Addressing inappropriate benzodiazepine prescribing among older Veterans

解决老年退伍军人中不当使用苯二氮卓类药物的问题

• 批准号: 10186531
• 负责人: DONOVAN T MAUST
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-02-01 至 2022-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10186531
• 关键词: Academic Detailing; Acute; Address; Administrator; Age; Age-Years; Attention; Benzodiazepines; Cessation of life; Characteristics; Chronic; Chronic Obstructive Airway Disease; Cognition; Data; Distress; Dose; Elderly; Equipment and supply inventories; Fracture; Future; Goals; Health; Impaired cognition; Injury; Interruption; Intervention; Intervention Studies; Interview; Lead; Learning; Measures; Medical; Methods; Monitor; Opioid; Outcome; Overdose; Patient-Focused Outcomes; Patients; Pharmaceutical Preparations; Pharmacologic Substance; Physical Dependence; Policies; Professional Organizations; Provider; Psychological Dependence; Psychotropic Drugs; Recommendation; Research Personnel; Role; Services; Site; Site Visit; Structure; Telephone Interviews; Testing; Thinking; Time Series Analysis; Veterans; Work; adverse outcome; automobile accident; clinical care; dementia risk; effectiveness trial; experience; fall risk; falls; improved; interest; medication safety; member; mortality; mortality risk; pharmacy benefit; success; vehicular accident

Background: Benzodiazepine (BZD) use is a significant and persistent concern among older Veterans given the association of BZDs with adverse outcomes including falls, fractures, motor vehicle accidents, impaired cognition, increased risk of dementia, and mortality. In FY2015, over 82,000 Veterans ≥75 years of age were prescribed a BZD despite abundant evidence of harms from both acute and chronic use and recommendations from professional organizations to limit use. Beginning in FY2013, the VA's Psychotropic Drug Safety Initiative (PDSI) began monitoring a variety of psychotropic quality measures, including BZD use among Veterans ≥75 years of age (hereafter referred to as “BZD≥75”). Among the 52 facilities (out of 140) that selected BZD≥75 as a priority, each developed its own local strategy to improve prescribing. In order for the VA to build upon local successes at addressing the seemingly intractable problem of BZD prescribing, the aim of this proposal is to understand the combinations of local facility strategies and context that generate these outcomes. In addition, it is critical to understand the patient experience of these strategies, as Veterans may experience some “successful” strategies as extremely distressful. This work may directly influence the clinical care of Veterans and is of both great interest and immediate relevance to our operational partners, including PDSI, Pharmacy Benefits Management, and the Academic Detailing Service. Objectives: Aim 1: Identify high- and low-performing facilities on acute and chronic BZD prescribing among facilities that prioritized the BZD≥75 measure. Aim 2: Assess facility-level strategies and associated barriers and facilitators to addressing the BZD≥75 goal along with the acceptability of those strategies to older Veterans. Aim 3: Identify and pilot test context-sensitive strategies for facilities to successfully reduce both acute and chronic BZD use among older Veterans. Methods: We will use interrupted time-series analyses of national VA administrative data to examine BZD prescribing across BZD≥75 priority facilities (n=52). We will specifically measure change in: (1) rate of acute use (new BZD initiation) and (2) intensity of chronic use (average daily dose [mg/day]). As an exploratory sub- aim, we will measure the rate of fall-related injury by facility to determine whether change in BZD prescribing is associated with change in associated adverse outcomes. In Aim 2a we will conduct semi-structured telephone interviews with up to 16 PDSI local facility champions and additional staff from top- and bottom-performing facilities (identified in Aim 1), followed by on-site, semi-structured interviews with key stakeholders at up to 6 sites. We will gather information on facility-level strategies, barriers, and facilitators that may help or hinder facility efforts. Finally, we will conduct telephone interviews with older Veterans prescribed chronic BZDs that attempted a taper to learn whether patients experienced these facility strategies as distressful. An expert panel of clinicians, researchers, and administrators will review the strategies, local context, associated BZD prescribing outcomes, and patient acceptability to develop a toolkit of context-sensitive best practices facilities can implement to address BZD use, which we will then pilot test.

背景：苯二氮卓类（BZD）的使用是给予的老年退伍军人的重要且持久的关注点 BZD与不良后果的关联，包括跌倒，断裂，机动车事故，受损 认知，痴呆症的风险增加和死亡率。在2015财年，超过82,000名退伍军人≥75岁 规定了BZD任务的丰富证据，证明了急性和长期使用和建议 从专业组织限制使用。从2013财年开始，VA的精神药物安全计划 （PDSI）开始监视各种精神质量措施，包括在≥75的退伍军人中使用BZD 年龄（以下称为“BZD≥75”）。在52个设施（在140个中）中选择了BZD≥75 一个优先事项，每个人都制定了自己的本地战略来改善处方。为了使VA建立 在解决看似棘手的BZD处方问题方面取得的本地成功，目的 提案是要了解当地设施策略和背景的组合，从而产生这些策略 结果。此外，了解这些策略的患者体验至关重要，因为 退伍军人可能会遇到一些“成功”的策略，因为他们非常痛苦。 这项工作可能直接影响退伍军人的临床护理，既有兴趣又直接 与我们的运营合作伙伴有关，包括PDSI，药房福利管理和学术 详细服务。 目标：目标1：确定急性和慢性BZD处方的高性能和低表现的设施 确定BZD≥75测量的设施。目标2：评估设施级策略和相关障碍 并协助解决BZD≥75目标，以及这些策略对较旧的目标的可接受性 退伍军人。目标3：确定和试点测试背景敏感的设施策略，以成功减少两者 老年退伍军人中使用急性和慢性BZD。 方法：我们将使用全国VA行政数据的中断时间序列分析来检查BZD 在BZD≥75优先设施的规定（n = 52）。我们将特别衡量：（1）急性速率 使用（新的BZD启动）和（2）长期使用强度（平均每日剂量[mg/day]）。作为探索性子 目的，我们将通过设施来衡量与跌倒相关的伤害率，以确定BZD处方的变化是否为 与关联不良结果的变化有关。在AIM 2A中，我们将进行半结构化电话 最多16位PDSI本地设施冠军的访谈以及表现最高和最底部的其他员工 设施（在AIM 1中确定），然后进行现场，半结构化的访谈，与主要利益相关者最多6岁 站点。我们将收集有关设施级策略，障碍和促进者的信息，这些信息可能会帮助或阻碍或阻碍 设施工作。最后，我们将对年长的退伍军人开处方的慢性BZD进行电话采访 试图锥度了解患者是否经历了这些设施策略的痛苦。专家小组 临床医生，研究人员和管理人员将审查策略，当地环境，相关的BZD 处方结果和患者的可接受性，以开发上下文敏感最佳实践设施的工具包 可以实施以解决BZD使用，然后我们将进行试点测试。