A program to change prescribing habits has yielded positive results for a large Rhode Island health system, reducing the number of potentially inappropriate drug prescriptions and dangerous outcomes for elderly patients.
In the largest implementation to date of the tool, designed by the U.S. Department of Veterans Affairs to reduce potentially inappropriate medication (PIM) use, Lifespan, a nonprofit whose partners include the Brown University, reported a significant drop in the number of such prescriptions. elderly people on discharge from the emergency department (ED).
The number of PIMs among monthly prescriptions fell by approximately 26% in Lifespan’s three adult acute care emergency departments after adopting the EQUiPPED system – Improving the quality of prescribing practices for discharged older adults of the emergency department. The VA rolled out a version of the tool in 2013 to address the lack of training most emergency clinicians receive in managing geriatric medications.
The model “should be implemented in other states and, with greater replication, could shape national policy regarding quality of care for the elderly,” according to the researchers, who reported the results May 12 to the American Geriatrics Society (AGS) 2022 Annual Scientific Meeting, in Orlando, Florida.
Older adults are three times more likely than younger patients to end up in an emergency department due to medication-related harms. This is partly due to the greater number of prescriptions American adults over 65 are taking daily.
A key measure of quality
Although the Centers for Medicare & Medicaid Services and other groups have considered PIM minimization an important quality measure, most emergency departments lack an expert in geriatric prescribing, said Elizabeth Goldberg, MD, associate professor of emergency medicine at Brown University, Providence. Medscape Medical News.
With EQUiPPED, clinicians have access to geriatric medication order sets integrated into electronic health records, individualized referral reports, and education on medication safety in older adults. PIMs are defined by the Beers criteria of the American Geriatrics Society and include drugs such as proton pump inhibitors and antipsychotics.
The Lifespan program involved 362 clinicians who treat approximately 230,000 patients per year, including 40,000 aged 65 and over. Goldberg said implementing the program in such a large population could “really move the needle for older adults” by reducing falls, improving cognitive function and preventing harm from medication use.
She and her fellow researchers examined ED prescribing 13 months before and 16 months after the implementation of EQUiPPED, in August and September 2019. Of the clinicians who participated, 48% were referring physicians, 37% were residents and 34% were advanced practice providers.
PIM prescription increased from 8.93% before implementation (95% CI: 8.5% -9.36%) to 6.59% after (95% CI: 6.2% – 6 .98%; P
Despite the improvements, the system did not meet the target of reducing PIM to less than 5%. Goldberg said training the large number of clinicians, some of whom rotated in and out of the ER, proved particularly challenging. The COVID-19 pandemic has also potentially diverted attention from the quality improvement project, she said.
In addition to its size, the project was notable because it was supported by Blue Cross & Blue Shield of Rhode Island. Goldberg said securing private funding proved to be a faster and less competitive process than securing a government grant. Other institutions interested in conducting similar studies may need to find insurers who are in the Medicare Advantage market or who have a significant number of young enrollees with chronic conditions such as kidney disease, who could benefit from prescribing practices. more cautious, she said.
The new study builds on previous research, such as a 2017 study that showed EQUiPPED reduced PIM prescribing at four VA hospitals. Results from a more recent deployment in three academic health systems suggested that the model could also be effective in targeting overuse of specific medications in settings where PIM prescribing is already low.
A researcher in those earlier studies, Susan Nicole Hastings, MD, a specialist in geriatric medicine at Duke University in Durham, North Carolina, and the Durham VA Health Care System, said Medscape Medical News that Lifespan’s experience supports the idea that “with the right attention to balance fidelity and adaptation to the new setting, there is enormous potential to move successful programs from VA to other health systems” .
Ann E. Vandenberg, PhD, MPH, a gerontologist at Emory University in Atlanta, said the fragmented nature of the US healthcare system makes it difficult to spread EQUiPPED at scale, but interoperability applications that extract data from different electronic health records could help hospital systems adopt the program without undergoing site-specific customization.
Hastings and Vandenberg received research funding to study EQUiPPED from the Agency for Healthcare Research and Quality. Hastings has also received research funding from the VA.
American Geriatrics Society (AGS) 2022 Annual Scientific Meeting: Presented May 12, 2022.
Mary Chris Jaklevic is a medical journalist in the Midwest.
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