Initiative Decreases Inappropriate Prescribing to Older Veterans Discharged from VA Emergency Department Care
Within the VA healthcare system, Veterans ages 65 and older represent approximately 40% of all emergency department (ED) visits. Recent guidelines for emergency geriatric care cite improving prescribing quality as a goal to provide high-quality ED care for older adults, who are particularly susceptible to suboptimal pharmacotherapy. This study evaluated the effectiveness and sustainability of the Enhancing Quality of Provider Practices for Older Adults in the ED (EQUiPPED) program to reduce the use of potentially inappropriate medications (PIMs). EQUiPPED is a multicomponent quality improvement initiative that combines provider education, clinical decision support for improved workflow, and provider feedback using audit and peer benchmarking. Investigators implemented this initiative in four urban, academically-affiliated VAMCs with a 24-hour emergency department. The primary outcome was the monthly proportion of PIMs prescribed to Veterans 65 years and older and discharged from the ED. PIMs were defined by the 2012 American Geriatrics Society Updated Beers Criteria medications to avoid in all older adults. The proportion of PIMs was tracked at all four sites for at least six months before any EQUiPPED interventions were started, throughout the implementation phase, and for at least 12 months after all EQUiPPED components were completed.
- EQUiPPED was associated with a sustained reduction in inappropriate medication prescribing at all four VAMCs. Post-intervention, the proportion of PIMs at site one decreased from 12% to 5%; at site two it decreased from 8% to 5%, at site three from 9% to 6%, and at site four from 7% to 6%.
- The implementation timeline for the initiative ranged from 6 to 14 months depending on the site. While the implementation timelines varied across sites, all VAMCs achieved a monthly PIM proportion between 5% and 6%.
- The Beers criteria served as a marker of prescribing quality in order to evaluate the impact of EQUiPPED on provider prescribing behavior, yet investigators only know that the number of PIMs declined. Additional analyses of broader health outcomes (i.e., repeat ED visits, hospitalizations) will allow insights into the potential impact on other areas.
- The EQUiPPED intervention led to safer prescribing and was sustainable across multiple VA sites. Implementation is currently underway at six additional VA emergency department sites, as well as three non-VA ED sites to evaluate broader dissemination.
This study was partly funded by HSR&D. Dr. Hastings is Director of HSR&D's Center for Health Services Research in Primary Care in Durham, NC.
Stevens M, Hastings S, Markland A, et al. Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED). Journal of the American Geriatrics Society. April 7, 2017;epub ahead of print.