Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme

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.

Enhancing the quality of prescribing practices for older adults discharged from the emergency department in Rhode Island

“…Our study showed comparable directionality of prescribing rates prior to and after the intervention, but the magnitude of change, while significant, was much lower in our study (0.7% vs. 4.8%). When EQUiPPED was first implemented outside of the VA at academic medical centers, only one of the three implementation sites demonstrated significant reduction in PIMs, 30 which was thought to be due to lower baseline PIM proportions when compared to the VA (5.6%–7.3% vs. 7.4%–11.9%). There may be other factors at academic medical centers that yield less significant reductions, such as a large amount of prescribing being initiated by rotating trainees.…”

You can lead clinicians to water, but you can’t make them drink: the role of tailoring in clinical performance feedback to improve care quality

“…Additionally, given that audit and feedback interventions may lead to unintended outcomes, including reduced confidence and cognitive interference,19 20 it may be helpful to prospectively use a theory-driven approach to identify possible unintended outcomes and mitigate the likelihood these occur 20. Although common contextual factors limiting the uptake of evidence are well documented (eg, available resources, values, individual beliefs, past experiences),21–23 how to adapt for contextual variations remains unclear.…”

Challenges and opportunities in creating a deprescribing program in the emergency department: A qualitative study

“…There are a few innovative programs to promote safe medication prescribing, such as Enhancing Quality of Provider Practiced for Older Adults in the Emergency Department (EQUiPPED) program, and the Screening Tool of Older Persons' Prescriptions (STOPP) program and Screening Tool to Alert to Right Treatment (START) program in the literature. 17 , 18 These approaches employ some of the following components: clinician training, clinical decision support, and performance feedback. 17 , 18 Nonetheless, there are persistent knowledge gaps.…”

“… 17 , 18 These approaches employ some of the following components: clinician training, clinical decision support, and performance feedback. 17 , 18 Nonetheless, there are persistent knowledge gaps. For example, the Beers Criteria await validation in the ED setting.…”

“…The reduction of potential culprit medications has not resulted in a significant improvement of the health outcomes 20 , 21 but has shown an effective reduction of high‐risk medications, using the provider education, clinical decision support, and feedback, such as the EQUIPPED studies. 17 , 22 , 23 , 24 , 25 One promising framework, the 4Ms, 26 which are of mentation , medication , mobility , and what matters , includes medication as a key component, and we need a deeper understanding of what patients, caregivers, and clinicians think about the issue to make any medication‐related intervention work in the aging‐friendly environment. We propose to focus on point‐of‐care medication management led by the ED pharmacist to screen and intervene for high‐risk medications.…”