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Prescribing quality in older veterans: a multifocal approach.

ABSTRACT: Quality prescribing for older adults involves multiple considerations. We evaluated multiple aspects of prescribing quality in older veterans to develop an integrated view of prescribing problems and to understand how the prevalence of these problems varies across clinically important subgroups of older adults.Cross-sectional observational study of veterans age 65 years and older who received medications from Department of Veterans Affairs (VA) pharmacies in 2007.Using VA pharmacy data linked with encounter, laboratory and other data, we assessed five types of prescribing problems.Among 462,405 patients age 65 and older, mean age was 75 years, 98 % were male, and patients were prescribed a median of five medications. Half of patients (50 %) had one or more prescribing problems, including 12 % taking one or more medications at an inappropriately high dose, 30 % with drug-drug interactions, 3 % with drug-disease interactions, and 26 % taking one or more Beers criteria drugs. In addition, 16 % were taking a high-risk drug (warfarin, insulin, and/or digoxin). On multivariable analysis, age was not strongly associated with four of the five types of prescribing issues assessed (relative risk < 1.3 across age groups), and comorbid burden conferred substantially increased risk only for drug-disease interactions and use of high-risk drugs. In contrast, the number of drugs used was consistently the strongest predictor of prescribing problems. Patients in the highest quartile of medication use had 6.6-fold to12.5-fold greater risk of each type of prescribing problem compared to patients in the lowest quartile (P?

SUBMITTER: Steinman MA

PROVIDER: S-EPMC4175643 | biostudies-literature | 2014 Oct

REPOSITORIES: biostudies-literature

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Prescribing quality in older veterans: a multifocal approach.

Steinman Michael A MA Miao Yinghui Y Boscardin W John WJ Komaiko Kiya D R KD Schwartz Janice B JB

Journal of general internal medicine 20140708 10

<h4>Background and objective</h4>Quality prescribing for older adults involves multiple considerations. We evaluated multiple aspects of prescribing quality in older veterans to develop an integrated view of prescribing problems and to understand how the prevalence of these problems varies across clinically important subgroups of older adults.<h4>Design and participants</h4>Cross-sectional observational study of veterans age 65 years and older who received medications from Department of Veterans ...[more]

PMID: 25002159

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Project description:The opioid epidemic has been fueled by prescribing unnecessary quantities of opioid pills for postoperative use. While evidence mounts that postoperative opioids can be reduced or eliminated, implementing such changes within various institutions can be met with many barriers to adoption. To address excess opioid prescribing within our institutions, we applied a plan-do-study-act (PDSA)-like quality improvement strategy to assess local opioid prescribing and use, modify our institutional protocols, and assess the impacts of the change. The opioid epidemic has been fueled by prescribing unnecessary quantities of opioid pills for postoperative use. While evidence mounts that postoperative opioids can be reduced or eliminated, implementing such changes within various institutions can be met with many barriers to adoption. We describe our approach, findings, and lessons learned from our quality improvement approach. We prospectively recorded home pain pill usage after robotic-assisted laparoscopic prostatectomy (RALP) and robotic-assisted partial nephrectomy (RAPN) at two academic institutions from July 2016 to July 2019. Patients prospectively recorded their home pain pill use on a take-home log. Other factors, including numeric pain rating scale on the day of discharge, were extracted from patient records. We analyzed our data and modified opioid prescription protocols to meet the reported use data of 80% of patients. We continued collecting data after the protocol change. We also used our prospectively collected data to assess the accuracy of a retrospective phone survey designed to measure postdischarge opioid use. Our primary outcomes were the proportion of patients taking zero opioid pills postdischarge, median pills taken after discharge and the number of excess pills prescribed but not taken. We compared these outcomes before and after protocol change. A total of 266 patients (193 RALP, 73 RAPN) were included. Reducing the standard number of prescribed pills did not increase the percentage of patients taking zero pills postdischarge in either group (RALP: 47% vs. 41%; RAPN 48% vs. 34%). The patients in either group reporting postoperative Day 1 pain score of 0 or 1 were much more likely to use zero postdischarge opioid pills. Our reduction in prescribing protocol resulted in an estimated reduction in excess pills from 1555 excess pills in the prior protocol to just 155 excess pills in the new protocol. Our PDSA-like approach led to an acceptable protocol revision resulting in significant reductions in excess pills released into the community. Reducing the quantity of opioids prescribed postoperatively does not increase the percentage of patients taking zero pills postdischarge. To eliminate opioid use may require no-opioid pathways. Our approach can be used in implementing zero opioid discharge plans and can be applied to opioid reduction interventions at other institutions where barriers to reduced prescribing exist.

Project description:BackgroundPain is common among individuals with Alzheimer's disease and related dementias (ADRD), and use of opioids has been increasing over the last decade. Yet, it is unclear to what extent opioids are appropriately prescribed for patients with ADRD and whether the appropriateness of opioid prescribing differs by ADRD status. The objective of this study is to compare the quality of opioid prescribing among patients with or without ADRD who have chronic noncancer pain.MethodsA nationally representative cohort study of Medicare beneficiaries aged 50 years or older who had chronic pain but who had no cancer, hospice, or palliative care from 2011 to 2015. Four indicators of potentially inappropriate opioid prescribing were measured in patients residing in communities (75,258 patients with and 435,870 patients without ADRD); five indicators were assessed in patients in nursing homes (NHs) (37,117 patients with and 5128 patients without ADRD). Each indicator was calculated as the proportion of eligible patients with inappropriate opioid prescribing in the year after a chronic pain diagnosis. Differences in proportions between ADRD and non-ADRD groups were estimated using a generalized linear model adjusting for covariates through inverse probability weighting.ResultsPatients with ADRD versus those without had higher concurrent use of opioids and central nervous system-active drugs (community 44.1% vs 33.3%; NH 58.8% vs 54.1%, both P < 0.001) and no opioids or scheduled pain medications for moderate or severe pain (NH 60.1% vs 52.5%, P < 0.001). The ADRD versus non-ADRD group had higher use of long-term opioids for treating neuropathic pain in communities (21.7% vs 19.5%, P = 0.003) but lower use in NHs (26.9% vs 36.0%, P < 0.001). Use of strong or high-dose opioids when naive to opioids (community 1.5% vs 2.8%; NH 2.5% vs 3.5%) and use of contraindicated opioids (community 0.08% vs 0.12%; NH 0.05% vs 0.21%) were rare for either group.ConclusionPotential inappropriate opioid prescribing in 2 areas of pain care was more common among patients with ADRD than among patients without ADRD in community or NH settings. Further studies aimed at understanding the factors and effects associated with opioid prescribing patterns that deviate from guidelines are warranted.

Project description:BACKGROUND:Electronic health records provide the opportunity to assess system-wide quality measures. Veterans Affairs Pharmacy Benefits Management Center for Medication Safety uses medication use evaluation (MUE) through manual review of the electronic health records. OBJECTIVE:To compare an electronic MUE approach versus human/manual review for extraction of antibiotic use (choice and duration) and severity metrics. RESEARCH DESIGN:Retrospective. SUBJECTS:Hospitalizations for uncomplicated pneumonia occurring during 2013 at 30 Veterans Affairs facilities. MEASURES:We compared summary statistics, individual hospitalization-level agreement, facility-level consistency, and patterns of variation between electronic and manual MUE for initial severity, antibiotic choice, daily clinical stability, and antibiotic duration. RESULTS:Among 2004 hospitalizations, electronic and manual abstraction methods showed high individual hospitalization-level agreement for initial severity measures (agreement=86%-98%, ?=0.5-0.82), antibiotic choice (agreement=89%-100%, ?=0.70-0.94), and facility-level consistency for empiric antibiotic choice (anti-MRSA r=0.97, P<0.001; antipseudomonal r=0.95, P<0.001) and therapy duration (r=0.77, P<0.001) but lower facility-level consistency for days to clinical stability (r=0.52, P=0.006) or excessive duration of therapy (r=0.55, P=0.005). Both methods identified widespread facility-level variation in antibiotic choice, but we found additional variation in manual estimation of excessive antibiotic duration and initial illness severity. CONCLUSIONS:Electronic and manual MUE agreed well for illness severity, antibiotic choice, and duration of therapy in pneumonia at both the individual and facility levels. Manual MUE showed additional reviewer-level variation in estimation of initial illness severity and excessive antibiotic use. Electronic MUE allows for reliable, scalable tracking of national patterns of antimicrobial use, enabling the examination of system-wide interventions to improve quality.

Project description:ObjectivesTo investigate the quality of drug treatment in older people from a broad family physician perspective, and to provide evidence for power calculations in full-scale studies on prescribing quality.DesignDescriptive, retrospective pilot study.SettingA primary healthcare centre in Sweden.Participants123 consecutive patients, ≥65 years, with a non-urgent physician consultation in January 2016.MeasuresThe drug treatment was assessed by a physician as either appropriate or suboptimal, taking individual factors like morbidity, life expectancy and concurrent drug treatment into account, and preceded by the application of 493 criteria from three screening tools for Potentially Inappropriate Medications (PIMs) and Potential Prescribing Omissions (PPOs). Suboptimal drug treatment was further categorised regarding priority: (1) immediate change suggested or (2) actions suggested in the longer term. Prevalence of the procedure code 'medication review' and the results thereof were also recorded.ResultsMedian age: 76 years; 48% women. When a family physician perspective was applied, and 593 PIMs/PPOs identified in 117 (95%) patients considered, 45 (37%) patients had suboptimal drug treatment. Immediate handling was suggested in 13 (11%) patients, most often concerning withdrawals of drugs for anxiety and insomnia. Handling in the longer term was suggested in 32 (26%) patients, most often concerning overuse of proton pump inhibitors. Over the last year, the procedure code 'medication review' was recorded for 65 (53%) patients. In medication reviews recorded during January 2016 (n=45), 23 (7%) drugs out of 309 were acted on, most often a dosage adjustment.ConclusionsThis pilot study shows that when a broad family physician perspective is applied, taking individual factors and medical priorities in the complex clinical situation into account, drug treatment in primary care is appropriate for the majority of older patients. The results may be useful in sample size considerations for future studies on prescribing practices.

Project description:IntroductionThe Veterans Health Administration (VHA) has taken a multifaceted approach to addressing opioid safety and promoting system-wide opioid stewardship.AimTo provide a comprehensive evaluation of current opioid prescribing practices and implementation of risk mitigation strategies in VHA.SettingVHA is the largest integrated health care system in the United States.Program descriptionVHA prescribing data in conjunction with implementation of opioid risk mitigation strategies are routinely tracked and reviewed by VHA's Pharmacy Benefits Management Services (including Academic Detailing Service) and the Pain Management Program Office. Additional data are derived from the Partnered Evidence-Based Policy Resource Center (PEPReC) and from a 2019 survey of interdisciplinary pain management teams at VHA facilities. Prescribing data are reported quarterly until first quarter fiscal year 2020 (Q1FY2020), ending December 31, 2019.Program evaluationVHA opioid dispensing peaked in 2012 with 679,376 Veterans receiving an opioid prescription, and when including tramadol, in 2013 with 869,956 Veterans. Since 2012, the number of Veterans dispensed an opioid decreased 56% and co-prescribed opioid/benzodiazepine decreased 83%. Veterans with high-dose opioids (≥ 100 mg morphine equivalent daily dose) decreased 77%. In Q1FY2020, among Veterans on long-term opioid therapy (LTOT), 91.1% had written informed consent, 90.8% had a urine drug screen, and 89.0% had a prescription drug monitoring program query. Naloxone was issued to 217,469 Veterans and resulted in > 1,000 documented overdose reversals. In 2019, interdisciplinary pain management teams were fully designated at 68%, partially designated at 28%, and not available at 4% of 140 VA parent facilities. Fifty percent of Veterans on opioids at very high risk for overdose/suicide received interdisciplinary team reviews.ImplicationsVHA clinicians have greatly reduced their volume of opioid prescribing for pain management and expanded implementation of opioid risk mitigation strategies.ImpactsVHA's integrated health care system provides a model for opioid stewardship and interdisciplinary pain care.

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Prescribing quality in older veterans: a multifocal approach.

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Prescribing quality in older veterans: a multifocal approach.

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