster-randomized trial of implementation strategies to optimize and sustain use of evidence-based practices in Veteran Health Administration (VHA) patients. Implement Sci Commun 2022; 3:53. [PMID: 35568903 PMCID: PMC9107220 DOI: 10.1186/s43058-022-00297-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background The adoption and sustainment of evidence-based practices (EBPs) is a challenge within many healthcare systems, especially in settings that have already strived but failed to achieve longer-term goals. The Veterans Affairs (VA) Maintaining Implementation through Dynamic Adaptations (MIDAS) Quality Enhancement Research Initiative (QUERI) program was funded as a series of trials to test multi-component implementation strategies to sustain optimal use of three EBPs: (1) a deprescribing approach intended to reduce potentially inappropriate polypharmacy; (2) appropriate dosing and drug selection of direct oral anticoagulants (DOACs); and (3) use of cognitive behavioral therapy as first-line treatment for insomnia before pharmacologic treatment. We describe the design and methods for a harmonized series of cluster-randomized control trials comparing two implementation strategies. Methods For each trial, we will recruit 8–12 clinics (24–36 total). All will have access to relevant clinical data to identify patients who may benefit from the target EBP at that clinic and provider. For each trial, clinics will be randomized to one of two implementation strategies to improve the use of the EBPs: (1) individual-level academic detailing (AD) or (2) AD plus the team-based Learn. Engage. Act. Process. (LEAP) quality improvement (QI) learning program. The primary outcomes will be operationalized across the three trials as a patient-level dichotomous response (yes/no) indicating patients with potentially inappropriate medications (PIMs) among those who may benefit from the EBP. This outcome will be computed using month-by-month administrative data. Primary comparison between the two implementation strategies will be analyzed using generalized estimating equations (GEE) with clinic-level monthly (13 to 36 months) percent of PIMs as the dependent variable. Primary comparative endpoint will be at 18 months post-baseline. Each trial will also be analyzed independently. Discussion MIDAS QUERI trials will focus on fostering sustained use of EBPs that previously had targeted but incomplete implementation. Our implementation approaches are designed to engage frontline clinicians in a dynamic optimization process that integrates the use of actional clinical data and making incremental changes, designed to be feasible within busy clinical settings. Trial registration ClinicalTrials.gov: NCT05065502. Registered October 4, 2021—retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00297-z.
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Affiliation(s)
- Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.
| | - Jeremy B Sussman
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Paul N Pfeiffer
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Jacob E Kurlander
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Michelle B Freitag
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Claire H Robinson
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Patrick Spoutz
- Veterans Health Affairs VISN 20 Pharmacy Benefits Management, Vancouver, WA, USA
| | - Melissa L D Christopher
- Pharmacy Benefits Management Services, Veterans Health Administration, 810 Vermont Ave NW, Washington DC, 20420, USA
| | - Saraswathy Battar
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | | | - Christopher Sedgwick
- Department of Veterans Affairs, VA Heartland Network (VISN 15), Kansas City, MO, USA
| | | | - Geoffrey D Barnes
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.,Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Amy M Linsky
- Section of General Medicine, VA Boston Healthcare System, Boston, MA, USA.,Center for Health Organizations and Implementation Research, VA Boston Healthcare System, Boston, MA, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Christi S Ulmer
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Julie C Lowery
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
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12
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Shih RD, Carpenter CR, Tolia V, Binder EF, Ouslander JG. Balancing Vision With Pragmatism: The Geriatric Emergency Department Guidelines-Realistic Expectations From Emergency Medicine and Geriatric Medicine. J Emerg Med 2022; 62:585-589. [PMID: 35181186 DOI: 10.1016/j.jemermed.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND In 2014, the Geriatric Emergency Department (GED) Guidelines were published and endorsed by four major medical organizations. The multidisciplinary GED Guidelines characterized the complex needs of the older emergency department (ED) patient and current best practices, with the goal of promoting more cost-effective and patient-centered care. The recommendations are extensive and most EDs then and now have neither the resources nor the hospital administrative support to provide this additional service. DISCUSSION At the 2021 American Academy of Emergency Medicine's Scientific Assembly, a panel of emergency physicians and geriatricians discussed the GED Guidelines and the current realities of EDs' capacity to provide best practice and guideline-recommended care of GED patients. This article is a synthesis of the panel's presentation and discussion. With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non-GED-accredited institutions. CONCLUSIONS In 2014, the GED Guidelines were published, describing the current best practices for GED patients. Unfortunately, most of the EDs worldwide do not provide the level of service recommended by the GED Guidelines. The GED Guidelines can best be termed aspirational for U.S. EDs at the present time.
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Affiliation(s)
- Richard D Shih
- Department of Emergency Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida and Delray Medical Center, Delray Beach, Florida
| | - Christopher R Carpenter
- Department of Emergency Medicine, Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Vaishal Tolia
- University of California San Diego Health, San Diego, California
| | - Ellen F Binder
- Division of Geriatrics and Nutritional Science, Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - Joseph G Ouslander
- Department of Integrated Medical Science, Charles E. Schmidt College of Medicine; Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida
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13
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Shih RD, Carpenter CR, Tolia V, Binder EF, Ouslander JG. Balancing vision with pragmatism: The geriatric emergency department guidelines‐realistic expectations from emergency medicine and geriatric medicine. J Am Geriatr Soc 2022; 70:1368-1373. [DOI: 10.1111/jgs.17745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Richard D. Shih
- Charles E. Schmidt College of Medicine Boca Raton Florida USA
| | - Christopher R. Carpenter
- Department of Emergency Medicine, Emergency Care Research Core Washington University in St. Louis, School of Medicine St. Louis Missouri USA
| | - Vaishal Tolia
- University of California San Diego Health San Diego California USA
| | - Ellen F. Binder
- School of Medicine, Division of Geriatrics and Nutritional Science Washington University in St. Louis St. Louis Missouri USA
| | - Joseph G. Ouslander
- Christine E. Lynn College of Nursing, Florida Atlantic University Boca Raton Florida USA
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14
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de Lusignan S, Hinton W, Seidu S, Mathew M, Feher MD, Munro N, Joy M, Carinci F, Hobbs FDR, Khunti K. Dashboards to reduce inappropriate prescribing of metformin and aspirin: A quality assurance programme in a primary care sentinel network. Prim Care Diabetes 2021; 15:1075-1079. [PMID: 34147402 DOI: 10.1016/j.pcd.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/01/2021] [Accepted: 06/06/2021] [Indexed: 11/21/2022]
Abstract
AIMS To pilot two dashboards to monitor prescribing of metformin and aspirin according to the National Institute for Health and Care Excellence (NICE) 'Do-Not-Do' recommendations. METHODS This quality assurance programme was conducted in twelve general practices of the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network. We developed dashboards to flag inappropriate prescribing of metformin and aspirin to people with type 2 diabetes mellitus (T2DM). In Phase 1, six practices (Group A) received a dashboard flagging suboptimal metformin prescriptions in people with reduced renal function. The other six practices (Group B) were controls. In Phase 2, Group B were provided a dashboard to flag inappropriate aspirin prescribing and Group A were controls. We used logistic regression to explore associations between dashboard exposure and inappropriate prescribing. RESULTS The cohort comprised 5644 individuals (Group A, n = 2656; Group B, n = 2988). Half (51.6%, n = 2991) were prescribed metformin of which 15 (0.5%) were inappropriate (Group A, n = 10; Group B, n = 5). A fifth (17.6%, n = 986) were prescribed aspirin of which 828 (84.0%) were inappropriate. During Phase 1, metformin was stopped in 50% (n = 5) of people in Group A, compared with 20% (n = 1) in the control group (Group B); in Phase 2, the odds ratio of inappropriate aspirin prescribing was significantly lower in practices that received the dashboard versus control (0.44, 95%CI 0.27-0.72). CONCLUSIONS It was feasible to use a dashboard to flag inappropriate prescribing. Whilst underpowered to report a change in metformin, we demonstrated a reduction in inappropriate aspirin prescribing.
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Affiliation(s)
- Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), London, UK.
| | - William Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Samuel Seidu
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Mekha Mathew
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Michael D Feher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Neil Munro
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Fabrizio Carinci
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK; Department of Statistical Sciences, University of Bologna, Italy
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
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15
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Vaughan CP, Hwang U, Vandenberg AE, Leong T, Wu D, Stevens MB, Clevenger C, Eucker S, Genes N, Huang W, Ikpe-Ekpo E, Nassisi D, Previl L, Rodriguez S, Sanon M, Schlientz D, Vigliotti D, Hastings SN. Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme. BMJ Open Qual 2021; 10:bmjoq-2021-001369. [PMID: 34750188 PMCID: PMC8576471 DOI: 10.1136/bmjoq-2021-001369] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 10/22/2021] [Indexed: 11/28/2022] Open
Abstract
Enhancing quality of prescribing practices for older adults discharged from the Emergency Department (EQUIPPED) aims to reduce the monthly proportion of potentially inappropriate medications (PIMs) prescribed to older adults discharged from the ED to 5% or less. We describe prescribing outcomes at three academic health systems adapting and sequentially implementing the EQUIPPED medication safety programme. EQUIPPED was adapted from a model developed in the Veterans Health Administration (VA) and sequentially implemented in one academic health system per year over a 3-year period. The monthly proportion of PIMs, as defined by the 2015 American Geriatrics Beers Criteria, of all medications prescribed to adults aged 65 years and older at discharge was assessed for 6 months preimplementation until 12 months postimplementation using a generalised linear time series model with a Poisson distribution. The EQUIPPED programme was translated from the VA health system and its electronic medical record into three health systems each using a version of the Epic electronic medical record. Adaptation occurred through local modification of order sets and in the generation and delivery of provider prescribing reports by local champions. Baseline monthly PIM proportions 6 months prior to implementation at the three sites were 5.6% (95% CI 5.0% to 6.3%), 5.8% (95% CI 5.0% to 6.6%) and 7.3% (95% CI 6.4% to 9.2%), respectively. Evaluation of monthly prescribing including the twelve months post-EQUIPPED implementation demonstrated significant reduction in PIMs at one of the three sites. In exploratory analyses, the proportion of benzodiazepine prescriptions decreased across all sites from approximately 17% of PIMs at baseline to 9.5%–12% postimplementation, although not all reached statistical significance. EQUIPPED is feasible to implement outside the VA system. While the impact of the EQUIPPED model may vary across different health systems, results from this initial translation suggest significant reduction in specific high-risk drug classes may be an appropriate target for improvement at sites with relatively low baseline PIM prescribing rates.
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Affiliation(s)
- Camille P Vaughan
- Medicine (CPV, AEV, MBS) & Emergency Medicine (DW), Emory University School of Medicine, Atlanta, Georgia, USA .,Birmingham/Atlanta VA Geriatric Research Education and Clinical Center, Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Ula Hwang
- Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Geriatric Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Ann E Vandenberg
- Medicine (CPV, AEV, MBS) & Emergency Medicine (DW), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Traci Leong
- Biostatistics and Bioinformatics, Emory University School of Public Health, Atlanta, Georgia, USA
| | - Daniel Wu
- Medicine (CPV, AEV, MBS) & Emergency Medicine (DW), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Melissa B Stevens
- Medicine (CPV, AEV, MBS) & Emergency Medicine (DW), Emory University School of Medicine, Atlanta, Georgia, USA.,Birmingham/Atlanta VA Geriatric Research Education and Clinical Center, Atlanta VA Medical Center, Decatur, Georgia, USA
| | | | - Stephanie Eucker
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA
| | - Nick Genes
- Emergency Medicine (NG, DN) and Medicine (MS), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Wennie Huang
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA
| | - Edidiong Ikpe-Ekpo
- Emergency Medicine, The Southeast Permanente Medical Group, Atlanta, Georgia, USA
| | - Denise Nassisi
- Emergency Medicine (NG, DN) and Medicine (MS), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura Previl
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA
| | - Sandra Rodriguez
- Columbia University School of Social Work, New York, New York, USA
| | - Martine Sanon
- Emergency Medicine (NG, DN) and Medicine (MS), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David Schlientz
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA
| | | | - S Nicole Hastings
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA.,Centre of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
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16
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Suvada K, Plantinga L, Vaughan CP, Markland AD, Mirk A, Burgio KL, Erni SM, Ali MK, Okosun I, Young H, Goode PS, Johnson TM. Comorbidities, Age, and Polypharmacy Limit the Use by US Older Adults with Nocturia of the Only FDA-approved Drugs for the Symptom. Clin Ther 2020; 42:e259-e274. [DOI: 10.1016/j.clinthera.2020.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 01/25/2023]
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17
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Hung WW, Chow S. Optimizing Medication Use in Older Adults. Clin Ther 2020; 42:556-558. [PMID: 32284190 DOI: 10.1016/j.clinthera.2020.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/28/2020] [Indexed: 11/15/2022]
Affiliation(s)
- William W Hung
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA; Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Stephanie Chow
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
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18
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