An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department
Restricted accessResearch articleFirst published online April, 2019
An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department
To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician–pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED).
Methods:
This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention.
Results:
Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug–disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 (P < .0001).
Conclusion:
Academic detailing led by a physician–pharmacist pair resulted in improved confidence in physician residents’ ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.
Institute of Medicine. Retooling for an Aging America: Building the Healthcare Workforce. Washington, DC: Institute of Medicine; 2008.
2.
Education in Geriatric Medicine. AGS education committee and public policy advisory group (PPAG). J Am Geriatr Soc. 2001;49(2):223–224.
3.
KellerIMakipaaAKalenscherT. Global Survey on Geriatrics in the Medical Curriculum. Geneva, Switzerland: World Health Organization; 2002.
4.
The American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American geriatrics society updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–2246.
5.
CaterinoJMEmondJACamargoCAJr. Inappropriate medication administration to the acutely ill elderly: a nationwide emergency department study, 1992-2000. J Am Geriatr Soc. 2004;52(11):1847–1855.
6.
KoyamaASteinmanMEnsrudK. Long-term cognitive and functional effects of potentially inappropriate medications in older women. J Gerontol A Biol Sci Med Sci. 2014;69(4):423–429.
7.
ThorpeJMThorpeCTKenneltyKA. The impact of family caregivers on potentially inappropriate medication use in noninstitutionalized older adults with dementia. Am J Geriatr Pharmacother. 2012;10(4):230–241.
8.
CoombesIDMitchellCAStowasserDA. Safe medication practice: attitudes of medical students about to begin their intern year. Med Educ. 2008;42(4):427–431.
9.
IllingJCMorrowGMRothwell nee KergonCR. Perceptions of UK medical graduates’ preparedness for practice: a multi-centre qualitative study reflecting the importance of learning on the job. BMC Med Educ. 2013;13:34.
10.
KostasTZimmermanKSalowM. Improving medication management competency of clinical trainees in geriatrics. J Am Geriatr Soc. 2014;62(8):1568–1574.
11.
ChinMHWangLCJinL. Appropriateness of medication selection for older persons in an urban academic emergency department. Acad Emerg Med. 1999;6(12):1232–1242.
12.
HusteyFMWallisNMillerJ. Inappropriate prescribing in an older ED population. Am J Emerg Med. 2007;25(7):804–807.
13.
MeurerWJPottiTAKerberKA. Potentially inappropriate medication utilization in the emergency department visits by older adults: analysis from a nationally representative sample. Acad Emerg Med. 2010;17(3):231–237.
14.
HastingsSNSchmaderKESloaneRJ. Quality of pharmacotherapy and outcomes for older veterans discharged from the emergency department. J Am Geriatr Soc. 2008;56(5):875–880.
15.
HoganTMHansotiBChanSB. Assessing knowledge base on geriatric competencies for emergency medicine residents. West J Emerg Med. 2014;15(4):409–413.
16.
LeipzigRMGranvilleLSimpsonD. The Future of Geriatric Care in Our Nation’s Emergency Departments: Impact and Implications. Dallas, TX: American College of Emergency Physicians; 2008.
17.
HoganTMLosmanEDCarpenterCR. Development of geriatric competencies for emergency medicine residents using an expert consensus process. Acad Emerg Med. 2010;17(3):316–324.
18.
Geriatric Emergency Department Guidelines. Ann Emerg Med. 2014;63(5):e7–e25.
19.
StevensMHastingsSNPowersJ. Enhancing the quality of prescribing practices for older veterans discharged from the emergency department: preliminary results from EQUiPPED, a novel multi-component interdisciplinary quality improvement initiative. J Am Geriatr Soc. 2015;63(5):1025–1029.
20.
HastingsSNVaughanCPStevensM. Invited commentary—research and operations: joining forces to improve care for veterans. N C Med J. 2015;76(5):315–319.
21.
MossJBryanWWilkersonLM. Impact of clinical pharmacy specialists on the design and implementation of a quality improvement initiative to decrease inappropriate medications in a veterans affairs emergency department. J Manag Care Spec Pharm. 2016;22(1):74–80.
22.
VandenbergAEVaughanCPStevensM. Improving geriatric prescribing in the ED: a qualitative study of facilitators and barriers to clinical decision support tool use. Int J Qual Health Care. 2016;29(1):117–123.
23.
VandenbergAStevensMEchtK. Implementation of a medication management program across 5 VA emergency departments. Fed Pract. 2016;33(4):29–32.
24.
KesslerCChenJDillC. State of affairs of emergency medicine in the Veterans Health Administration. Am J Emerg Med. 2010;28(8):947–951.
25.
RamaswamyRMaioVDiamondJJ. Potentially inappropriate prescribing in elderly: assessing doctor knowledge, confidence, and barriers. J Eval Clin Pract. 2011;17(6):1153–1159.
26.
UryWARahnMTolentinoV. Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents?J Gen Intern Med. 2002;17(8):625–631.
27.
BieseKJRobertsELaMantiaM. Effect of a geriatric curriculum on emergency medicine resident attitudes, knowledge, and decision-making. Acad Emerg Med. 2011;18 suppl 2:S92–S96.
28.
RyskinaKLDineCJKimEJ. Effect of attending practice style on generic medication prescribing by residents in the clinic setting: an observational study. J Gen Intern Med. 2015;30(9):1286–1293.
29.
FoxADKuninsHVStarrelsJL. Which skills are associated with residents’ sense of preparedness to manage chronic pain?J Opioid Manag. 2012;8(5):328–336.
30.
O’BrienMARogersSJamtvedtG. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Syst Rev. 2007;(4):CD000409.
31.
AvornJSoumeraiSBEverittDE. A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. N Engl J Med. 1992;327(3):168–173.
32.
CrottyMWhiteheadCRowettD. An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial. BMC Health Serv Res. 2004;4(1):6.
33.
SchmidtIClaessonCBWesterholmB. The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. J Am Geriatr Soc. 1998;46(1):77–82.
34.
van EijkMECAvornJPorsiusAJ. Reducing prescribing of highly anticholinergic antidepressants for elderly people: randomized trial of group vs individual academic detailing. BMJ. 2001;322(7287):1–6.
35.
SolomonDHVan HoutenLGlynnRJ. Academic detailing to improve use of broad-spectrum antibiotics at an academic medical center. Arch Intern Med. 2001;161(15):1897–1902.
36.
KisuuleFWrightSBarretoJ. Improving antibiotic utilization among hospitalists: a pilot academic detailing project with a public health approach. J Hosp Med. 2008;3(1):64–70.
37.
MajumdarSRGuirguisLMTothEL. Controlled trial of a multifaceted intervention for improving quality of care for rural patients with type 2 diabetes. Diabetes Care. 2003;26(11):3061–3066.
38.
ChangCMLiuPYYangYH. Use of the Beers criteria to predict adverse drug reactions among first-visit elderly outpatients. Pharmacotherapy. 2005;25(6):831–838.
39.
CorbiGGambassiGPaganoG. Impact of an innovative educational strategy on medication appropriate use and length of stay in elderly patients. Medicine (Baltimore). 2015;94(24):e918.
40.
PitkalaKHJuolaALKautiainenH. Education to reduce potentially harmful medication use among residents of assisted living facilities: a randomized controlled trial. J Am Med Dir Assoc. 2014;15(12):892–898.
