Background: With more than 120 VAMC Emergency Departments (EDs) providing services for more than 2 million visits annually, VHA is one of the nation's largest providers of emergency care. Older veterans are among the most frequent users of VAMC ED care. Despite a high frequency of chronic health conditions and functional impairments in this population, the majority of older veterans evaluated in the ED are not admitted to the hospital. Up to 75% of older veterans are discharged from the ED with new diagnoses and treatment plans, which often include new medications (hereafter referred to as discharge medications). In a chart review performed at the Durham VAMC, we found that nearly one-third of veterans had potentially inappropriate prescribing or inadequate medication monitoring with regard to their ED discharge medications. Furthermore, suboptimal pharmacotherapy was associated with a 32% increased risk of repeat ED visits, hospitalizations or death. Objectives: The overall goal of this pilot study is to provide critical dataset validation work and prevalence estimates needed for a national study using VA databases that will extend our understanding about the frequency and type of quality problems and adverse health outcomes associated with ED discharge medications.
The specific aims of this pilot study are: (1) to construct and validate a national VHA dataset for measuring the quality of ED discharge pharmacotherapy; and (2) to examine the feasibility of measuring the quality of ED discharge pharmacotherapy in a nationally representative cohort of veterans. Methods: The dataset will be constructed by: (1) identifying all eligible veterans aged 65 and older with a VAMC ED visit; (2) drawing a random sample of the cohort from each VAMC; and (3) extracting demographic, clinical and utilization data for these veterans. Data will be drawn from 4 national VHA sources including for FY07 and FY08. Medical record review (via VistA Web) for a random subset of veterans will be used to validate portions of the dataset by analyzing matches in total number of outpatient ED visits and total number of ED discharge drugs in the constructed dataset compared to chart abstraction. Next, quality measures will be applied to the ED discharge medications identified in the constructed dataset. Dependent variables will be 12 individual quality measures, and combined measures of quality based on: source of the measure), medication quality domain (e.g. presence of a high risk medication, and targeted drug class (e.g. presence of problem related to an NSAID). Multivariable logistic regression models will be used to examine the association between patient and ED visit characteristics and the presence of ED discharge medication quality problems. Impact: This pilot study will result in validated methodology for identifying outpatient ED visits and ED discharge medications, and preliminary data regarding the quality of ED discharge medications. These data and methods will be used to develop an IIR that will examine the association between ED medication quality problems and adverse health outcomes among older veterans in a larger, nationally representative sample of veterans. The long-term goal of this program of research is to develop strategies to improve ED discharge pharmacotherapy and, ultimately, the health of older veterans who seek care at VAMC EDs.
Up to one-third of older veterans visit the Emergency Department (ED) at least once over the course of a year;therefore, it is vitally important that more VA research be performed in this setting. Many older veterans are discharged from the ED with new medications, but frequently these medications are not prescribed or monitored in the safest possible way, and this may lead to repeat ED visits and/or hospitalizations. The pilot study proposed in this application will lead to a greater understanding of the problems associated with medication use in the ED. Our goal is to translate this knowledge into strategies to improve the quality and safety of ED discharge medications and, ultimately, the health of older veterans who seek care at VAMC EDs.
| Hastings, S Nicole; Smith, Valerie A; Weinberger, Morris et al. (2011) Emergency department visits in Veterans Affairs medical facilities. Am J Manag Care 17:e215-23 |
