Aging
Conditions
Keywords
Emergency Department, Potentially Inappropriate Medications, Inappropriate Prescribing, Quality Improvement, Veteran Health, Older Adults
Brief summary
This research is being conducted to learn which implementation strategy of EQUIPPED is most effective to improve prescribing practices of ED providers toward older Veterans and determine the factors influencing implementation of this program to reduce the prescribing of PIMs to older adults upon discharge from the ED. The study has three research aims. The procedures for these research aims are described below: * Aim 1 - Examining the Impact of Passive Provider Feedback vs. Active Provider Feedback Through a Randomized Trial * Aim 2 - Determination of Factors Affecting Organizational Adoption of EQUIPPED * Aim 3 - Micro-Costing the Active and Passive Feedback Versions of the EQUIPPED Intervention
Detailed description
Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED is a multi-component program to reduce the prescribing of potentially inappropriate medications (PIMs) to older adults upon discharge from the Emergency Department (ED). It has three core components: 1) provider education, 2) Electronic Health Record (EHR)-based clinical decision support (CDS) including pharmacy quick order sets to facilitate provider order entry, and 3) provider audit and feedback with peer benchmarking. In order to inform a Veterans Affairs (VA) system-wide approach to improve prescribing safety for older Veterans, the investigators will conduct a study to determine best practices for influencing provider prescribing behavior in order to decrease PIMs prescribed for older Veterans at the time of ED discharge. The overall goal of this project is to determine which EQUIPPED implementation strategy (active or passive feedback) is most effective to reduce prescribing of PIMs for older Veterans discharged from the ED.
Interventions
OTHEREQUIPPED with Active Feedback
Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED is a multi-component program to reduce the prescribing of potentially inappropriate medications (PIMs) to older adults upon discharge from the Emergency Department (ED). It has three core components: 1) provider education, 2) Electronic Health Record (EHR)-based clinical decision support (CDS) including pharmacy quick order sets to facilitate provider order entry, and 3) provider audit and feedback with peer benchmarking. The active feedback group will receive one-to-one (1:1) in-person academic detailing from a professional colleague that includes in-person audit, feedback, and peer benchmarking and provide on-site expertise.
OTHEREQUIPPED with Passive Feedback
Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED is a multi-component program to reduce the prescribing of potentially inappropriate medications (PIMs) to older adults upon discharge from the Emergency Department (ED). It has three core components: 1) provider education, 2) Electronic Health Record (EHR)-based clinical decision support (CDS) including pharmacy quick order sets to facilitate provider order entry, and 3) provider audit and feedback with peer benchmarking. The passive feedback group will receive monthly provider feedback via an electronic dashboard with audit, feedback and peer benchmarking.
Sponsors
VA Office of Research and Development
Durham VA Health Care System
VA Salt Lake City Health Care System
Birmingham, Alabama VA Medical Center
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Intervention model description
In order to inform a Veterans Affairs (VA) system-wide approach to improve prescribing safety for older Veterans, the investigators will conduct a randomized study to determine best practices for influencing provider prescribing behavior in order to decrease PIMs prescribed for older Veterans at the time of ED discharge. The overall goal of this project is to determine which EQUIPPED implementation strategy (active or passive feedback) is most effective to reduce prescribing of PIMs for older Veterans discharged from the ED. Eight sites will be randomized to either active feedback with individual, in-person academic detailing or passive feedback delivered via an individualized electronic dashboard.
Eligibility
Sex/Gender
ALL
Healthy volunteers
No
Inclusion criteria
* Prescribers at VA Medical Centers that are implementing EQUIPPED * Members of the EQUIPPED implementation team at enrolled sites
Exclusion criteria
* Providers at VA Medical Centers that are not part of the upcoming EQUIPPED implementation trial.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Percentage of PIMs Prescribed | 12-Months Post Implementation of EQUIPPED | Percentage of prescriptions that are PIMS (potentially inappropriate medications) as defined according to the Beers criteria prescribed to adults aged 65 and older and discharged from the ED. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Social Cognitive Theory Survey - Perceived Control Domain | 12-Months After the Delivery of the First EQUIPPED Report | Prescribers at participating EDs completed a survey at baseline, 6, and 12 months to assess perceived control related to prescribing as a factor that could be impacted by the EQUIPPED intervention. The outcome relates to the average reported perception of 'control' across site respondents by implementation group assignment. The 'perceived control' domain is assessed with a 1-5 Likert scale where 1=strongly disagree and 5=strongly agree with the statement, "I am in control of reducing the potentially inappropriate medications that I prescribe for older Veterans at the time of emergency department." |
| Micro-Costing the Active and Passive Feedback Versions of the EQUIPPED Intervention | 12-Months Post Implementation of EQUIPPED | Micro-costing of the intervention will be done to learn details of specific factors that may impact the cost of the intervention to the Veterans Health Administration (organization) |
Countries
United States
Contacts
PRINCIPAL_INVESTIGATORElizabeth Camille Vaughan, MD MS
Atlanta VA Medical and Rehab Center, Decatur, GA
PRINCIPAL_INVESTIGATORGeorge Lee Jackson, PhD MHA
Durham VA Medical Center, Durham, NC
Participant flow
Pre-assignment details
Participants were EQUIPPED implementation team members or providers at EQUIPPED implementation sites.
Participants by arm
| Arm | Count |
|---|---|
| Active Feedback EQUIPPED with active provider feedback, implementing one-to-one (1:1) in-person academic detailing from a professional colleague that includes in-person audit, feedback, and peer benchmarking and provide on-site expertise.
EQUIPPED with Active Feedback: Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED is a multi-component program to reduce the prescribing of potentially inappropriate medications (PIMs) to older adults upon discharge from the Emergency Department (ED). It has three core components: 1) provider education, 2) Electronic Health Record (EHR)-based clinical decision support (CDS) including pharmacy quick order sets to facilitate provider order entry, and 3) provider audit and feedback with peer benchmarking. The active feedback group will receive one-to-one (1:1) in-person academic detailing from a professional colleague that includes in-person audit, feedback, and peer benchmarking and provide on-site expertise. | 36 |
| Passive Feedback EQUIPPED with passive provider feedback, implementing monthly provider feedback via an electronic dashboard with audit, feedback and peer benchmarking.
EQUIPPED with Passive Feedback: Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED is a multi-component program to reduce the prescribing of potentially inappropriate medications (PIMs) to older adults upon discharge from the Emergency Department (ED). It has three core components: 1) provider education, 2) Electronic Health Record (EHR)-based clinical decision support (CDS) including pharmacy quick order sets to facilitate provider order entry, and 3) provider audit and feedback with peer benchmarking. The passive feedback group will receive monthly provider feedback via an electronic dashboard with audit, feedback and peer benchmarking. | 38 |
| Total | 74 |
Baseline characteristics
| Characteristic | Passive Feedback | Total | Active Feedback |
|---|---|---|---|
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 0 Participants | 4 Participants | 4 Participants |
| Age, Categorical Between 18 and 65 years | 30 Participants | 54 Participants | 24 Participants |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants | 1 Participants | 1 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 25 Participants | 46 Participants | 21 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 13 Participants | 27 Participants | 14 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 2 Participants | 4 Participants | 2 Participants |
| Race (NIH/OMB) Black or African American | 1 Participants | 2 Participants | 1 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 14 Participants | 29 Participants | 15 Participants |
| Race (NIH/OMB) White | 21 Participants | 39 Participants | 18 Participants |
| Region of Enrollment United States | 38 Participants | 74 Participants | 36 Participants |
| Sex: Female, Male Female | 22 Participants | 34 Participants | 12 Participants |
| Sex: Female, Male Male | 10 Participants | 25 Participants | 15 Participants |
| Total Number of Discharge Prescriptions for Older Adults Number of Discharge Prescriptions at Baseline | 26,936 Prescriptions | 44680 Prescriptions | 17,744 Prescriptions |
| Total Number of Discharge Prescriptions for Older Adults Number of Potentially Inappropriate Medications Prescribed at Baseline | 2,166 Prescriptions | 3,590 Prescriptions | 1,421 Prescriptions |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 36 | 0 / 38 |
| other Total, other adverse events | 0 / 36 | 0 / 38 |
| serious Total, serious adverse events | 0 / 36 | 0 / 38 |
Outcome results
Primary
Percentage of PIMs Prescribed
Percentage of prescriptions that are PIMS (potentially inappropriate medications) as defined according to the Beers criteria prescribed to adults aged 65 and older and discharged from the ED.
Time frame: 12-Months Post Implementation of EQUIPPED
Population: Discharge prescriptions for Veterans 65 and older at EQUIPPED implementation sites
| Arm | Measure | Value (COUNT_OF_UNITS) |
|---|---|---|
| Active Feedback | Percentage of PIMs Prescribed | 1,672 Prescriptions |
| Passive Feedback | Percentage of PIMs Prescribed | 2,979 Prescriptions |
Secondary
Impact of EQUIPPED on Behavior Change and Factors Impacting Implementation
Prescribers at participating EDs will be asked to complete a brief survey at baseline, 6, and 12 months to assess key components of the social cognitive factors that we expect to be impacted by the intervention. Interviews will be conducted with EQUIPPED implementation team members to assess implementation facilitators and barriers.
Time frame: 12-Months After the Delivery of the First EQUIPPED Report
Secondary
Micro-Costing the Active and Passive Feedback Versions of the EQUIPPED Intervention
Micro-costing of the intervention will be done to learn details of specific factors that may impact the cost of the intervention to the organization.
Time frame: 12-Months Post Implementation of EQUIPPED