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Quality Improvement Toward Decreasing High-Risk Medications for Older Veteran Outpatients

Authors

  • Alan J. Zillich PharmD,

    1. From the aCenter for Excellence in Implementing Evidence-Based Practices and lQuality and Clinical Informatics Roudebush Veterans Affairs Medical Center, Indianapolis, IndianabSchool of Pharmacy, Purdue University, West Lafayette, IndianacGeriatric Programs, Office of Geriatrics and Extended Care and dGeriatrics and Extended Care Service Line and fMental Health Service Line, oVeterans Healthcare Network 11, Department of Veterans Affairs, Ann Arbor, MichiganePharmacy Benefits Management, Strategic Health Care Group, Department of Veterans Affairs, Battle Creek, MichigangSection of Geriatric Psychiatry and pDepartment of Internal Medicine, University of Michigan, Ann Arbor, MichiganhCenter for Aging Research and Departments of iMedicine, mPathology and Laboratory Medicine, and nGeneral Internal Medicine, School of Medicine, Indiana University, Indianapolis, IndianajGeriatrics Research, Education and Clinical Center, Veterans Affairs Salt Lake City, Salt Lake City, UtahkDivision of Geriatrics, School of Medicine, University of Utah, Salt Lake City, Utah.
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  • ab Kenneth Shay DDS, MS,

    1. From the aCenter for Excellence in Implementing Evidence-Based Practices and lQuality and Clinical Informatics Roudebush Veterans Affairs Medical Center, Indianapolis, IndianabSchool of Pharmacy, Purdue University, West Lafayette, IndianacGeriatric Programs, Office of Geriatrics and Extended Care and dGeriatrics and Extended Care Service Line and fMental Health Service Line, oVeterans Healthcare Network 11, Department of Veterans Affairs, Ann Arbor, MichiganePharmacy Benefits Management, Strategic Health Care Group, Department of Veterans Affairs, Battle Creek, MichigangSection of Geriatric Psychiatry and pDepartment of Internal Medicine, University of Michigan, Ann Arbor, MichiganhCenter for Aging Research and Departments of iMedicine, mPathology and Laboratory Medicine, and nGeneral Internal Medicine, School of Medicine, Indiana University, Indianapolis, IndianajGeriatrics Research, Education and Clinical Center, Veterans Affairs Salt Lake City, Salt Lake City, UtahkDivision of Geriatrics, School of Medicine, University of Utah, Salt Lake City, Utah.
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  • c Barbara Hyduke MSA,

    1. From the aCenter for Excellence in Implementing Evidence-Based Practices and lQuality and Clinical Informatics Roudebush Veterans Affairs Medical Center, Indianapolis, IndianabSchool of Pharmacy, Purdue University, West Lafayette, IndianacGeriatric Programs, Office of Geriatrics and Extended Care and dGeriatrics and Extended Care Service Line and fMental Health Service Line, oVeterans Healthcare Network 11, Department of Veterans Affairs, Ann Arbor, MichiganePharmacy Benefits Management, Strategic Health Care Group, Department of Veterans Affairs, Battle Creek, MichigangSection of Geriatric Psychiatry and pDepartment of Internal Medicine, University of Michigan, Ann Arbor, MichiganhCenter for Aging Research and Departments of iMedicine, mPathology and Laboratory Medicine, and nGeneral Internal Medicine, School of Medicine, Indiana University, Indianapolis, IndianajGeriatrics Research, Education and Clinical Center, Veterans Affairs Salt Lake City, Salt Lake City, UtahkDivision of Geriatrics, School of Medicine, University of Utah, Salt Lake City, Utah.
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  • d Thomas R. Emmendorfer PharmD,

    1. From the aCenter for Excellence in Implementing Evidence-Based Practices and lQuality and Clinical Informatics Roudebush Veterans Affairs Medical Center, Indianapolis, IndianabSchool of Pharmacy, Purdue University, West Lafayette, IndianacGeriatric Programs, Office of Geriatrics and Extended Care and dGeriatrics and Extended Care Service Line and fMental Health Service Line, oVeterans Healthcare Network 11, Department of Veterans Affairs, Ann Arbor, MichiganePharmacy Benefits Management, Strategic Health Care Group, Department of Veterans Affairs, Battle Creek, MichigangSection of Geriatric Psychiatry and pDepartment of Internal Medicine, University of Michigan, Ann Arbor, MichiganhCenter for Aging Research and Departments of iMedicine, mPathology and Laboratory Medicine, and nGeneral Internal Medicine, School of Medicine, Indiana University, Indianapolis, IndianajGeriatrics Research, Education and Clinical Center, Veterans Affairs Salt Lake City, Salt Lake City, UtahkDivision of Geriatrics, School of Medicine, University of Utah, Salt Lake City, Utah.
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  • e Alan M. Mellow MD, PhD,

    1. From the aCenter for Excellence in Implementing Evidence-Based Practices and lQuality and Clinical Informatics Roudebush Veterans Affairs Medical Center, Indianapolis, IndianabSchool of Pharmacy, Purdue University, West Lafayette, IndianacGeriatric Programs, Office of Geriatrics and Extended Care and dGeriatrics and Extended Care Service Line and fMental Health Service Line, oVeterans Healthcare Network 11, Department of Veterans Affairs, Ann Arbor, MichiganePharmacy Benefits Management, Strategic Health Care Group, Department of Veterans Affairs, Battle Creek, MichigangSection of Geriatric Psychiatry and pDepartment of Internal Medicine, University of Michigan, Ann Arbor, MichiganhCenter for Aging Research and Departments of iMedicine, mPathology and Laboratory Medicine, and nGeneral Internal Medicine, School of Medicine, Indiana University, Indianapolis, IndianajGeriatrics Research, Education and Clinical Center, Veterans Affairs Salt Lake City, Salt Lake City, UtahkDivision of Geriatrics, School of Medicine, University of Utah, Salt Lake City, Utah.
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  • fg Steven R. Counsell MD,

    1. From the aCenter for Excellence in Implementing Evidence-Based Practices and lQuality and Clinical Informatics Roudebush Veterans Affairs Medical Center, Indianapolis, IndianabSchool of Pharmacy, Purdue University, West Lafayette, IndianacGeriatric Programs, Office of Geriatrics and Extended Care and dGeriatrics and Extended Care Service Line and fMental Health Service Line, oVeterans Healthcare Network 11, Department of Veterans Affairs, Ann Arbor, MichiganePharmacy Benefits Management, Strategic Health Care Group, Department of Veterans Affairs, Battle Creek, MichigangSection of Geriatric Psychiatry and pDepartment of Internal Medicine, University of Michigan, Ann Arbor, MichiganhCenter for Aging Research and Departments of iMedicine, mPathology and Laboratory Medicine, and nGeneral Internal Medicine, School of Medicine, Indiana University, Indianapolis, IndianajGeriatrics Research, Education and Clinical Center, Veterans Affairs Salt Lake City, Salt Lake City, UtahkDivision of Geriatrics, School of Medicine, University of Utah, Salt Lake City, Utah.
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  • hi Mark A. Supiano MD,

    1. From the aCenter for Excellence in Implementing Evidence-Based Practices and lQuality and Clinical Informatics Roudebush Veterans Affairs Medical Center, Indianapolis, IndianabSchool of Pharmacy, Purdue University, West Lafayette, IndianacGeriatric Programs, Office of Geriatrics and Extended Care and dGeriatrics and Extended Care Service Line and fMental Health Service Line, oVeterans Healthcare Network 11, Department of Veterans Affairs, Ann Arbor, MichiganePharmacy Benefits Management, Strategic Health Care Group, Department of Veterans Affairs, Battle Creek, MichigangSection of Geriatric Psychiatry and pDepartment of Internal Medicine, University of Michigan, Ann Arbor, MichiganhCenter for Aging Research and Departments of iMedicine, mPathology and Laboratory Medicine, and nGeneral Internal Medicine, School of Medicine, Indiana University, Indianapolis, IndianajGeriatrics Research, Education and Clinical Center, Veterans Affairs Salt Lake City, Salt Lake City, UtahkDivision of Geriatrics, School of Medicine, University of Utah, Salt Lake City, Utah.
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  • jk Peter Woodbridge MD, MBA,

    1. From the aCenter for Excellence in Implementing Evidence-Based Practices and lQuality and Clinical Informatics Roudebush Veterans Affairs Medical Center, Indianapolis, IndianabSchool of Pharmacy, Purdue University, West Lafayette, IndianacGeriatric Programs, Office of Geriatrics and Extended Care and dGeriatrics and Extended Care Service Line and fMental Health Service Line, oVeterans Healthcare Network 11, Department of Veterans Affairs, Ann Arbor, MichiganePharmacy Benefits Management, Strategic Health Care Group, Department of Veterans Affairs, Battle Creek, MichigangSection of Geriatric Psychiatry and pDepartment of Internal Medicine, University of Michigan, Ann Arbor, MichiganhCenter for Aging Research and Departments of iMedicine, mPathology and Laboratory Medicine, and nGeneral Internal Medicine, School of Medicine, Indiana University, Indianapolis, IndianajGeriatrics Research, Education and Clinical Center, Veterans Affairs Salt Lake City, Salt Lake City, UtahkDivision of Geriatrics, School of Medicine, University of Utah, Salt Lake City, Utah.
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  • and almn Pamela Reeves MD op

    1. From the aCenter for Excellence in Implementing Evidence-Based Practices and lQuality and Clinical Informatics Roudebush Veterans Affairs Medical Center, Indianapolis, IndianabSchool of Pharmacy, Purdue University, West Lafayette, IndianacGeriatric Programs, Office of Geriatrics and Extended Care and dGeriatrics and Extended Care Service Line and fMental Health Service Line, oVeterans Healthcare Network 11, Department of Veterans Affairs, Ann Arbor, MichiganePharmacy Benefits Management, Strategic Health Care Group, Department of Veterans Affairs, Battle Creek, MichigangSection of Geriatric Psychiatry and pDepartment of Internal Medicine, University of Michigan, Ann Arbor, MichiganhCenter for Aging Research and Departments of iMedicine, mPathology and Laboratory Medicine, and nGeneral Internal Medicine, School of Medicine, Indiana University, Indianapolis, IndianajGeriatrics Research, Education and Clinical Center, Veterans Affairs Salt Lake City, Salt Lake City, UtahkDivision of Geriatrics, School of Medicine, University of Utah, Salt Lake City, Utah.
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Address correspondence to Alan J. Zillich, Purdue University, Pharmacy Programs—Indianapolis, W7555, Myers Building, 1001 West 10th Street, Indianapolis, IN 46202. E-mail: azillich@purdue.edu

Abstract

OBJECTIVES: To examine the effectiveness of a quality improvement program to decrease prescribing of high-risk medications.

DESIGN: Single cohort, pre- and postintervention.

SETTING: Regional network of Department of Veterans Affairs medical facilities.

PARTICIPANTS: Outpatient veterans aged 65 and older who received one or more high-risk medications and the prescribing clinicians.

INTERVENTION: A two-stage intervention was implemented. First, a real-time warning message to prescribers appeared whenever one of the high-risk drugs was ordered; second, a personally addressed letter from the Chief Medical Officer asking prescribers to consider discontinuing the high-risk medication along with a copy of the Beers criteria article, a list of suggested alternatives to high-risk medications, and a list of older patients receiving the high-risk medications who had upcoming appointments with these prescribers.

MEASUREMENTS: The primary outcome was the absence of prescribed high-risk medications for all patients in the cohort during the postintervention period. For a subgroup of the cohort whose prescribers received the second-stage intervention, an additional outcome was the absence of prescribed high-risk medications within the subgroup.

RESULTS: Two thousand seven hundred fifty-three unique patients were identified in the cohort; 1,396 (50.7%) had high-risk medications discontinued, resulting in a significant decrease in the number of patients prescribed high-risk medications from the preintervention period to the postintervention period (P<.001). Of the 801 patients in the subgroup, 72.0% (n=577) had high-risk medications discontinued (P<.001).

CONCLUSION: This multimethod intervention significantly decreased prescribing of high-risk medications to older patients. Further studies are needed to confirm the findings.

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