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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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Ruiz Ramos J, Alquézar-Arbé A, Juanes Borrego A, Burillo Putze G, Aguiló S, Jacob J, Fernández C, Llorens P, Quero Espinosa FDB, Gordo Remartinez S, Hernando González R, Moreno Martín M, Sánchez Aroca S, Sara Knabe A, González González R, Carrión Fernández M, Artieda Larrañaga A, Adroher Muñoz M, Hong Cho JU, Escolar Martínez Berganza MT, Gayoso Martín S, Sánchez Sindín G, Silva Penas M, Gómez y Gómez B, Arenos Sambro R, González del Castillo J, Miró Ò. Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project. Ther Adv Drug Saf 2024; 15:20420986241228129. [PMID: 38323189 PMCID: PMC10846059 DOI: 10.1177/20420986241228129] [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: 09/24/2023] [Accepted: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
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.
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Affiliation(s)
- Jesus Ruiz Ramos
- Pharmacy Department, Hospital de la Santa Creu I Sant Pau, Institut de Recerca Sant Pau (IR SANT PAU), C/San Quintin 56-58, Barcelona 08025, Spain
| | - Aitor Alquézar-Arbé
- Emergency Department, Hospital de la Santa Creu I Sant Pau, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
| | - Ana Juanes Borrego
- Pharmacy Department, Hospital de la Santa Creu I Sant Pau, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
| | - Guillermo Burillo Putze
- Facultad de Ciencias de la Salud, Universidad Europea de Canarias, Santa Cruz de Tenerife, Spain
| | - Sira Aguiló
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, l’Hospitalet de Llobregat, Spain
| | - Cesáreo Fernández
- Emergency Department, Hospital Clínico San Carlos, IDISSC, Universidad Complutense, Madrid, Spain
| | - Pere Llorens
- Emergency Department, Hospital Doctor Balmis, Instituto de Investigación Sanitaria y Biómedica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, Spain
| | | | | | | | | | - Sara Sánchez Aroca
- Emergency Department, Hospital Universitario Morales Meseguer, Murcia, Spain
| | | | | | | | | | | | | | | | - Sara Gayoso Martín
- Emergency Department, Hospital Comarcal El Escorial, San Lorenzo de El Escorial, Spain
| | | | | | | | | | | | - Òscar Miró
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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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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Donnelly C, Janssen A, Vinod S, Stone E, Harnett P, Shaw T. A Systematic Review of Electronic Medical Record Driven Quality Measurement and Feedback Systems. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:ijerph20010200. [PMID: 36612522 PMCID: PMC9819986 DOI: 10.3390/ijerph20010200] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 06/09/2023]
Abstract
Historically, quality measurement analyses utilize manual chart abstraction from data collected primarily for administrative purposes. These methods are resource-intensive, time-delayed, and often lack clinical relevance. Electronic Medical Records (EMRs) have increased data availability and opportunities for quality measurement. However, little is known about the effectiveness of Measurement Feedback Systems (MFSs) in utilizing EMR data. This study explores the effectiveness and characteristics of EMR-enabled MFSs in tertiary care. The search strategy guided by the PICO Framework was executed in four databases. Two reviewers screened abstracts and manuscripts. Data on effect and intervention characteristics were extracted using a tailored version of the Cochrane EPOC abstraction tool. Due to study heterogeneity, a narrative synthesis was conducted and reported according to PRISMA guidelines. A total of 14 unique MFS studies were extracted and synthesized, of which 12 had positive effects on outcomes. Findings indicate that quality measurement using EMR data is feasible in certain contexts and successful MFSs often incorporated electronic feedback methods, supported by clinical leadership and action planning. EMR-enabled MFSs have the potential to reduce the burden of data collection for quality measurement but further research is needed to evaluate EMR-enabled MFSs to translate and scale findings to broader implementation contexts.
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Affiliation(s)
- Candice Donnelly
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2006, Australia
| | - Anna Janssen
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2006, Australia
| | - Shalini Vinod
- Liverpool Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, NSW 2170, Australia
- South West Sydney Clinical Campuses, University of New South Wales, Liverpool, NSW 2170, Australia
| | - Emily Stone
- Department of Thoracic Medicine and Lung Transplantation, St Vincent’s Hospital, Darlinghurst, NSW 2010, Australia
- School of Clinical Medicine, University of New South Wales, Randwick, NSW 2031, Australia
| | - Paul Harnett
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2006, Australia
- Crown Princess Mary Cancer Centre, Western Sydney Local Health District, Westmead, NSW 2145, Australia
| | - Tim Shaw
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2006, Australia
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7
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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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van Dam CS, Labuschagne HA, van Keulen K, Kramers C, Kleipool EE, Hoogendijk EO, Knol W, Nanayakkara PWB, Muller M, Trappenburg MC, Peters MJL. Polypharmacy, comorbidity and frailty: a complex interplay in older patients at the emergency department. Eur Geriatr Med 2022; 13:849-857. [PMID: 35723840 PMCID: PMC9378326 DOI: 10.1007/s41999-022-00664-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/22/2022] [Indexed: 11/30/2022]
Abstract
Aim To investigate the association of polypharmacy with adverse health outcomes, in relation to comorbidity and frailty. Findings Excessive polypharmacy (≥ 10 medications) is highly prevalent in older adults at the emergency department and associated with falls, mortality and readmission. Frailty and comorbidity partly drive the association of polypharmacy with adverse health outcomes. Message Trials that target polypharmacy and inappropriate prescribing are needed to answer the lingering question of causality in the observed polypharmacy–mortality association and to evaluate whether medication review improves health outcomes in older patients at the ED. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-022-00664-y. Purpose Older adults at the emergency department (ED) with polypharmacy, comorbidity, and frailty are at risk of adverse health outcomes. We investigated the association of polypharmacy with adverse health outcomes, in relation to comorbidity and frailty. Methods This is a prospective cohort study in ED patients ≥ 70 years. Non-polypharmacy was defined as 0–4 medications, polypharmacy 5–9 and excessive polypharmacy ≥ 10. Comorbidity was classified by the Charlson comorbidity index (CCI). Frailty was defined by the Identification of Seniors At Risk—Hospitalized Patients (ISAR-HP) score. The primary outcome was 3-month mortality. Secondary outcomes were readmission to an ED/hospital ward and a self-reported fall < 3 months. The association between polypharmacy, comorbidity and frailty was analyzed by logistic regression. Results 881 patients were included. 43% had polypharmacy and 18% had excessive polypharmacy. After 3 months, 9% died, 30% were readmitted, and 21% reported a fall. Compared with non-polypharmacy, the odds ratio (OR) for mortality ranged from 2.62 (95% CI 1.39–4.93) in patients with polypharmacy to 3.92 (95% CI 1.95–7.90) in excessive polypharmacy. The OR weakened after adjustment for comorbidity: 1.80 (95% CI 0.92–3.52) and 2.32 (95% CI 1.10–4.90). After adjusting for frailty, the OR weakened to 2.10 (95% CI 1.10–4.00) and OR 2.40 (95% CI 1.15–5.02). No significant association was found for readmission or self-reported fall. Conclusions Polypharmacy is common in older patients at the ED. Polypharmacy, and especially excessive polypharmacy, is associated with an increased risk of mortality. The observed association is complex given the confounding effect of comorbidity and frailty. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-022-00664-y.
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Affiliation(s)
- Carmen S van Dam
- Department of Internal Medicine and Geriatrics, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands.
| | - Helena A Labuschagne
- Department of Internal Medicine and Geriatrics, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Kris van Keulen
- Department of Pharmacy, Amstelland Hospital, Amstelveen, the Netherlands
| | - Cornelis Kramers
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Emma E Kleipool
- Department of Internal Medicine and Geriatrics, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Emiel O Hoogendijk
- Department of Epidemiology and Data Science, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Wilma Knol
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Prabath W B Nanayakkara
- Section General and Acute Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Majon Muller
- Department of Internal Medicine and Geriatrics, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Marijke C Trappenburg
- Department of Internal Medicine and Geriatrics, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands.,Department of Pharmacy, Amstelland Hospital, Amstelveen, the Netherlands
| | - Mike J L Peters
- Department of Internal Medicine and Geriatrics, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands.,Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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9
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Willis VC, Thomas Craig KJ, Jabbarpour Y, Scheufele EL, Arriaga YE, Ajinkya M, Rhee KB, Bazemore A. Digital Health Interventions to Enhance Prevention in Primary Care: Scoping Review. JMIR Med Inform 2022; 10:e33518. [PMID: 35060909 PMCID: PMC8817213 DOI: 10.2196/33518] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/19/2021] [Accepted: 12/04/2021] [Indexed: 12/20/2022] Open
Abstract
Background Disease prevention is a central aspect of primary care practice and is comprised of primary (eg, vaccinations), secondary (eg, screenings), tertiary (eg, chronic condition monitoring), and quaternary (eg, prevention of overmedicalization) levels. Despite rapid digital transformation of primary care practices, digital health interventions (DHIs) in preventive care have yet to be systematically evaluated. Objective This review aimed to identify and describe the scope and use of current DHIs for preventive care in primary care settings. Methods A scoping review to identify literature published from 2014 to 2020 was conducted across multiple databases using keywords and Medical Subject Headings terms covering primary care professionals, prevention and care management, and digital health. A subgroup analysis identified relevant studies conducted in US primary care settings, excluding DHIs that use the electronic health record (EHR) as a retrospective data capture tool. Technology descriptions, outcomes (eg, health care performance and implementation science), and study quality as per Oxford levels of evidence were abstracted. Results The search yielded 5274 citations, of which 1060 full-text articles were identified. Following a subgroup analysis, 241 articles met the inclusion criteria. Studies primarily examined DHIs among health information technologies, including EHRs (166/241, 68.9%), clinical decision support (88/241, 36.5%), telehealth (88/241, 36.5%), and multiple technologies (154/241, 63.9%). DHIs were predominantly used for tertiary prevention (131/241, 54.4%). Of the core primary care functions, comprehensiveness was addressed most frequently (213/241, 88.4%). DHI users were providers (205/241, 85.1%), patients (111/241, 46.1%), or multiple types (89/241, 36.9%). Reported outcomes were primarily clinical (179/241, 70.1%), and statistically significant improvements were common (192/241, 79.7%). Results were summarized across the following 5 topics for the most novel/distinct DHIs: population-centered, patient-centered, care access expansion, panel-centered (dashboarding), and application-driven DHIs. The quality of the included studies was moderate to low. Conclusions Preventive DHIs in primary care settings demonstrated meaningful improvements in both clinical and nonclinical outcomes, and across user types; however, adoption and implementation in the US were limited primarily to EHR platforms, and users were mainly clinicians receiving alerts regarding care management for their patients. Evaluations of negative results, effects on health disparities, and many other gaps remain to be explored.
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Affiliation(s)
- Van C Willis
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Kelly Jean Thomas Craig
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Yalda Jabbarpour
- Policy Studies in Family Medicine and Primary Care, The Robert Graham Center, American Academy of Family Physicians, Washington, DC, United States
| | - Elisabeth L Scheufele
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Yull E Arriaga
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Monica Ajinkya
- Policy Studies in Family Medicine and Primary Care, The Robert Graham Center, American Academy of Family Physicians, Washington, DC, United States
| | - Kyu B Rhee
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Andrew Bazemore
- The American Board of Family Medicine, Lexington, KY, United States
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10
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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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11
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Doffou E, Avi C, Yao KC, Abrogoua DP. Expert Consensus on a List of Inappropriate Prescribing after Prescription Review in Pediatric Units in Abidjan, Côte d'Ivoire. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2021; 10:79-91. [PMID: 34476206 PMCID: PMC8407673 DOI: 10.2147/iprp.s322141] [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: 06/04/2021] [Accepted: 08/05/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Inappropriate prescribing (IP) includes inappropriate prescription and omission of prescription. IP can adversely affect the quality of health care in pediatric units. A list of IP taking into account frequently encountered drug-related problems (DRPs) can be useful to optimize prescriptions in pediatrics. The aim of this study was to validate by expert consensus a list of IP after a prescription review in pediatric units in Abidjan. Materials and Methods A list of IPs was developed from a prescription review of inpatients and outpatients aged 1 month to 15 years and followed in pediatric units at teaching hospitals of Abidjan during 16 months. A two-round Delphi method was used to validate a qualitative list of IPs by experts according to their level of agreement on a six-point Likert scale of 0–5 (0, no opinion; 5, strongly agree). Only propositions obtaining the agreement (rating 4 or 5) of >70% of experts who gave a non-zero rating for the first round and 80% for the second round were retained. Results A qualitative list of 54 IPs was drawn up from 267 DRPs detected after prescription review of 4,992 prescription lines for 881 patients. Our panel comprised 22 pediatricians (96%) and one clinical pharmacist (4%). Mean agreement ratings were 4.43/5 (95% CI 4.39–4.48) and 4.6/5 (95% CI 4.56–4.64), respectively, during the first Delphi round and the second (p<0.001). At the end of the first round, all items submitted (54) were retained, including 13 items that had been reworded. In the second round, 20 experts participated and two IPs (4%) were not retained for the final list. This list comprised 52 IPs (44 inappropriate prescriptions and eight omissions of prescription). Conclusion The list of IP validated in this study should help in the detection of DRPs and optimize prescriptions in pediatric units in Côte d’Ivoire.
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Affiliation(s)
- Elisée Doffou
- Therapeutic and Clinical Pharmacy Laboratory, Faculty of Pharmaceutical and Biological Sciences, Félix Houphouët-Boigny University, Abidjan, Côte d'Ivoire.,Department of Pharmacy, Teaching Hospital of Cocody, Abidjan, Côte d'Ivoire
| | - Christelle Avi
- Department of Pediatrics, Teaching Hospital of Bouaké, Bouaké, Côte d'Ivoire
| | | | - Danho Pascal Abrogoua
- Therapeutic and Clinical Pharmacy Laboratory, Faculty of Pharmaceutical and Biological Sciences, Félix Houphouët-Boigny University, Abidjan, Côte d'Ivoire.,Department of Clinical Pharmacology, Teaching Hospital of Cocody, Abidjan, Côte d'Ivoire
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12
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Damoiseaux-Volman BA, van der Velde N, Ruige SG, Romijn JA, Abu-Hanna A, Medlock S. Effect of Interventions With a Clinical Decision Support System for Hospitalized Older Patients: Systematic Review Mapping Implementation and Design Factors. JMIR Med Inform 2021; 9:e28023. [PMID: 34269682 PMCID: PMC8325084 DOI: 10.2196/28023] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/10/2021] [Accepted: 05/17/2021] [Indexed: 01/25/2023] Open
Abstract
Background Clinical decision support systems (CDSSs) form an implementation strategy that can facilitate and support health care professionals in the care of older hospitalized patients. Objective Our study aims to systematically review the effects of CDSS interventions in older hospitalized patients. As a secondary aim, we aim to summarize the implementation and design factors described in effective and ineffective interventions and identify gaps in the current literature. Methods We conducted a systematic review with a search strategy combining the categories older patients, geriatric topic, hospital, CDSS, and intervention in the databases MEDLINE, Embase, and SCOPUS. We included controlled studies, extracted data of all reported outcomes, and potentially beneficial design and implementation factors. We structured these factors using the Grol and Wensing Implementation of Change model, the GUIDES (Guideline Implementation with Decision Support) checklist, and the two-stream model. The risk of bias of the included studies was assessed using the Cochrane Collaboration’s Effective Practice and Organisation of Care risk of bias approach. Results Our systematic review included 18 interventions, of which 13 (72%) were effective in improving care. Among these interventions, 8 (6 effective) focused on medication review, 8 (6 effective) on delirium, 7 (4 effective) on falls, 5 (4 effective) on functional decline, 4 (3 effective) on discharge or aftercare, and 2 (0 effective) on pressure ulcers. In 77% (10/13) effective interventions, the effect was based on process-related outcomes, in 15% (2/13) interventions on both process- and patient-related outcomes, and in 8% (1/13) interventions on patient-related outcomes. The following implementation and design factors were potentially associated with effectiveness: a priori problem or performance analyses (described in 9/13, 69% effective vs 0/5, 0% ineffective interventions), multifaceted interventions (8/13, 62% vs 1/5, 20%), and consideration of the workflow (9/13, 69% vs 1/5, 20%). Conclusions CDSS interventions can improve the hospital care of older patients, mostly on process-related outcomes. We identified 2 implementation factors and 1 design factor that were reported more frequently in articles on effective interventions. More studies with strong designs are needed to measure the effect of CDSS on relevant patient-related outcomes, investigate personalized (data-driven) interventions, and quantify the impact of implementation and design factors on CDSS effectiveness. Trial Registration PROSPERO (International Prospective Register of Systematic Reviews): CRD42019124470; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=124470.
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Affiliation(s)
- Birgit A Damoiseaux-Volman
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Nathalie van der Velde
- Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sil G Ruige
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Johannes A Romijn
- Department of Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Stephanie Medlock
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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13
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Elliott R, Mei J, Wormleaton N, Fry M. Interventions for the discharge of older people to their home from the emergency department: a systematic review. Australas Emerg Care 2021; 25:1-12. [PMID: 34112626 DOI: 10.1016/j.auec.2021.01.001] [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: 11/09/2020] [Revised: 12/14/2020] [Accepted: 01/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clinicians have limited evidence on which to base their practice to effectively discharge older people from emergency. The aim of the review was to assess the effectiveness of interventions used for the discharge of older people from the emergency department to their home in the community by emergency clinicians. METHODS The PRISMA guidelines were followed. The search comprised seven databases including CINAHL Complete, Medline and EMBASE, and additionally unpublished literature sources including trial registries and theses databases. The results were presented for three outcomes: mortality; emergency department representation after the index visit; and physical function. A narrative analysis was performed. RESULTS Twenty-five studies met the inclusion criteria; 13 RCTs and 12 quasi-experimental. Risk of bias was moderate to high. There was a trend towards reduced probability of representing to the emergency department within 3 months of the index visit for individualised focussed elder discharge health interventions. Results were equivocal for other outcomes. CONCLUSIONS Greater clarity and consensus is needed to determine the most appropriate discharge measures, screening tools, information sources and discharge roles for the emergency setting. Rigorous multicentre trials to improve the evidence on which to base this aspect of emergency care are required.
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Affiliation(s)
- Rosalind Elliott
- Nursing and Midwifery Research Centre, Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia; Faculty of Health, University of Technology Sydney, Ultimo, 2007 NSW, Australia.
| | - Joy Mei
- Emergency Department, Hornsby Hospital, Northern Sydney Local Health District, Palmerston Road, Hornsby, NSW 2077, Australia
| | - Nicola Wormleaton
- NSLHD Libraries, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia
| | - Margaret Fry
- Nursing and Midwifery Research Centre, Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia; Faculty of Health, University of Technology Sydney, Ultimo, 2007 NSW, Australia
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14
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Shadyab AH, Castillo EM, Chan TC, Tolia VM. Developing and Implementing a Geriatric Emergency Department (GED): Overview and Characteristics of GED Visits. J Emerg Med 2021; 61:131-139. [PMID: 34006420 DOI: 10.1016/j.jemermed.2021.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/22/2021] [Accepted: 02/21/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The traditional model of emergency care may not be sufficient to address the complex care needs of older adults, who present to the emergency department with multiple comorbidities, geriatric syndromes, and social determinants of health, complicating diagnosis and management. Geriatric emergency departments (GEDs) have emerged throughout the last decade to address these concerns and improve the emergency care of older adults. OBJECTIVE Our aim was to describe the policies, procedures, and workflow of our GEDs, and to provide data on patient outcomes and discuss challenges and recommendations in the development and implementation of a GED. DISCUSSION Our GED includes interdisciplinary staff trained in geriatric emergency medicine, evidence-based protocols for geriatric care, physical modifications to accommodate older adults' functional limitations, administration of geriatric assessments, care coordination with case managers and social workers, and referrals to care. Assessments screen for geriatric syndromes and social determinants of health. Quality improvement is a critical component and includes a robust medication safety plan to reduce use of potentially inappropriate medications. Hospital administrators considering developing a GED should create a care planning team, conduct an institutional needs assessment, and identify the GED model that will most efficiently help them achieve an age-friendly health system. CONCLUSIONS The GED will play an important role in addressing the diverse health care needs of older adults in the coming decades. Future research studies of health outcomes among older adults receiving care at GEDs compared with traditional EDs will be critical in informing future improvements and innovations in geriatric emergency care.
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Affiliation(s)
- Aladdin H Shadyab
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, California
| | - Edward M Castillo
- Department of Emergency Medicine, University of California, San Diego, La Jolla, California
| | - Theodore C Chan
- Department of Emergency Medicine, University of California, San Diego, La Jolla, California
| | - Vaishal M Tolia
- Department of Emergency Medicine, University of California, San Diego, La Jolla, California
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15
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Addressing Fall Risk From the Emergency Department: What Are We Missing? Adv Emerg Nurs J 2021; 43:2-9. [PMID: 33952869 DOI: 10.1097/tme.0000000000000337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Research to Practice column focuses on improving the research critique skills of emergency nurses and advanced practice providers to assist with the translation of research into practice. In this issue, we discuss the findings of a secondary data analysis conducted by K. Davenport, M. Alazemi, J. Sri-On, and S. Liu (2020) that examined emergency department provider identification of modifiable risk factors when assessing older adults who present after a fall. The results found that providers frequently miss identifying and intervening in modifiable risk factors that contribute to adverse outcomes and readmissions following discharge. The results suggest future research needs and have implications for emergency nurse practitioner educational preparation.
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16
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Licata S, Tullio A, Valent F. Audit and Feedback in emergency: a systematic review and an Italian project to investigate and improve quality of care. EMERGENCY CARE JOURNAL 2020. [DOI: 10.4081/ecj.2020.9201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The Audit and Feedback process (AandF) is commonly accepted as a good way to improve quality in health care, also in Emergency Departments (ED), where health aspects and pathologies are very different, usually acute and highly complex. Within an Italian Ministry of Health research project called EASY-NET, we conducted a systematic review of literature on AandF in EDs from 2014 to December 2019 to evaluate the impact of this approach in a particular setting where time-dependent indicators are fundamental. We selected 24 articles: 9 about infective pathologies (i.e. antibiotic stewardship), 6 about cardiovascular acute emergencies (i.e. cardiac arrest), 2 about stroke, 3 about laboratory tests, and 4 about other fields (i.e. diabetic ketoacidosis or use of prothrombin complex). Most of articles proposed a multimodal approach: only 7 concerned AandF alone. Despite the wide range on interventions modality and the poor comparability of the considered studies, the results are encouraging and confirm the importance to implement AandF both in emergency and in other clinical settings.
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17
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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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18
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Vandenberg AE, Kegler M, Hastings SN, Hwang U, Wu D, Stevens MB, Clevenger C, Eucker S, Genes N, Huang W, Ikpe-Ekpo E, Nassisi D, Previll L, Rodriguez S, Sanon M, Schlientz D, Vigliotti D, Vaughan CP. Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system. Int J Qual Health Care 2020; 32:470-476. [PMID: 32671390 DOI: 10.1093/intqhc/mzaa077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 01/26/2023] Open
Abstract
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.
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Affiliation(s)
| | - Michelle Kegler
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | | | - Ula Hwang
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Daniel Wu
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | | | | | - Stephanie Eucker
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Nick Genes
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Wennie Huang
- Duke University School of Medicine, Durham, NC 27710, USA
| | | | - Denise Nassisi
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Laura Previll
- Duke University School of Medicine, Durham, NC 27710, USA
| | - Sandra Rodriguez
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Martine Sanon
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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19
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Burningham Z, Jackson GL, Kelleher J, Stevens M, Morris I, Cohen J, Maloney G, Vaughan CP. The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUIPPED) Potentially Inappropriate Medication Dashboard: A Suitable Alternative to the In-person Academic Detailing and Standardized Feedback Reports of Traditional EQUIPPED? Clin Ther 2020; 42:573-582. [DOI: 10.1016/j.clinthera.2020.02.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/15/2020] [Accepted: 02/20/2020] [Indexed: 11/25/2022]
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20
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Vandenberg AE, Echt KV, Kemp L, McGwin G, Perkins MM, Mirk AK. Academic Detailing with Provider Audit and Feedback Improve Prescribing Quality for Older Veterans. J Am Geriatr Soc 2019. [PMID: 29532466 DOI: 10.1111/jgs.15247] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Suboptimal prescribing persists as a driver of poor quality care of older veterans and is associated with risk of hospitalization and emergency department visits. We adapted a successful medication management model, Integrated Management and Polypharmacy Review of Vulnerable Elders (IMPROVE), from an urban geriatric specialty clinic to rural community-based clinics that deliver primary care. The goals were to promote prescribing quality and safety for older adults, including reduced prescribing of potentially inappropriate medications (PIMs). We augmented the original model, which involved a pharmacist-led, one-on-one medication review with high-risk older veterans, to provide rural primary care providers (PCPs) and pharmacists with educational outreach through academic detailing and tools to support safe geriatric prescribing practices, as well as individual audit and feedback on prescribing practice and confidential peer benchmarking. Twenty PCPs and 4 pharmacists at 4 rural Georgia community-based outpatient clinics participated. More than 7,000 older veterans were seen in more than 20,000 PCP encounters during the 14-month intervention period. Implementation of the IMPROVE intervention reduced PIM prescribing incidence from 9.6 new medications per 100 encounters during baseline to 8.7 after the intervention (P = .009). IMPROVE reduced PIM prevalence (proportion of encounters involving veterans who were taking at least 1 PIM) from 22.6% to 16.7% (P < .001). These approaches were effective in reducing PIMs prescribed to older veterans in a rural setting and constitute a feasible model for disseminating geriatric best practices to the primary care setting.
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Affiliation(s)
- Ann E Vandenberg
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Decatur, Georgia.,Division of General Medicine and Geriatrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Katharina V Echt
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Decatur, Georgia.,Division of General Medicine and Geriatrics, School of Medicine, Emory University, Atlanta, Georgia.,Atlanta Veterans Affairs Medical Center, Decatur, Georgia
| | - Lawanda Kemp
- Atlanta Veterans Affairs Medical Center, Decatur, Georgia
| | - Gerald McGwin
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Decatur, Georgia
| | - Molly M Perkins
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Decatur, Georgia.,Division of General Medicine and Geriatrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Anna K Mirk
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Decatur, Georgia.,Division of General Medicine and Geriatrics, School of Medicine, Emory University, Atlanta, Georgia.,Atlanta Veterans Affairs Medical Center, Decatur, Georgia
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21
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Moss JM, Bryan WE, Wilkerson LM, King HA, Jackson GL, Owenby RK, Van Houtven CH, Stevens MB, Powers J, Vaughan CP, Hung WW, Hwang U, Markland AD, Sloane R, Knaack W, Hastings SN. An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department. J Pharm Pract 2019; 32:167-174. [PMID: 29277130 PMCID: PMC6533068 DOI: 10.1177/0897190017747424] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician-pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED). METHODS This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention. RESULTS Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug-disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 ( P < .0001). CONCLUSION Academic detailing led by a physician-pharmacist pair resulted in improved confidence in physician residents' ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.
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Affiliation(s)
- Jason M. Moss
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - William E. Bryan
- Pharmacy Service, Veterans Affairs Health Care System, Durham, NC, USA
| | - Loren M. Wilkerson
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Heather A. King
- Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - George L. Jackson
- Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Ryan K. Owenby
- Pharmacy Service, Veterans Affairs Health Care System, Durham, NC, USA
| | - Courtney H. Van Houtven
- Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Melissa B. Stevens
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Atlanta/Decatur, GA, USA
- Emory University School of Medicine, Atlanta/Decatur, GA, USA
| | - James Powers
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Nashville, TN, USA
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Camille P. Vaughan
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Atlanta/Decatur, GA, USA
- Emory University School of Medicine, Atlanta/Decatur, GA, USA
| | - William W. Hung
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Bronx, NY, USA
- Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Ula Hwang
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Bronx, NY, USA
- Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | | | - Richard Sloane
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA
- Department of Duke Aging Center, Duke University Medical Center, Durham, NC, USA
| | - William Knaack
- Division of General Internal Medicine, Veterans Affairs Health Care System, Durham, NC, USA
| | - Susan Nicole Hastings
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA
- Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
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22
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Abstract
BACKGROUND AND PURPOSE The elderly population is expected to double by 2050 with falls and hospitalizations due to adverse drug events having a major effect on health and quality of life. With the release of the revised 2015 American Geriatrics Society (AGS) Beers criteria, usage of potentially inappropriate medications (PIMs) should be studied to determine their effect on falls and hospitalizations in frail populations such as those in assisted living facilities. METHODS This quality improvement project used a retrospective chart review on residents from a purposive sample of two assisted living facilities in Northern Virginia. Residents were aged ≥65 and lived at the facility for at least 6 months and were not enrolled in hospice and/or palliative care or living in the dementia unit. The 2015 AGS Beers criteria were used to evaluate the effect of PIMs on falls and hospitalization rates. CONCLUSIONS This project did not find statistical significance between PIMs and falls (p = .276). A favorable, but not statistically significant trend, was noted between PIMs and hospitalizations (p = .079). IMPLICATIONS FOR PRACTICE Understanding the effect of PIMs on falls and hospitalizations could help providers improve prescribing practices for the elderly population who are at the greatest risk for potential adverse effects from polypharmacy.
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23
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Scope and Influence of Electronic Health Record-Integrated Clinical Decision Support in the Emergency Department: A Systematic Review. Ann Emerg Med 2019; 74:285-296. [PMID: 30611639 DOI: 10.1016/j.annemergmed.2018.10.034] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/08/2018] [Accepted: 10/29/2018] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE As electronic health records evolve, integration of computerized clinical decision support offers the promise of sorting, collecting, and presenting this information to improve patient care. We conducted a systematic review to examine the scope and influence of electronic health record-integrated clinical decision support technologies implemented in the emergency department (ED). METHODS A literature search was conducted in 4 databases from their inception through January 18, 2018: PubMed, Scopus, the Cumulative Index of Nursing and Allied Health, and Cochrane Central. Studies were included if they examined the effect of a decision support intervention that was implemented in a comprehensive electronic health record in the ED setting. Standardized data collection forms were developed and used to abstract study information and assess risk of bias. RESULTS A total of 2,558 potential studies were identified after removal of duplicates. Of these, 42 met inclusion criteria. Common targets for clinical decision support intervention included medication and radiology ordering practices, as well as more comprehensive systems supporting diagnosis and treatment for specific disease entities. The majority of studies (83%) reported positive effects on outcomes studied. Most studies (76%) used a pre-post experimental design, with only 3 (7%) randomized controlled trials. CONCLUSION Numerous studies suggest that clinical decision support interventions are effective in changing physician practice with respect to process outcomes such as guideline adherence; however, many studies are small and poorly controlled. Future studies should consider the inclusion of more specific information in regard to design choices, attempt to improve on uncontrolled before-after designs, and focus on clinically relevant outcomes wherever possible.
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24
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Ammerman CA, Simpkins BA, Warman N, Downs TN. Potentially Inappropriate Medications in Older Adults: Deprescribing with a Clinical Pharmacist. J Am Geriatr Soc 2018; 67:115-118. [PMID: 30300947 DOI: 10.1111/jgs.15623] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 08/29/2018] [Accepted: 08/29/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the effects of a Geriatric Patient-Aligned Care Team (GeriPACT) on deprescribing of potentially inappropriate medications (PIMs) in individuals aged 80 and older with usual care (UC) in the Veterans Affairs setting. DESIGN Retrospective cohort study. SETTING Veterans Affairs Medical Center in Lexington, Kentucky. PARTICIPANTS Individuals aged 80 and older who filled a PIM at least 90 days before a GeriPACT or primary care appointment between January 1, 2015, and September 6, 2017 (N = 568). MEASUREMENTS The primary outcome was to determine whether an interdisciplinary team (IDT) including a clinical pharmacy specialist (CPS) resulted in greater deprescribing of PIMs for older adults than UC. RESULTS One hundred twenty-one (26.8%) PIMs were deprescribed in GeriPACT, compared with 73 (16.1%) in UC (p = <.001). Of PIMs not deprescribed, 9.7% (n = 32) were dose reduced in GeriPACT, versus 2.8% (n = 11) in UC (p < .001). Documentation of risk versus benefit discussion between a provider and participant or pharmacist and participant occurred with 65.2% (n = 215) of PIMs not deprescribed in GeriPACT and 0.003% (n = 1) in UC (p < .001). CONCLUSION An IDT that included a CPS led to significantly more deprescribing of PIMs in older veterans. Including a CPS on an IDT for the management of older adults can decrease PIM use in our rapidly growing aging population. J Am Geriatr Soc 67:115-118, 2019.
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Affiliation(s)
| | | | - Nora Warman
- Veterans Affairs Medical Center, Lexington, Kentucky
| | - Tara N Downs
- Veterans Affairs Medical Center, Lexington, Kentucky
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25
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Kim M, Kaplan SJ, Mitchell SH, Gatewood M, Bentov I, Bennett KA, Crawford CA, Sutton PR, Matsuwaka D, Damodarasamy M, Reed MJ. The Effect of Computerized Physician Order Entry Template Modifications on the Administration of High-Risk Medications in Older Adults in the Emergency Department. Drugs Aging 2018; 34:793-801. [PMID: 28956283 DOI: 10.1007/s40266-017-0489-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Older adults are more susceptible to adverse events when administered certain medications at doses appropriate for younger adults. OBJECTIVE The aim of this study was to investigate the effect of default geriatric dosing on computerized physician order entry (CPOE) templates on the subsequent administration of recommended starting doses of opioids, benzodiazepines (BZDs) and non-steroidal anti-inflammatory drugs (NSAIDs) to older adults in the emergency department (ED). METHODS This was a before-after comparison of the frequency of the recommended starting doses of high-risk medications to adults aged 65 years and older. Computerized records were queried for the administration of the above medication classes in two academic EDs over two similar 4-month periods in 2015 and 2016. Between study periods, the doses of high-risk medications on ED CPOE templates were adjusted for older adults based on established pharmacy guidelines and expert consensus. RESULTS There was a significant improvement in the rate of recommended dose administration of all medications of interest (27.3 vs. 32.5%, p < 0.001). Not surprisingly, the medications that were maximally impacted were also those most frequently prescribed, with a significant increase in the recommended dosing of opioids (29.0 vs. 35.2%, p < 0.001) accounting for the majority of the change. Although there were no differences in BZDs as a group, there were significant differences in selected BZDs such as midazolam and diazepam. Changes in the recommended dosing of NSAIDs could not be determined due to low numbers of administered doses in both phases of the study. CONCLUSION Simple changes in the CPOE template resulted in increased administration of the recommended starting doses of high-risk medications to older adults in the ED.
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Affiliation(s)
- Mitchell Kim
- Department of Emergency Medicine, University of Washington, Box 359702, 325 Ninth Avenue, Seattle, WA, USA.
| | - Stephen J Kaplan
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA.,Section of General, Thoracic, and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Steven H Mitchell
- Department of Emergency Medicine, University of Washington, Box 359702, 325 Ninth Avenue, Seattle, WA, USA
| | - Medley Gatewood
- Department of Emergency Medicine, University of Washington, Box 359702, 325 Ninth Avenue, Seattle, WA, USA
| | - Itay Bentov
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Katherine A Bennett
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | | | - Paul R Sutton
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Diane Matsuwaka
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Mamatha Damodarasamy
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - May J Reed
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
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26
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Kim M, Mitchell SH, Gatewood M, Bennett KA, Sutton PR, Crawford CA, Bentov I, Damodarasamy M, Kaplan SJ, Reed MJ. Older adults and high-risk medication administration in the emergency department. Drug Healthc Patient Saf 2017; 9:105-112. [PMID: 29184448 PMCID: PMC5685141 DOI: 10.2147/dhps.s143341] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Older adults are susceptible to adverse effects from opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines (BZDs). We investigated factors associated with the administration of elevated doses of these medications of interest to older adults (≥65 years old) in the emergency department (ED). PATIENTS AND METHODS ED records were queried for the administration of medications of interest to older adults at two academic medical center EDs over a 6-month period. Frequency of recommended versus elevated ("High doses" were defined as doses that ranged between 1.5 and 3 times higher than the recommended starting doses; "very high doses" were defined as higher than high doses) starting doses of medications, as determined by geriatric pharmacy/medicine guidelines and expert consensus, was compared by age groups (65-69, 70-74, 75-79, 80-84, and ≥85 years), gender, and hospital. RESULTS There were 17896 visits representing 11374 unique patients >65 years of age (55.3% men, 44.7% women). A total of 3394 doses of medications of interest including 1678 high doses and 684 very high doses were administered to 1364 different patients. Administration of elevated doses of medications was more common than that of recommended doses. Focusing on opioids and BZDs, the 65-69-year age group was much more likely to receive very high doses (1481 and 412 doses, respectively) than the ≥85-year age groups (relative risk [RR] 5.52, 95% CI 2.56-11.90), mainly reflecting elevated opioid dosing (RR 8.28, 95% CI 3.69-18.57). Men were more likely than women to receive very high doses (RR 1.47, 95% CI 1.26-1.72), primarily due to BZDs (RR 2.12, 95% CI 2.07-2.16). CONCLUSION Administration of elevated doses of opioids and BZDs in the older population occurs frequently in the ED, especially to the 65-69-year age group and men. Further attention to potentially unsafe dosing of high-risk medications to older adults in the ED is warranted.
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Affiliation(s)
- Mitchell Kim
- Department of Emergency Medicine, University of Washington
| | | | | | - Katherine A Bennett
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington
| | - Paul R Sutton
- Division of General Internal Medicine, Department of Medicine, University of Washington
| | | | - Itay Bentov
- Department of Anesthesiology and Pain Medicine, University of Washington
| | - Mamatha Damodarasamy
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington
| | - Stephen J Kaplan
- Section of General, Thoracic and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - May J Reed
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington
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27
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Vandenberg AE, Vaughan CP, Stevens M, Hastings SN, Powers J, Markland A, Hwang U, Hung W, Echt KV. Improving geriatric prescribing in the ED: a qualitative study of facilitators and barriers to clinical decision support tool use. Int J Qual Health Care 2017; 29:117-123. [PMID: 27852639 DOI: 10.1093/intqhc/mzw129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 10/12/2016] [Indexed: 11/14/2022] Open
Abstract
Quality problem or issue Clinical decision support (CDS) may improve prescribing for older adults in the Emergency Department (ED) if adopted by providers. Initial assessment Existing prescribing order entry processes were mapped at an initial Veterans Administration Medical Center site, demonstrating cognitive burden, effort and safety concerns. Choice of solution Geriatric order sets incorporating 2012 Beers guidelines and including geriatric prescribing advice and prepopulated order options were developed. Implementation Geriatric order sets were implemented at two sites as part of the multicomponent 'Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department' quality improvement initiative. Evaluation Facilitators and barriers to order sets use at the two sites were evaluated. Phone interviews were conducted with two provider groups (n = 20), those 'EQUiPPED' with the interventions (n = 10, 5 at each site) and Comparison providers who were only exposed to order sets through a clickable option on the ED order menu within the patient's medical record (n = 10, 5 at each site). All providers were asked about order set 'use' and 'usefulness'. Users (n = 11) were asked about 'usability'. Lessons learned Order set adopters described 'usefulness' in terms of 'safety' and 'efficiency', whereas order set consultants and order set non-users described 'usefulness' in terms of 'information' or 'training'. Provider 'autonomy', 'comfort' level with existing tools, and 'learning curve' were stated as barriers to use. Conclusions Quantifying efficiency advantages and communicating safety benefit over preexisting practices and tools may improve adoption of CDS in ED and in other settings of care.
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Affiliation(s)
- Ann E Vandenberg
- Birmingham/Atlanta VA GRECC, Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.,Birmingham/Atlanta VA GRECC, Birmingham VA Medical Center, 700 S. 19th St, Birmingham, AL 35233, USA.,Department of Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA
| | - Camille P Vaughan
- Birmingham/Atlanta VA GRECC, Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.,Birmingham/Atlanta VA GRECC, Birmingham VA Medical Center, 700 S. 19th St, Birmingham, AL 35233, USA.,Department of Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA
| | - Melissa Stevens
- Birmingham/Atlanta VA GRECC, Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.,Birmingham/Atlanta VA GRECC, Birmingham VA Medical Center, 700 S. 19th St, Birmingham, AL 35233, USA.,Department of Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA
| | - Susan N Hastings
- Durham VA GRECC and HSR&D Center, Durham VA Medical Centre, 508 Fulton St, Durham, NC 27705, USA.,Center for the Study of Aging and Department of Medicine, Duke University Medical Center 3710, Durham, NC 27710, USA
| | - James Powers
- Tennessee Valley VA GRECC, Tennessee Valley Healthcare System, 1310 24th Avenue S, Nashville, TN 37212-2637, USA.,Division of Geriatrics, Department of Medicine, Vanderbilt University School of Medicine, 7159 Vanderbilt Medical Center East, Nashville, TN 37232, USA
| | - Alayne Markland
- Birmingham/Atlanta VA GRECC, Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.,Birmingham/Atlanta VA GRECC, Birmingham VA Medical Center, 700 S. 19th St, Birmingham, AL 35233, USA.,Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294, USA
| | - Ula Hwang
- James J Peters VA Medical Center GRECC, 130 West Kingsbridge Road, GRECC, 4A-17, Bronx, NY 10468, USA.,Departments of Emergency Medicine and Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1428 Madison Avenue, New York, NY 10029, USA
| | - William Hung
- James J Peters VA Medical Center GRECC, 130 West Kingsbridge Road, GRECC, 4A-17, Bronx, NY 10468, USA.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1428 Madison Avenue, New York, NY 10029, USA
| | - Katharina V Echt
- Birmingham/Atlanta VA GRECC, Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.,Birmingham/Atlanta VA GRECC, Birmingham VA Medical Center, 700 S. 19th St, Birmingham, AL 35233, USA.,Department of Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA
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Desnoyer A, Blanc AL, Pourcher V, Besson M, Fonzo-Christe C, Desmeules J, Perrier A, Bonnabry P, Samer C, Guignard B. PIM-Check: development of an international prescription-screening checklist designed by a Delphi method for internal medicine patients. BMJ Open 2017; 7:e016070. [PMID: 28760793 PMCID: PMC5642656 DOI: 10.1136/bmjopen-2017-016070] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Potentially inappropriate medication (PIM) occurs frequently and is a well-known risk factor for adverse drug events, but its incidence is underestimated in internal medicine. The objective of this study was to develop an electronic prescription-screening checklist to assist residents and young healthcare professionals in PIM detection. DESIGN Five-step study involving selection of medical domains, literature review and 17 semistructured interviews, a two-round Delphi survey, a forward/back-translation process and an electronic tool development. SETTING 22 University and general hospitals from Canada, Belgium, France and Switzerland. PARTICIPANTS 40 physicians and 25 clinical pharmacists were involved in the study.Agreement with the checklist statements and their usefulness for healthcare professional training were evaluated using two 6-point Likert scales (ranging from 0 to 5). PRIMARY AND SECONDARY OUTCOME MEASURES Agreement and usefulness ratings were defined as: >65% of the experts giving the statement a rating of 4 or 5, during the first Delphi-round and >75% during the second. RESULTS 166 statements were generated during the first two steps. Mean agreement and usefulness ratings were 4.32/5 (95% CI 4.28 to 4.36) and 4.11/5 (4.07 to 4.15), respectively, during the first Delphi-round and 4.53/5 (4.51 to 4.56) and 4.36/5 (4.33 to 4.39) during the second (p<0.001). The final checklist includes 160 statements in 17 medical domains and 56 pathologies. An algorithm of approximately 31 000 lines was developed including comorbidities and medications variables to create the electronic tool. CONCLUSION PIM-Check is the first electronic prescription-screening checklist designed to detect PIM in internal medicine. It is intended to help young healthcare professionals in their clinical practice to detect PIM, to reduce medication errors and to improve patient safety.
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Affiliation(s)
- Aude Desnoyer
- Department of Pharmacy, Hôpitaux Universitaires de Genève, Geneva, Switzerland
- Department of Pharmacy, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Anne-Laure Blanc
- Department of Pharmacy, Hôpitaux Universitaires de Genève, Geneva, Switzerland
- Department of Pharmacy, Hôpitaux de l’Est Lémanique, Vevey, Switzerland
| | - Valérie Pourcher
- Department of Infectious and Tropical Diseases, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- UMR996—Inflammation, Chemokines and Immunopathology, Inserm, Clamart, France
| | - Marie Besson
- Department of Clinical Pharmacology and Toxicology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Jules Desmeules
- Department of Clinical Pharmacology and Toxicology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
- Section of Pharmaceutical Sciences, Université de Genève, Université de Lausanne, Geneva, Switzerland
| | - Arnaud Perrier
- Department of General Internal Medicine, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Pascal Bonnabry
- Department of Pharmacy, Hôpitaux Universitaires de Genève, Geneva, Switzerland
- Section of Pharmaceutical Sciences, Université de Genève, Université de Lausanne, Geneva, Switzerland
| | - Caroline Samer
- Department of Clinical Pharmacology and Toxicology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Bertrand Guignard
- Department of Pharmacy, Hôpitaux Universitaires de Genève, Geneva, Switzerland
- Department of Clinical Pharmacology and Toxicology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
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29
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Stevens M, Hastings SN, Markland AD, Hwang U, Hung W, Vandenberg AE, Bryan W, Cross D, Powers J, McGwin G, Fattouh N, Ho W, Clevenger C, Vaughan CP. Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (
EQU
i
PPED
). J Am Geriatr Soc 2017; 65:1609-1614. [DOI: 10.1111/jgs.14890] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Melissa Stevens
- Birmingham/Atlanta VA GRECC Atlanta Georgia
- Emory University Atlanta Georgia
| | - Susan N. Hastings
- Durham VA GRECC and HSR&D Durham North Carolina
- Duke University Durham North Carolina
| | - Alayne D. Markland
- Birmingham/Atlanta VA GRECC Birmingham Alabama
- University of Alabama at Birmingham Birmingham Alabama
| | - Ula Hwang
- Bronx VA GRECC Bronx New York
- Mount Sinai Hospital New York New York
| | - William Hung
- Bronx VA GRECC Bronx New York
- Mount Sinai Hospital New York New York
| | - Ann E. Vandenberg
- Birmingham/Atlanta VA GRECC Atlanta Georgia
- Emory University Atlanta Georgia
| | | | | | - James Powers
- Tennessee Valley VA GRECC Nashville Tennessee
- Vanderbilt University Nashville Tennessee
| | - Gerald McGwin
- Birmingham/Atlanta VA GRECC Birmingham Alabama
- University of Alabama at Birmingham Birmingham Alabama
| | - Noor Fattouh
- James J. Peters VA Medical Center Bronx New York
| | - William Ho
- James J. Peters VA Medical Center Bronx New York
| | - Carolyn Clevenger
- Birmingham/Atlanta VA GRECC Atlanta Georgia
- Emory University Atlanta Georgia
| | - Camille P. Vaughan
- Birmingham/Atlanta VA GRECC Atlanta Georgia
- Emory University Atlanta Georgia
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Vanderman AJ, Moss JM, Bryan WE, Sloane R, Jackson GL, Hastings SN. Evaluating the Impact of Medication Safety Alerts on Prescribing of Potentially Inappropriate Medications for Older Veterans in an Ambulatory Care Setting. J Pharm Pract 2016; 30:82-88. [PMID: 26702027 DOI: 10.1177/0897190015621803] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Potentially inappropriate medications (PIMs) have been associated with poor outcomes in older adults. Electronic health record (EHR)-based interventions may be an effective way to reduce PIM prescribing. The main objective of this study was to evaluate changes in PIM prescribing to older adult veterans ≥65 years old in the ambulatory care setting preimplementation and postimplementation of medication alert messages at the point of computerized provider order entry (CPOE). Additional exploratory objectives included evaluating provider type and patient-provider relationship as a factor for change in PIM prescribing. A total of 1539 patients prealert and 1490 patients postalert were prescribed 1952 and 1897 PIMs, respectively. End points were reported as the proportion of new PIM orders of total new prescriptions. There was no significant difference in the rate of new PIMs prealert and postalert overall, 12.6% to 12.0% ( P = .13). However, there was a significant reduction in the rate of the top 10 most common newly prescribed PIMs, 9.0% to 8.3% ( P = .016), and resident providers prescribed fewer PIMs during both time periods. A simple, age-specific medication alert message during CPOE decreased the incidence of the most frequently prescribed PIMs in older adults receiving care in an ambulatory care setting.
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Affiliation(s)
- Adam J Vanderman
- 1 Geriatric Research, Education and Clinical Center (GRECC), Durham VA Medical Center, Durham, NC, USA.,2 Pharmacy Service, Durham VA Medical Center, Durham, NC, USA
| | - Jason M Moss
- 1 Geriatric Research, Education and Clinical Center (GRECC), Durham VA Medical Center, Durham, NC, USA.,3 Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - William E Bryan
- 2 Pharmacy Service, Durham VA Medical Center, Durham, NC, USA
| | - Richard Sloane
- 1 Geriatric Research, Education and Clinical Center (GRECC), Durham VA Medical Center, Durham, NC, USA.,4 Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA
| | - George L Jackson
- 5 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA.,6 Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA
| | - S Nicole Hastings
- 1 Geriatric Research, Education and Clinical Center (GRECC), Durham VA Medical Center, Durham, NC, USA.,4 Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA.,5 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA.,7 Division of Geriatric Medicine, Duke University Medical Center, Durham, NC, USA
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Moss JM, Bryan WE, Wilkerson LM, Jackson GL, Owenby RK, Van Houtven C, Stevens MB, Powers JS, Vaughan CP, Hung WW, Hwang U, Markland AD, McGwin G, Hastings SN. Impact of Clinical Pharmacy Specialists on the Design and Implementation of a Quality Improvement Initiative to Decrease Inappropriate Medications in a Veterans Affairs Emergency Department. J Manag Care Spec Pharm 2016; 22:74-80. [PMID: 27015054 PMCID: PMC10397930 DOI: 10.18553/jmcp.2016.22.1.74] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND As the proportion of older adult patients who interface with the health care system grows, clinical pharmacy specialists (CPS) have a pivotal role in reducing potentially inappropriate medication (PIM) use in this population. OBJECTIVES To (a) describe CPS involvement in the design and implementation of a quality improvement (QI) initiative to decrease PIM prescribing in a Veterans Affairs (VA) emergency department (ED) and (b) report on changes in PIM prescribing before and after the initiative. METHODS Enhancing Quality of Prescribing Practices for Veterans Discharged from the Emergency Department (EQUiPPED) is an ongoing multisite QI project that aims to decrease ED PIM prescribing. We used a mixed-method approach that applied qualitative and quantitative measures in describing the CPS role and evaluating PIM rates. PIMs were defined using the 2012 Beers Criteria. We reported monthly PIM rates in patients aged 65 years and older who were discharged from the ED from January 2012 to November 2014. A piecewise, nonlinear regression model evaluated the pattern in PIM prescriptions over time. RESULTS At the Durham, North Carolina, VA Medical Center, a total of 4 CPS were involved with tailoring the design and implementation of the EQUiPPED intervention for local use. CPS input led to 3 key innovations: academic detailing performed by a physician-CPS pair, medication alert messages identifying medications as PIMs in the computerized patient record system, and automated reports describing the frequency and type of PIMs prescribed by each ED provider. Between February 2013 and November 2014, 73 ED providers received the academic detailing. The ED facility experienced a relative reduction of 47.5% in the rate of PIM prescribing over the observation period. CONCLUSIONS This QI project resulted in a meaningful decrease in PIM prescribing in older ED adults. CPS contributions to QI can extend beyond pharmacotherapy and provider education to also include information technology tools using formulary management expertise.
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