The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUIPPED) Potentially Inappropriate Medication Dashboard: A Suitable Alternative to the In-person Academic Detailing and Standardized Feedback Reports of Traditional EQUIPPED?

doi:10.1016/j.clinthera.2020.02.013

Clinical Therapeutics

Volume 42, Issue 4, April 2020, Pages 573-582

https://doi.org/10.1016/j.clinthera.2020.02.013 Get rights and content

Abstract

Purpose

The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUIPPED) program is a quality improvement initiative that combines education, clinical decision support (ie, geriatric pharmacy order sets), and in-person academic detailing coupled with audit and feedback in an effort to improve appropriate prescribing to older veterans discharged from the emergency department. Although the EQUIPPED program is effective at reducing the prescribing of potentially inappropriate medications, the reliance on in-person academic detailing may be a limitation for broader dissemination. The EQUIPPED dashboard is a passive yet continuous audit and feedback mechanism developed to potentially replace the in-person academic detailing of the traditional EQUIPPED program. We describe the development process of the EQUIPPED dashboard and the key audit and feedback components found within.

Methods

The Veterans Affairs (VA) Corporate Data Warehouse (CDW) serves as the underlying data source for the EQUIPPED dashboard. SQL Server Integration Services was used to build the backend data architecture. Data were isolated from the CDW for reporting purposes using an extract, load, transform (ELT) approach. The team used SQL Server Reporting Services to produce the user interface and add interactive functionality. The team used an agile development approach when designing the user interface, engaging end users at 2 VA EQUIPPED implementation sites by providing printed screenshots of a beta version of the dashboard.

Findings

The EQUIPPED dashboard ELT process executes nightly to provide dashboard end users with a near real-time data experience and the potential for daily audit and feedback. The following dashboard components were identified as necessary for the EQUIPPED dashboard to be a suitable audit and feedback tool: key performance indicators, peer-to-peer benchmarking, individual patient or encounter drill down, educational decision support, and longitudinal performance tracking.

Implications

To our knowledge, the EQUIPPED dashboard is the first information display of its kind with built-in audit and feedback that has been developed for VA emergency department practitioners as the primary end users. Further investigation is warranted to determine whether the EQUIPPED dashboard is a suitable alternative to in-person academic detailing. The EQUIPPED dashboard will be leveraged in a formal implementation trial that will entail the randomization of multiple VA sites to either (1) traditional EQUIPPED with in-person academic detailing coupled with audit and feedback or (2) EQUIPPED with passive audit and feedback delivered through the EQUIPPED dashboard without in-person prescribing outreach.

Introduction

The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUIPPED) program is a multifaceted quality improvement initiative that combines education, clinical decision support (ie, tailored geriatric pharmacy order sets), and in-person academic detailing coupled with audit and feedback in an effort to improve appropriate prescribing to older veterans discharged from the emergency department (ED).1, 2, 3, 4 Academic detailing, also frequently referred to as educational outreach, involves trained clinical consultants meeting in person with prescribers to provide an interactive review of evidence-based clinical practice guidelines with the goal of inducing practice change.5, 6, 7 EQUIPPED academic detailers are clinical specialists (ie, pharmacists and physicians) trained in geriatrics and/or emergency medicine who have expertise in potentially inappropriate medications (PIMs), a commonly used proxy that represents poor quality of prescribing and adverse outcomes.8, 9, 10 Audit and feedback entails providing prescribers with a personalized review of their prescribing patterns and often includes peer benchmarking. The knowledge of prescribing performance, relative to their peers, serves as a catalyst for rapid-cycle improvements in prescribing processes.11, 12, 13

Audit and feedback are delivered to participating EQUIPPED ED practitioners by means of 2 pathways: (1) during face-to-face academic detailing sessions and (2) through a standardized feedback report that is e-mailed monthly.¹ The EQUIPPED standardized feedback report includes the number of patients 65 years and older evaluated in the ED by the target practitioner, the proportion of PIMs prescribed, and details regarding how their PIM rate compares with that of their colleagues. Although the EQUIPPED program has been implemented within 12 EDs and found to be effective at reducing the prescribing of PIMs,² the use of in-person academic detailing may be a barrier to broad dissemination. Academic detailing alone is modestly effective at improving prescribing practices,⁶^,¹⁴ and when coupled with individual practitioner feedback, effectiveness appears to further increase.¹³ However, studies have found no difference in effectiveness when comparing academic detailing coupled with audit and feedback versus audit and feedback provided solely from prepared reports and without in-person prescribing outreach.15, 16, 17 Furthermore, academic detailing is much more costly compared with stand-alone audit and feedback reports, largely because of staffing costs.¹⁵

Thus, the EQUIPPED standardized feedback reports may eliminate the need for resource-intensive in-person academic detailing without reducing overall program effectiveness. However, before considering altering the EQUIPPED strategy, current limitations of the EQUIPPED standardized feedback reports should be addressed. For example, days or even weeks could pass before an inappropriate prescribing event could be brought to the attention of an ED practitioner when feedback is provided through a static monthly report.¹⁸ With the recent advent of health information technology, audit and feedback could be provided as near to real time as possible by means of a clinical dashboard reporting system. This knowledge led to the development of the EQUIPPED PIM dashboard, a passive yet continuous stand-alone audit and feedback mechanism developed to potentially replace in-person academic detailing and the standardized feedback reports of the traditional EQUIPPED program. We describe the development process of the EQUIPPED dashboard and the core components identified as necessary to ensure the end users' experience provides similar benefits as one would obtain when participating in EQUIPPED's face-to-face academic detailing.

Section snippets

Patients and Methods

The Veterans Affairs (VA) Corporate Data Warehouse (CDW), a national repository of data from clinical (i., electronic health record (EHR) and administrative systems, serves as the underlying data source for the EQUIPPED dashboard.¹⁹ At the point of care, data are entered into the VA's EHR by barcode scanning, automated instrumentation, or manual entry. This information is transferred to the CDW nightly. The National Data Systems group, a division under the Veterans Health Administration Office

Results

The EQUIPPED dashboard ELT process executes nightly to provide the dashboard end users with a near real-time data experience, with the potential for daily audit and feedback. The ELT process takes a mean of 9 min to complete and initiates after the nightly CDW upload. The available data elements produced by the EQUIPPED dashboard ELT process include demographic characteristics of each veteran who meets the inclusion and exclusion criteria (eg, age and sex), characteristics of all reported ED

Discussion

Dashboard reporting systems have become increasingly popular in the clinical setting, presenting information that can be easily processed in support of quality improvement initiatives, program performance monitoring, and clinical decision support.28, 29, 30, 31 In recent years, the VA has invested in the development of clinical dashboards to support and improve adherence to prescribing-related clinical practice guidelines. However, in most cases, these dashboards have been designed specifically

Conclusion

We developed a near real-time dashboard reporting system, supported by a robust ELT, capable of serving as a passive yet continuous audit and feedback resource for participating EQUIPPED sites. In addition, an automated e-mail system integrated into the backend architecture of the EQUIPPED dashboard ELT process provides a monthly summary of prescribing performance, praises end users for achieving a 30-day PIM prescribing rate of <5%, and encourages ED practitioners to access the dashboard

Funding Sources

This work was supported in part by grant 1I01 HX 002527-01A1 from the Department of Veterans Affairs Health Services Research & Development Service, Department of Veterans Affairs Office of Geriatrics and Extended Care, and Department of Veterans Affairs Office of Rural Health.

Disclaimer

The views expressed in this article are those of the authors and do not reflect the position or policy of the Department of Veterans Affairs, US government, or other organizations with which authors are affiliated.

Disclosures

The authors have indicated that they have no conflicts of interest regarding the content of this article.

Acknowledgments

Concept and design (Z. Burningham, G.L. Jackson, J. Kelleher, M. Stevens, J. Cohen, G. Maloney, C.P. Vaughan); acquisition of data (Z. Burningham, J. Kelleher, C.P. Vaughan); data extraction, manipulation, and validation (Z. Burningham, G.L. Jackson, J. Kelleher, M. Stevens, I. Morris, J. Cohen, G. Maloney, C.P. Vaughan); drafting of the manuscript (Z. Burningham, G.L. Jackson, J. Kelleher, C.P. Vaughan); critical revision of the manuscript for important intellectual content (Z. Burningham,

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Published by Elsevier Inc.

Abstract

Purpose

Methods

Findings

Implications

Introduction

Section snippets

Patients and Methods

Results

Discussion

Conclusion

Funding Sources

Disclaimer

Disclosures

Acknowledgments

Pediatr Clin North Am

J Am Pharm Assoc (2003)

Int J Med Inform

Int J Med Inform

J Am Geriatr Soc

Enhancing quality of provider practices for older adults in the emergency department (EQUiPPED)

J Am Geriatr Soc

An interdisciplinary academic detailing approach to decrease inappropriate medication prescribing by physician residents for older veterans treated in the emergency department

J Pharm Pract

Evaluating the impact of medication safety alerts on prescribing of potentially inappropriate medications for older veterans in an ambulatory care setting

J Pharm Pract

Effect of an educational outreach program on prescribing potential drug-drug interactions

J Manag Care Pharm

Educational outreach visits: effects on professional practice and health care outcomes

Cochrane Database Syst Rev

Systematic review of interventions to improve prescribing

Ann Pharmacother

Assessing potentially inappropriate prescribing in the elderly Veterans Affairs population using the HEDIS 2006 quality measure

J Manag Care Pharm

Beers criteria as a proxy for inappropriate prescribing of other medications among older adults

Ann Pharmacother

Agreement between drugs-to-avoid criteria and expert assessments of problematic prescribing

Arch Intern Med

A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project

Implement Sci

Audit and feedback: effects on professional practice and healthcare outcomes

Cochrane Database Syst Rev

Principles and uses of academic detailing to improve the management of psychiatric disorders

Int J Psychiatry Med