The quality of pharmacotherapy in older veterans discharged from the emergency department or urgent care clinic

Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration

BACKGROUND

Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration.

METHODS

We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process.

RESULTS

We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal.

CONCLUSIONS

The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.

Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project

Background

Polypharmacy is a growing phenomenon among elderly individuals. However, there is little information about the frequency of polypharmacy among the elderly population treated in emergency departments (EDs) and its prognostic effect. This study aims to determine the prevalence and short-term prognostic effect of polypharmacy in elderly patients treated in EDs.

Methods

A retrospective analysis of the Emergency Department Elderly in Needs (EDEN) project's cohort was performed. This registry included all elderly patients who attended 52 Spanish EDs for any condition. Mild and severe polypharmacy was defined as the use of 5-9 drugs and ⩾10 drugs, respectively. The assessed outcomes were ED revisits, hospital readmissions, and mortality 30 days after discharge. Crude and adjusted logistic regression analyses, including the patient's comorbidities, were performed.

Results

A total of 25,557 patients were evaluated [mean age: 78 (IQR: 71-84) years]; 10,534 (41.2%) and 5678 (22.2%) patients presented with mild and severe polypharmacy, respectively. In the adjusted analysis, mild polypharmacy and severe polypharmacy were associated with an increase in ED revisits [odds ratio (OR) 1.13 (95% confidence interval (CI): 1.04-1.23) and 1.38 (95% CI: 1.24-1.51)] and hospital readmissions [OR 1.18 (95% CI: 1.04-1.35) and 1.36 (95% CI: 1.16-1.60)], respectively, compared to non-polypharmacy. Mild and severe polypharmacy were not associated with increased 30-day mortality [OR 1.05 (95% CI: 0.89-2.26) and OR 0.89 (95% CI: 0.72-1.12)], respectively.

Conclusion

Polypharmacy was common among the elderly treated in EDs and associated with increased risks of ED revisits and hospital readmissions ⩽30 days but not with an increased risk of 30-day mortality. Patients with polypharmacy had a higher risk of ED revisits and hospital readmissions ⩽30 days after discharge.

Use of the consolidated framework for implementation research in a mixed methods evaluation of the EQUIPPED medication safety program in four academic health system emergency departments

Background

Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is an effective quality improvement program initially designed in the Veterans Administration (VA) health care system to reduce potentially inappropriate medication prescribing for adults aged 65 years and older. This study examined factors that influence implementation of EQUIPPED in EDs from four distinct, non-VA academic health systems using a convergent mixed methods design that operationalized the Consolidated Framework for Implementation Research (CFIR). Fidelity of delivery served as the primary implementation outcome.

Materials and methods

Four EDs implemented EQUIPPED sequentially from 2017 to 2021. Using program records, we scored each ED on a 12-point fidelity index calculated by adding the scores (1-3) for each of four components of the EQUIPPED program: provider receipt of didactic education, one-on-one academic detailing, monthly provider feedback reports, and use of order sets. We comparatively analyzed qualitative data from focus groups with each of the four implementation teams (n = 22) and data from CFIR-based surveys of ED providers (108/234, response rate of 46.2%) to identify CFIR constructs that distinguished EDs with higher vs. lower levels of implementation.

Results

Overall, three sites demonstrated higher levels of implementation (scoring 8-9 of 12) and one ED exhibited a lower level (scoring 5 of 12). Two constructs distinguished between levels of implementation as measured through both quantitative and qualitative approaches: patient needs and resources, and organizational culture. Implementation climate distinguished level of implementation in the qualitative analysis only. Networks and communication, and leadership engagement distinguished level of implementation in the quantitative analysis only.

Discussion

Using CFIR, we demonstrate how a range of factors influence a critical implementation outcome and build an evidence-based approach on how to prime an organizational setting, such as an academic health system ED, for successful implementation.

Conclusion

This study provides insights into implementation of evidence-informed programs targeting medication safety in ED settings and serves as a potential model for how to integrate theory-based qualitative and quantitative methods in implementation studies.

Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system

OBJECTIVES

To present the three-site EQUIPPED academic health system research collaborative, which engaged in sequential implementation of the EQUIPPED medication safety program, as a learning health system; to understand how the organizations worked together to build resources for program scale-up.

DESIGN

Following the Replicating Effective Programs framework, we analyzed content from implementation teams' focus groups, local and cross-site meeting minutes and sites' organizational profiles to develop an implementation package.

SETTING

Three academic emergency departments that each implemented EQUIPPED over three successive years.

PARTICIPANTS

Implementation team members at each site participating in focus groups (n = 18), local meetings during implementation years, and cross-site meetings during all years of the projects.

INTERVENTION(S)

EQUIPPED provides Emergency Department providers with clinical decision support (education, order sets, and feedback) to reduce prescribing of potentially inappropriate medications to adults aged 65 years and older who received a prescription at time of discharge.

MAIN OUTCOME MEASURE(S)

Implementation process components assembled through successive implementation.

RESULTS

Each site had clinical and environmental characteristics to be addressed in implementing the EQUIPPED program. We identified 10 process elements and describe lessons for each. Lessons guided the compilation of the EQUIPPED intervention package or toolkit, including the EQUIPPED logic model.

CONCLUSIONS

Our academic health system research collaborative addressing medication safety through sequential implementation is a learning health system that can serve as a model for other quality improvement projects with multiple sites. The network produced an implementation package that can be vetted, piloted, evaluated, and finalized for large-scale dissemination in community-based settings.

Quality indicators in the care of older persons in the emergency department: A systematic review of the literature

OBJECTIVE

A systematic review of the literature was undertaken to assess the methodological quality of existing quality indicators (QIs) for the emergency department (ED) care of older persons.

METHODS

MEDLINE, CINAHL, EMBASE and grey literature were searched. Articles were included if they addressed ED care of persons aged ≥65 years and defined a QI amenable to influence by ED providers. The methodological quality of QIs was assessed using relevant items from the Appraisal of Indicators through Research and Evaluation and the QUALIFY tools.

RESULTS

Sixty-one articles were included in the review, with identification of 50 QIs meeting predefined inclusion criteria. Thirty-six of fifty ED QIs for older persons were process indicators. The appraisal instruments' total ratings ranged from 39 to 67%, with only 18 QIs scoring 50% or more for all five domains.

CONCLUSION

There is a need for a balanced, methodologically robust set of QIs for care of older persons in the ED.

Determinants of Potentially Inappropriate Medication Use in Long-Term and Acute Care Settings: A Systematic Review

BACKGROUND

Potentially inappropriate medications (PIMs) are widely used in institutionalized older adults, yet the key determinants that drive their use are incompletely characterized.

METHODS

We systematically searched published literature within MEDLINE and Embase from January 1998 to March 2017. We searched for studies conducted in the United States that described determinants of PIM use in adults ≥60 years of age in a nursing home or residential care facility, in the emergency department (ED), or in the hospital. Paired reviewers independently screened abstracts and full-text articles, assessed quality, and extracted data.

RESULTS

Among 30 included articles, 12 examined PIM use in the nursing home or residential care settings, 4 in the ED, 12 in acute care hospitals, and 2 across settings. The Beers criteria were most frequently used to identify PIM use, which ranged from 3.6% to 92.0%. Across all settings, the most common determinants of PIM use were medication burden and geographic region. In the nursing home, the most common additional determinants were younger age, and diagnoses of depression or diabetes. In both the ED and hospital, patients receiving care in the West, Midwest, and South, relative to the Northeast, were at greater risk of receiving a PIM. Very few studies examined clinician determinants of PIM use; geriatricians used fewer PIMs in the hospital than other clinicians.

CONCLUSIONS

Among older adults, those who are on many medications are at increased risk for PIM use across multiple settings. We propose that careful testing of interventions that target modifiable determinants are indicated to assess their impact on PIM use.

Evaluation of pharmacy services in emergency departments of Veterans Affairs Medical Centers

OBJECTIVE

In 2008, the American Society of Health-System Pharmacists (ASHP) published a national survey that revealed only 6.8% of hospitals surveyed had a pharmacist assigned to the emergency department (ED) for any period of time. This survey was distributed among general and children's medical-surgical hospitals in the United States and did not include any Veterans Affairs (VA) Medical Centers. To date, there have been no identified survey studies describing the prevalence of pharmacy services within VA EDs. The objectives of this study are to determine the prevalence of dedicated pharmacy services within VA EDs, categorize the types of pharmacy services, determine if interventions/outcomes related to pharmacy services were collected, and assess the desire for pharmacy services in facilities that did not currently have dedicated pharmacy services.

METHODS

The study was designed as a cross-sectional survey study conducted between January 14, 2010 and March 29, 2010. The study population included Pharmacy Clinical Coordinators employed at a VA facility. An initial email containing a link to the web-based survey was distributed via the national Pharmacy Clinical Coordinator listserv. Results of the survey were analyzed using descriptive statistics.

RESULTS

The survey was distributed to 153 VA Medical Centers and a total of 33 (21.6%) responses were received. Of the responses, 24 facilities (72.7%) documented the presence of an ED, and of those, 5 (20.8%) indicated that they had a pharmacist dedicated to providing pharmacy services to the ED. The most common pharmacy services provided included medication reconciliation, patient education/ counseling, pharmacotherapy recommendations, ED staff education, precepting activities, adverse drug reaction (ADR) reporting, and ensuring formulary compliance. Three of the 5 facilities documented interventions, with 1 facility documenting ADRs prevented and cost avoidance in addition to interventions. Of the 19 facilities that did not have a pharmacist dedicated to the ED, 16 (84.2%) indicated a desire for such services.

CONCLUSION

A greater prevalence of ED pharmacy services was reported in VA facilities compared with a national sample of non-VA facilities. Despite the high prevalence and variety of dedicated pharmacy services provided to the ED, documentation of these services remains an area in need of improvement.

A Novel Design for Drug-Drug Interaction Alerts Improves Prescribing Efficiency

BACKGROUND

Drug-drug interactions (DDIs) are common in clinical care and pose serious risks for patients. Electronic health records display DDI alerts that can influence prescribers, but the interface design of DDI alerts has largely been unstudied. In this study, the objective was to apply human factors engineering principles to alert design. It was hypothesized that redesigned DDI alerts would significantly improve prescribers' efficiency and reduce prescribing errors.

METHODS

In a counterbalanced, crossover study with prescribers, two DDI alert designs were evaluated. Department of Veterans Affairs (VA) prescribers were video recorded as they completed fictitious patient scenarios, which included DDI alerts of varying severity. Efficiency was measured from time-stamped recordings. Prescribing errors were evaluated against predefined criteria. Efficiency and prescribing errors were analyzed with the Wilcoxon signed-rank test. Other usability data were collected on the adequacy of alert content, prescribers' use of the DDI monograph, and alert navigation.

RESULTS

Twenty prescribers completed patient scenarios for both designs. Prescribers resolved redesigned alerts in about half the time (redesign: 52 seconds versus original design: 97 seconds; p<.001). Prescribing errors were not significantly different between the two designs. Usability results indicate that DDI alerts might be enhanced by facilitating easier access to laboratory data and dosing information and by allowing prescribers to cancel either interacting medication directly from the alert. Results also suggest that neither design provided adequate information for decision making via the primary interface.

CONCLUSION

Applying human factors principles to DDI alerts improved overall efficiency. Aspects of DDI alert design that could be further enhanced prior to implementation were also identified.

Prevalence of drug interactions in hospital healthcare

AIM OF THE REVIEW

To study the prevalence of drug interactions in hospital healthcare by reviewing literature.

METHOD

A review was carried out of studies written in Spanish and English on the prevalence of drug interactions in hospital care published in Pubmed between January 1990 and September 2008. The search strategy combined free text and MeSH terms, using the following keywords: "Drug interaction", "prevalence" and "hospital". For each article, we classified independent variables (pathology, age of population, whether patients were hospitalized or not, geographical location, etc.) and dependent variables (number of interactions per 100 patients studied, prevalence of patients with interactions, most common drug interactions, and others).

RESULTS

The search generated 436 articles. Finally, 47 articles were selected for the study, 3 provided results about drug interactions with real clinical consequences, 42 about potential interactions, and 2 described both. The prevalence of patients with interactions was between 15 and 45 % and the number of interactions per 100 patients was between 37 and 106, depending on the group of studies analyzed. There was a considerable increase in these rates in patients with heart diseases and elderly persons.

CONCLUSION

There is a large number of studies on the prevalence of drug interactions in hospitals but they report widely varying results. The prevalence is higher in patients with heart diseases and elderly people.

Health care utilization before and after an outpatient ED visit in older people

BACKGROUND

Older adults in the United States receive a significant amount of care in the emergency department (ED), yet the associations between ED and other types of health care utilization have not been adequately studied in this population.

OBJECTIVES

The goals of this study were to examine the relationships between health care use before and after an ED visit among older adults.

METHODS

This retrospective cohort study examined health care use among 308 patients 65 years or older discharged from a university-affiliated ED. Proportional-hazards models were used to assess the relationship between pre-ED health care use (primary care physician [PCP], specialist, ED, and hospital) and risk of return ED visits.

RESULTS

Older ED patients in this study had visited other types of providers frequently in the previous year (median number of PCP and specialist visits, 4). Patients who used the ED on 2 or more occasions in the previous year were found to have visited their PCP more often than those without frequent ED use (median number of visits, 7.0 vs 4.0; P < .001). Despite more PCP use in this population, frequent ED use was associated with increased risk of a repeat ED visit (hazard ratio, 2.20; 95% confidence interval, 1.15-4.21), in models adjusted for demographics and health status.

CONCLUSION

Older adults who use the ED are also receiving significant amounts of care from other sources; simply providing additional access to care may not improve outcomes for these vulnerable individuals.

Exposure to potentially harmful drug-disease interactions in older community-dwelling veterans based on the Healthcare Effectiveness Data and Information Set quality measure: who is at risk?

OBJECTIVES

To identify prevalence and risk factors for exposure to drug-disease interactions included in the Healthcare Effectiveness Data and Information Set (HEDIS) Drug-Disease Interaction (Rx-DIS) measure.

DESIGN

Cross-sectional retrospective database analysis.

SETTING

Outpatient clinics within the Department of Veterans Affairs (VA).

PARTICIPANTS

Individuals aged 65 and older who received VA outpatient care between October 1, 2003, and September 30, 2006.

MEASUREMENTS

Rx-DIS exposure based on the HEDIS measure was identified in VA patients with dementia, falls, and chronic renal failure using VA pharmacy and administrative databases. Factors associated with Rx-DIS exposure were examined, including demographic, health status, and access-to-care factors, including VA outpatient health services use and copayment status.

RESULTS

Of the 305,041 older veterans who met criteria for inclusion, the 1-year prevalence of Rx-DIS exposure was 15.2%; prevalence was 20.2% for dementia, 16.2% for falls, and 8.5% for chronic renal failure. Patients with high disease burden (physical, psychiatric, number of medications) were significantly more likely to have Rx-DIS exposure, regardless of condition. Hispanics and individuals with no copayments were more likely to have Rx-DIS exposure than whites or those with required copayments. There was variation in other predictors based on the type of Rx-DIS.

CONCLUSION

The prevalence of Rx-DIS was common in older VA outpatients. Future studies should examine the risk of Rx-DIS exposure on health outcomes using separate analyses for each type of Rx-DIS separately before combining all Rx-DIS into a single measure of exposure. Studies that examine the effectiveness of interventions to reduce Rx-DIS exposure will also be helpful in improving the quality of care for older adults.