Team-Based Care Reduces Inappropriate Prescribing for Older Patients

Clinical pharmacists included in team-based interventions can reduce the proportion of potentially inappropriate medications (PIMs) dispensed to elderly patients in the emergency department (ED).

One initiative to measure this outcome, the Enhancing the Quality of Prescribing Practices for Older Veterans Discharged from the ED (EQUiPPED) intervention, involved a team comprised of ED clinical pharmacists, physicians, geriatricians, nurses, and clinical applications coordinators.

The EQUiPPED strategy integrated provider education, electronic medical record (EMR)-embedded pharmacy order sets, and peer feedback and benchmarking into the care model.

In the first phase of the study, the care team detailed process improvements aimed at reducing the number of PIMs prescribed for veterans aged 65 years and older when they transitioned from Department of Veterans Affairs EDs to home. For instance, geriatric outpatient pharmacy order sets were categorized by common discharge diagnoses with preferred medications, and then placed next to the original order sets in the EMR.

Implementing these interventions reduced dispensing rates for skeletal muscle relaxants, chronic nonsteroidal anti-inflammatory drugs, and promethazine—3 of the 5 most commonly prescribed PIMs for the elderly, according to the American Geriatrics Society 2012 Beers Criteria Update.

“The average monthly proportion of PIMs prescribed was 9.4± 1.5%” before the EQUiPPED interventions, but “this declined to 4.6 ± 1.0% after,” the authors wrote.

Smooth transitions of care processes are particularly important for elderly patients in the ED.

Jacqui Allen, an older populations researcher at Deakin University’s School of Nursing and Midwifery, noted that elderly patients “typically have comorbid chronic health problems and experience considerable deconditioning after a hospital stay.” Additionally, “they might be housebound, socially isolated, have mobility problems, and complex medication regimens to get their heads around,” she told Pharmacy Times in an e-mail.

According to geriatric ED guidelines from the American College of Emergency Physicians, “Older ED patients identify misinformation as a primary source of dissatisfaction with their emergency care—a problem confounded and magnified by ongoing under-recognition of cognitive dysfunction, lower health literacy, and financial impediments for prescriptions and recommended outpatient follow-up.”

Allen told Pharmacy Times that team-based models such as EQUiPPED can help mitigate these population-specific challenges.

“There is a vital role for pharmacists in supporting older people with quality use of medications at the point of hospital discharge and over the care transition,” she said. “This role includes supporting medical practitioners with safe prescribing, liaising with community pharmacists, and providing comprehensive and easily understandable education for the older person…about the medication regimen.”

The EQUiPPED study was published in the Journal of the American Geriatrics Society.