» Back to Table of Contents

Research Highlight

EQUIPPED for Safe Prescribing in the Emergency Department

Older Veterans are a vulnerable population at high risk of adverse drug events, especially at the time of discharge from the emergency department (ED). More than half of older adults discharged from the ED leave with a new prescription medication. Multiple studies show that between 6 percent and 13 percent of prescriptions written for older adults at ED discharge represent a potentially inappropriate medication. Prescribing new medications for older Veterans outside their primary care setting increases the opportunity for suboptimal prescribing as well as adverse drug events, both major concerns and contributors to repeat ED visits, hospitalization, and other poor health outcomes.

EQUIPPED (Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department) was initially designed as an innovative quality improvement (QI) initiative to reduce potentially inappropriate medication prescribing for adults aged 65 years and older and is particularly well suited for the busy ED environment. Initially funded by the Office of Geriatrics and Extended Care, the EQUIPPED QI intervention has three components aimed at influencing provider prescribing behavior: a) provider education; b) electronic clinical decision support via specialized geriatric pharmacy order sets at the point of prescribing; and c) academic detailing, including audit and feedback, and peer benchmarking. EQUIPPED is informed by the American Geriatrics Society Beers Criteria®, which indicate drugs that should be avoided in older adults because of the increased risk of adverse drug events. These criteria are widely used by government agencies and supported by research in various clinical settings as a marker of prescribing quality.

Results from four of the initial EQUIPPED implementation sites with in-person academic detailing demonstrated sustained pre-post improvement (reduction) in potentially inappropriate prescribing rates by nearly 50 percent at six months, suggesting the possibility of provider prescribing behavior culture change.¹ The EQUIPPED QI intervention typically involves at least one in-person academic detailing session using audit and feedback with peer benchmarking delivered by a local clinical champion, which is more resource intensive.

VA already uses both passive feedback (i.e., dashboards to report psychotropic medication use in community living center residents) and active feedback (e.g., implementation of a national academic detailing pharmacy program); however, there is little guidance on which strategy is most effective in the emergency department to deliver audit and feedback. To inform the optimal EQUIPPED implementation strategy for improving provider prescribing behavior toward older Veterans in EDs, we conducted a Health Systems Research funded cluster randomized trial comparing EQUIPPED with active provider feedback including academic detailing to EQUIPPED with passive provider feedback using individual electronic reports via a clinical dashboard. We randomized eight VA facilities to implement EQUIPPED with audit and feedback delivered through either passive provider feedback (dashboard sites) or active provider feedback (academic detailing sites).

During the six-month baseline period, the academic detailing and dashboard sites had similar monthly prescribing rates of potentially inappropriate medications. After pausing EQUIPPED implementation due to the emergence of the COVID-19 pandemic, one of the original eight VA sites determined it was not able to continue EQUIPPED implementation. An additional VA ED site was recruited to fill the open study spot and completed implementation of EQUIPPED using the active provider feedback strategy.

Comparing 12 months of prescribing data after EQUIPPED implementation, the academic detailing group significantly reduced potentially inappropriate medication prescribing compared to the dashboard group, with 14 percent higher odds that prescribers demonstrated safe prescribing at sites with academic detailing audit and feedback.²

Based on the fluctuations in prescribers each month for a given site (i.e., intermittent providers, health professions trainees, deployments during the COVID-19 pandemic), it was not feasible to continually update the audit and feedback reports, thus audit and feedback focused on staff providers determined by the site champion at baseline. In an exploratory analysis in which the prescribing evaluation was limited to providers who received EQUIPPED audit and feedback, both groups showed a statistically significant improvement in prescribing safety after EQUIPPED, and there was no statistical difference between the two implementation strategies.

In conclusion, eight VA EDs successfully implemented the core components of the EQUIPPED program amid the unprecedented challenges posed by the COVID-19 pandemic, suggesting EQUIPPED is tailored to the needs of the ED clinical environment. 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 dashboard-based audit and feedback is a reasonable strategy in resource- limited settings.

Since completion of the project, the EQUIPPED provider feedback dashboard continues to be used to provide direct feedback to providers at sites that have opted for this during their sustainment phase.3 The dashboard approach includes continued automated monthly feedback as well as site champion monitoring depending on each site’s desired sustainment plan. More broadly, of the first twenty VA EDs that were accredited by the American College of Emergency Physicians (ACEP) as Geriatric EDs, nine implemented EQUIPPED and used data from the program to demonstrate a commitment to medication safety for older adults.

References

1. Stevens M, et al. “Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED),” Journal of the American Geriatrics Society 2017;65(7):1609-14.
2. Vaughan CP, et al. “A Cluster Randomized Trial of Two Implementation Strategies to Deliver Audit and Feedback in the EQUIPPED Medication Safety Program,” Academic Emergency Medicine 2023;30(4):340-8.
3. Burningham Z, et al. “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?” Clinical Therapeutics 2020;42(4):573-82.