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VA Geriatric Scholars Program’s Impact on Prescribing Potentially Inappropriate Medications
Zachary Burningham, PhD; Wei Chen, PhD; Brian C. Sauer, PhD; Regina Richter Lagha, PhD; Jared Hansen, MStat; Tina Huynh, MPH, MHA; Shardool Patel, PharmD; Jianwei Leng, MStat; Ahmad Halwani, MD; and B. Josea Kramer, PhD
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VA Geriatric Scholars Program’s Impact on Prescribing Potentially Inappropriate Medications

Zachary Burningham, PhD; Wei Chen, PhD; Brian C. Sauer, PhD; Regina Richter Lagha, PhD; Jared Hansen, MStat; Tina Huynh, MPH, MHA; Shardool Patel, PharmD; Jianwei Leng, MStat; Ahmad Halwani, MD; and B. Josea Kramer, PhD
Primary care teams reduced their prescribing of potentially inappropriate medications to older veterans after participation in the Veterans Affairs (VA) Geriatric Scholars Program.
ABSTRACT

Objectives: The Veterans Affairs (VA) Geriatric Scholars Program (GSP) is a workforce development program to enhance skills and competencies among VA clinicians who provide healthcare for older veterans in VA primary care clinics. An intensive geriatrics didactics (IGD) course is a core element of this professional development program. The objective of this study was to evaluate the impact of completing the IGD course on providers’ rates of prescribing definite potentially inappropriate medications (DPIMs) based on Beers Criteria from 2008 to 2016.

Study Design: We applied a longitudinal interrupted time series design to examine changes in DPIM prescribing rates for GSP participants before and after completing the IGD course.

Methods: The time series was divided into two 12-month periods, representing the preintervention period (ie, 12 months prior to completing the IGD course) and the postintervention period (ie, 12 months after completing the IGD course), and populated with pharmacy dispensing data from the VA’s Corporate Data Warehouse. An adjusted slope impact model was developed to estimate the postintervention change in the proportion of the dispensed medications identified as DPIMs.

Results: After adjusting for case mix, we observed a statistically significant reduction in the proportion of DPIMs dispensed post IGD (slope change, 0.994; 95% CI, 0.991-0.997). This change in slope reflects a total decrease of 7971 DPIM dispensings during the postintervention period. This equates to an estimated 24 fewer DPIM dispensings per provider during the postintervention period.

Conclusions: Although the size of the effect was modest, we found that participation in the GSP IGD course reduced prescribing of DPIMs for older veterans.

Am J Manag Care. 2019;25(9):425-430
Takeaway Points

Multifaceted educational outreach programs are a viable approach to influencing care processes and improving the quality of care administered.
  • Deprescribing of potentially inappropriate medications is a central tenet of geriatric medicine.
  • Knowing evidence-based alternative therapies is important prior to developing a deprescribing plan.
  • Synergy must exist among the components of a workforce development program to enhance potential benefits.
The Veterans Affairs (VA) Geriatric Scholars Program (GSP) is a workforce development program designed to enhance skills and competencies among VA clinicians who provide healthcare in primary care teams.1 The GSP was created as a response to the Institute of Medicine’s report on an aging America, which noted that the existing workforce was insufficient to meet the growing needs of expertise in care of older Americans.2 The national supply of trained geriatricians does not meet the current or projected demand, and the deficit is greater in the VA.1,3 Participation in the GSP is not mandatory. All of the Veterans Integrated Service Networks (VISNs) are invited to nominate eligible individuals to participate in the program. The number of nominees per VISN can fluctuate each year and is dependent on the program’s approved budget. To be eligible, nominees must be employed at the VA and actively provide healthcare as a primary care clinician (eg, physician, physician assistant, advance practice nurse) or support a primary care team as a clinical pharmacist, social worker, or rehabilitation therapist. The GSP is a longitudinal program that includes 3 core components and then offers educational activities that are tailored to each clinician’s self-identified gaps in education and training; these include webinars, self-directed web-based learning, clinical practicum experiences, and on-site team training. The core components include participation in an intensive geriatrics didactics (IGD) course (an accredited didactic education course and board review in geriatric medicine offered through several prominent universities), participation in a daylong quality improvement (QI) course, and initiation of a local QI project.

The IGD course addresses major geriatric syndromes and effective management of these syndromes, as well as the latest evidence in geriatric medicine, including promising practices and risks of new treatments. More specifically, the IGD course includes concepts of the comprehensive geriatric assessment, which is appropriate in geriatric specialty care as well as in nonspecialty care4; Assessing Care of Vulnerable Elders (ACOVE) through quality indicators for vulnerable elders 75 years or older5; and appropriate medication selection for older adults, with the goal of reducing adverse drug events. The standard of practice for appropriate prescribing taught during the IGD course is based on the American Geriatrics Society (AGS) Beers Criteria and alternative treatment recommendations supported by the National Committee for Quality Assurance and the Pharmacy Quality Alliance.6,7 The AGS Beers Criteria contain explicit lists of potentially inappropriate medications (PIMs) to avoid in older adults. Training on the Beers Criteria is woven throughout the intensive multiday course. The GSP uses several university-sponsored courses, which also serve as board reviews for the added certification in geriatric medicine, as its core IGD course. Although content may vary somewhat based on the expertise of faculty at the various universities, the courses cover similar topics on evidence-based clinical practices, and GSP evaluators have shown that no significant differences exist among these courses as measured by knowledge outcomes of participants.1,3,8,9

A retrospective pre-post survey design study has examined the impact of the GSP on clinical behaviors and practices.1 Authors reported that program participants were more likely to use evidence-based standardized assessments and relevant standards of care after participating in the GSP. However, that study was based on self-report, and further evaluation is needed through direct measurement to determine if care processes improved after participation in the GSP. The purpose of our study was to determine if participation in the GSP was associated with a change in providers’ prescribing behaviors.

The primary objectives of our study were (1) to determine whether exposure to the GSP IGD course resulted in a lower rate of definite potentially inappropriate medications (DPIMs) dispensed in the year following the educational intervention compared with the year prior to attending the IGD course and (2) to examine these rate changes by therapeutic class in determining whether providers prioritized specific groups of medications after exposure to the GSP IGD course. DPIMs are medications that originate from the explicit list of PIMs for adults 65 years or older found in Table 2 of the AGS 2015 Beers Criteria.6 However, DPIMs exclude medications from this list with conditional recommendation properties suggesting that the medication be avoided only for certain indications or for those with certain disease characteristics. Thus, DPIMs include medications from the 2015 Beers Criteria that prescribers should always avoid (ie, definitely inappropriate). The list of DPIMs we examined can be found in the eAppendix Table (available at ajmc.com). We also tested hypotheses for 2 secondary objectives, which included the examination of pre- to postintervention DPIM rate changes for (1) advanced-age veterans (ie, ≥75 years), reflecting ACOVE quality indicators as an IGD topic, and (2) by location of provider in a rural or urban clinic, a factor that has emerged in other evaluations of the GSP.1

METHODS

We applied a longitudinal interrupted time series (ITS) design that examined trends and slope changes of DPIM dispensing rates, pre- and post completion of IGD. The ITS design was used to explore the effect of the IGD course on DPIM rates while controlling for pre-existing trends. In this study, pre-existing trends represent the time series of DPIM dispensing rates prior to being interrupted by IGD (ie, underlying trend). Theoretically, had IGD not been implemented, then the pre-existing trend would in turn represent the expected trend. Thus, observed changes in the underlying trend, post intervention, represent the impact of completing the IGD course.


 
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