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

Abstract

Background We sought to examine the effectiveness of the Enhancing the Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUiPPED) medication safety program in three emergency departments (EDs) within the largest health system in Rhode Island (RI) with funding through a quality incentive payment by a private insurance partner. Methods This study utilized a quasi‐experimental interrupted time series design to implement EQUiPPED, a three‐prong intervention aimed at reducing potentially inappropriate medication (PIM) prescriptions to 5% or less per month. We included clinicians who prescribed medications to older ED patients during the pre‐and post‐intervention periods from July 2018 to January 2021. We determined the monthly rate of PIM prescribing among older adults discharged from the ED, according to the American Geriatrics Society Beers Criteria, using Poisson regression. Results 247 ED clinicians (48% attendings [n = 119], 27% residents [n = 67], 25% advanced practice providers [n = 61]) were included in EQUiPPED, of which 92% prescribed a PIM during the study period. In the pre‐implementation period (July 2018–July 2019) the average monthly rate of PIM prescribing was 9.30% (95% CI: 8.82%, 9.78%). In the post‐implementation period (October 2019–January 2021) the PIM prescribing rate decreased significantly to 8.62% (95% CI: 8.14%, 9.10%, p < 0.01). During pre‐implementation, 1325 of the 14,193 prescribed medications were considered inappropriate, while only 1108 of the 13,213 prescribed medications in post‐implementation were considered inappropriate. The greatest reduction was observed among antihistamines, skeletal muscle relaxants, and benzodiazepines. Conclusions EQUiPPED contributed to a modest improvement in PIM prescribing to older adults among clinicians in these RI EDs even in the midst of the COVID‐19 pandemic. The quality incentive funding model demonstrates a successful strategy for implementation and, with greater replication, could shape national policy regarding health care delivery and quality of care for older adults.

A cluster‐randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program

“…While multiple sites have implemented the EQUIPPED program as a quality improvement initiative, 1–6 this was the first trial of two different implementation strategies for the audit and feedback component of the EQUIPPED program. The study was designed to better understand resources needed to broadly disseminate EQUIPPED within VA EDs.…”

“…While multiple sites have implemented the EQUIPPED program as a quality improvement initiative, [1][2][3][4][5][6] within VA EDs. While one might assume that an academic detailing approach to audit and feedback, which relies on more direct peerto-peer interaction, would be more effective, it is a more personnelintensive technique and may not be feasible for all settings of care, particularly the fast-paced clinical environment of the ED.…”

“…Enhancing the Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is a quality improvement program focused on enhancing safe medication prescribing for older adults at the time of emergency department (ED) discharge and is associated with reduction in the use of potentially inappropriate medications (PIMs) in multiple implementation sites. [1][2][3][4][5][6] Initially developed in the Department of Veterans Affairs (VA) health care system, multiple non-VA health care systems have also successfully implemented the program. EQUIPPED implementation involves three key components, including provider education, clinical decision support, and provider audit and feedback to influence prescribing behavior of ED clinicians.…”

Clin‐STAR corner: Practice changing advances in prescribing for geriatric emergency department patients

“…Three authors reviewed the titles and abstracts of these articles and candidate manuscripts for this Clin-STAR Corner review were selected unanimously based on two criteria: ED-based and related to medication prescribing. The Table (Supplementary Table S1) synthesizes the key components of all seven studies selected, [8][9][10][11][12][13][14] and in the text below we summarize the four studies deemed most relevant to emergency medicine in the United States. [8][9][10][11]…”

Use of the consolidated framework for implementation research in a mixed methods evaluation of the EQUIPPED medication safety program in four academic health system emergency departments

“…EQUIPPED has been successfully implemented in 20 urban and rural Veterans Affairs (VA) Medical Centers, with the first eight sites reducing PIM rates from a preimplementation baseline of 7.4-11.9% of all prescriptions to 4.5-9.0% of prescriptions for 2 to 4 years after the initial 12-month implementation (11,15) and additional results forthcoming. Early results based upon export and expansion of this VA innovation to additional VA and non-VA health systems also demonstrate reduction in PIMs at multiple sites (16)(17)(18)(19).…”