Exploring the Impact of COVID-19 Restrictions on Nursing Home Residents', Families', and Staff's Perceptions of Bioethical Principles: A Qualitative Study.

In this study, we employed a pre-interview survey and conducted interviews with nursing home staff members and residents/family members to understand their perceptions of whether the COVID-19 restrictions fulfilled obligations to nursing home residents under various principles, including autonomy, beneficence, nonmaleficence, justice, and privacy. We conducted 20 semi-structured interviews with staff members from 14 facilities, and 20 with residents and/or family members from 13 facilities. We used a qualitative descriptive study design and thematic analysis methodology to analyze the interviews. Findings from the pre-interview survey indicated that, compared to nursing home staff, residents and their families perceived lower adherence to bioethics principles during the pandemic. Qualitative analysis themes included specific restrictions, challenges, facility notifications, consequences, communication, and relationships between staff and residents/family members. Our study exposes the struggle to balance infection control with respecting bioethical principles in nursing homes, suggesting avenues for improving processes and policies during public health emergencies.

Pharmacist, nurse, and physician perspectives on the implementation of the pharmacist discharge care (pharm-dc) intervention: A qualitative study.

BACKGROUND: The PHARMacist Discharge Care (PHARM-DC) intervention is a pharmacist-led Transitions of Care (TOC) program intended to reduce 30-day hospital readmissions and emergency department visits which has been implemented at two hospitals in the United States. The objectives of this study were to: 1) explore perspectives surrounding the PHARM-DC program from healthcare providers, leaders, and administrators at both institutions, and 2) identify factors which may contribute to intervention success and sustainability. METHODS: Focus groups and interviews were conducted with pharmacists, physicians, nurses, hospital leaders, and pharmacy administrators at two institutions in the Northeastern and Western United States. Interviews were audio recorded and transcribed, with transcriptions imported into NVivo for qualitative analysis. Thematic analysis was performed using an iterative process, with two study authors independently coding transcripts to identify themes. RESULTS: Overall, 37 individuals participated in ten focus groups and seven interviews. The themes identified included: 1) Organizational, Pharmacist, and Patient Factors Contributing to Transitions of Care, 2) Medication Challenges in Transitions of Care at Admission and Discharge, 3) Transitions of Care Communication and Discharge Follow-up, and 4) Opportunities for Improvement and Sustainability. The four themes were mapped to the constructs of the CFIR and RE-AIM frameworks. Some factors facilitating intervention success and sustainability were accurate medication histories collected on admission, addressing medication barriers before discharge, coordinating discharge using electronic health record discharge features, and having a structured process for intervention training and delivery. Barriers to intervention implementation and sustainability included gaps in communication with other care team members, and variable pharmacist skills for delivering the intervention. This study identified that using educational resources to standardize the TOC process addressed the issue of variations in pharmacists' skills for delivering TOC interventions. CONCLUSIONS: Nurses, physicians, pharmacists, pharmacist leaders, and hospital administrators were in agreement regarding the usefulness of the PHARM-DC intervention, while acknowledging challenges in its implementation and opportunities for improvement. Future research should focus on developing training materials to standardize and scale the intervention, eliminating barriers to medication access pre-discharge, coordinating discharge across care team members, and communicating medication changes to primary care providers post-discharge.

Implementation of an intervention aimed at deprescribing benzodiazepines in a large US healthcare system using patient education materials: a pre/post-observational study with a control group.

OBJECTIVES: Long-term benzodiazepine use is common despite known risks. In the original Eliminating Medications Through Patient Ownership of End Results (EMPOWER) Study set in Canada, patient education led to increased rates of benzodiazepine cessation. We aimed to determine the effectiveness of implementing an adapted EMPOWER quality improvement (QI) initiative in a US-based healthcare system. DESIGN: We used a pre-post design with a non-randomised control group. SETTING: A network of primary care clinics. PARTICIPANTS: Patients with ≥60 days' supply of benzodiazepines in 6 months and ≥1 risk factor (≥65 years of age, a concurrent high-risk medication prescribed or a diazepam equivalent daily dose ≥10) were eligible. INTERVENTION: In March 2022, we engaged 22 primary care physicians (PCPs), and 308 of their patients were mailed an educational brochure, physician letter and flyer detailing benzodiazepine risks; the control group included 4 PCPs and 291 of their patients. PRIMARY AND SECONDARY MEASURES: The primary measure was benzodiazepine cessation by 9 months. We used logistic regression and a generalised estimating equations approach to control for clustering by PCP, adjusting for demographics, frailty, number of risk factors, and diagnoses of arthritis, depression, diabetes, falls, and pain. RESULTS: Patients in the intervention and control groups were comparable across most covariates; however, a greater proportion of intervention patients had pain-related diagnoses and depression. By 9 months, 26% of intervention patients (81 of 308) had discontinued benzodiazepines, compared with 17% (49 of 291) of control patients. Intervention patients had 1.73 greater odds of benzodiazepine discontinuation compared with controls (95% CI: 1.09, 2.75, p=0.02). The unadjusted number needed to treat was 10.5 (95% CI: 6.30, 34.92) and the absolute risk reduction was 0.095 (95% CI: 0.03 to 0.16). CONCLUSIONS: Results from this non-randomised QI initiative indicate that patient education programmes using the EMPOWER brochures have the potential to promote cessation of benzodiazepines in primary care.

Cumulative Update of a Systematic Overview Evaluating Interventions Addressing Polypharmacy.

Importance: Polypharmacy is associated with mortality, falls, hospitalizations, and functional and cognitive decline. The study of polypharmacy-related interventions has increased substantially, prompting the need for an updated, more focused systematic overview. Objective: To systematically evaluate and summarize evidence across multiple systematic reviews (SRs) examining interventions addressing polypharmacy. Evidence Review: A search was conducted of MEDLINE, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects for articles published from January 2017-October 2022, as well as those identified in a previous overview (January 2004-February 2017). Systematic reviews were included regardless of study design, setting, or outcome. The evidence was summarized by 4 categories: (1) medication-related process outcomes (eg, potentially inappropriate medication [PIM] and potential prescribing omission reductions), (2) clinical and functional outcomes, (3) health care use and economic outcomes, and (4) acceptability of the intervention. Findings: Fourteen SRs were identified (3 from the previous overview), 7 of which included meta-analyses, representing 179 unique published studies. Nine SRs examined medication-related process outcomes (low to very low evidence quality). Systematic reviews using pooled analyses found significant reductions in the number of PIMs, potential prescribing omissions, and total number of medications, and improvements in medication appropriateness. Twelve SRs examined clinical and functional outcomes (very low to moderate evidence quality). Five SRs examined mortality; all mortality meta-analyses were null, but studies with longer follow-up periods found greater reductions in mortality. Five SRs examined falls incidence; results were predominantly null save for a meta-analysis in which PIMs were discontinued. Of the 8 SRs examining quality of life, most (7) found predominantly null effects. Ten SRs examined hospitalizations and readmissions (very low to moderate evidence quality) and 4 examined emergency department visits (very low to low evidence quality). One SR found significant reductions in hospitalizations and readmissions among higher-intensity medication reviews with face-to-face patient components. Another meta-analysis found a null effect. Of the 7 SRs without meta-analyses for hospitalizations and readmissions, all had predominantly null results. Two of 4 SRs found reductions in emergency department visits. Two SRs examined acceptability (very low evidence quality), finding wide variation in the adoption of polypharmacy-related interventions. Conclusions and Relevance: This updated systematic overview noted little evidence of an association between polypharmacy-related interventions and reduced important clinical and health care use outcomes. More evidence is needed regarding which interventions are most useful and which populations would benefit most.

Deprescribing medications among patients with multiple prescribers: A socioecological model.

Deprescribing is the intentional dose reduction or discontinuation of a medication. The development of deprescribing interventions should take into consideration important organizational, interprofessional, and patient-specific barriers that can be further complicated by the presence of multiple prescribers involved in a patient's care. Patients who receive care from an increasing number of prescribers may experience disruptions in the timely transfer of relevant healthcare information, increasing the risk of exposure to drug-drug interactions and other medication-related problems. Furthermore, the fragmentation of healthcare information across health systems can contribute to the refilling of discontinued medications, reducing the effectiveness of deprescribing interventions. Thus, deprescribing interventions must carefully consider the unique characteristics of patients and their prescribers to ensure interventions are successfully implemented. In this special article, an international working group of physicians, pharmacists, nurses, epidemiologists, and researchers from the United States Deprescribing Research Network (USDeN) developed a socioecological model to understand how multiple prescribers may influence the implementation of a deprescribing intervention at the individual, interpersonal, organizational, and societal level. This manuscript also includes a description of the concept of multiple prescribers and outlines a research agenda for future investigations to consider. The information contained in this manuscript should be used as a framework for future deprescribing interventions to carefully consider how multiple prescribers can influence the successful implementation of the service and ensure the intervention is as effective as possible.

Identifying Implementation Factors for the Development, Operation, and Sustainment of Ambulatory Care Pharmacy Programs: a Qualitative Study.

BACKGROUND: Pharmacist-led programs and clinics have been integrated into primary and specialty care clinics in a variety of ways, for example, to improve diabetes outcomes via patient education and counseling. However, factors important to the implementation of different outpatient pharmacy models have not been well elucidated. OBJECTIVE: To identify provider- and health system-level drivers of implementation and sustainability of pharmacy-led programs in the outpatient setting. DESIGN: Qualitative study of key informants using semi-structured interviews of individuals working in various roles throughout a large health system, including ambulatory clinical pharmacists, pharmacy managers, medical directors and physician leaders, and operations and quality managers. PARTICIPANTS: Key informants (n=19) with leadership roles in pharmacy programs and front-line experience providing integrated pharmacy care were selected purposively and with snowball sampling. APPROACH: We coded the interviews using a codebook derived from the 2022 Consolidated Framework for Implementation Research (CFIR), which details various internal and external factors important for implementation. KEY RESULTS: We identified the following themes related to implementing ambulatory care pharmacy programs: (1) pharmacy programs varied in their level of embeddedness in the outpatient clinic, (2) establishing pharmacy program required leadership advocacy and coordination among stakeholders, (3) continued operations required integrated workflows and demonstrated value to the health system and clinicians, and (4) established revenue streams or added indirect value and continued improvement of integration sustained programs over time. CONCLUSIONS: External policies and incentives such as new reimbursement codes and quality measurement programs that rely on pharmacy input play a significant role in shaping the design, implementation, and sustainability of health system outpatient pharmacy programs. Ensuring that quality metrics used in value-based contracts or programs demonstrate pharmacy benefits will be critical to supporting and growing pharmacy programs.

Barriers to Implementing the Kidney Disease Outcomes Quality Initiative End-Stage Kidney Disease Life Plan Guideline.

OBJECTIVE: The updated 2019 National Kidney Foundation Kidney Disease Outcomes Quality Initiative vascular access guidelines recommend patient-centered, multi-disciplinary construction and regular update of an individualized end-stage kidney disease (ESKD) Life-Plan (LP) for each patient, a dramatic shift from previous recommendations and policy. The objective of this study was to examine barriers and facilitators to implementing the LP among key stakeholders. METHODS: Semi-structured individual interviews were analyzed using inductive and deductive coding. Codes were mapped to relevant domains in the Consolidated Framework for Implementation Research (CFIR). RESULTS: We interviewed 34 participants: 11 patients with end-stage kidney disease, 2 care partners, and 21 clinicians who care for patients with end-stage kidney disease. In both the clinician and the patient/care partner categories, saturation (where no new themes were identified) was reached at 8 participants. We identified significant barriers and facilitators to implementation of the ESKD LP across three CFIR domains: Innovation, Outer setting, and Inner setting. Regarding the Innovation domain, patients and care partners valued the concept of shared decision-making with their care team (CFIR construct: innovation design). However, both clinicians and patients had significant concerns about the complexity of decision-making around kidney substitutes and the ability of patients to digest the overwhelming amount of information needed to effectively participate in creating the LP (innovation complexity). Clinicians expressed concerns regarding the lack of existing evidence base which limits their ability to effectively counsel patients (innovation evidence base) and the implementation costs (innovation cost). Within the Outer Setting, both clinicians and patients were concerned about performance measurement pressure under the existing "Fistula First" policies and had concerns about reimbursement (financing). In the Inner Setting, clinicians and patients stressed the lack of available resources and access to knowledge and information. CONCLUSION: Given the complexity of decision-making around kidney substitutes and vascular access, our findings point to the need for implementation strategies, infrastructure development, and policy change to facilitate ESKD LP development.

Patient and researcher stakeholder preferences for use of electronic health record data: a qualitative study to guide the design and development of a platform to honor patient preferences.

OBJECTIVE: This qualitative study aimed to understand patient and researcher perspectives regarding consent and data-sharing preferences for research and a patient-centered system to manage consent and data-sharing preferences. MATERIALS AND METHODS: We conducted focus groups with patient and researcher participants recruited from three academic health centers via snowball sampling. Discussions focused on perspectives on the use of electronic health record (EHR) data for research. Themes were identified through consensus coding, starting from an exploratory framework. RESULTS: We held two focus groups with patients (n = 12 patients) and two with researchers (n = 8 researchers). We identified two patient themes (1-2), one theme common to patients and researchers (3), and two researcher themes (4-5). Themes included (1) motivations for sharing EHR data, (2) perspectives on the importance of data-sharing transparency, (3) individual control of personal EHR data sharing, (4) how EHR data benefits research, and (5) challenges researchers face using EHR data. DISCUSSION: Patients expressed a tension between the benefits of their data being used in studies to benefit themselves/others and avoiding risk by limiting data access. Patients resolved this tension by acknowledging they would often share their data but wanted greater transparency on its use. Researchers expressed concern about incorporating bias into datasets if patients opted out. CONCLUSIONS: A research consent and data-sharing platform must consider two competing goals: empowering patients to have more control over their data and maintaining the integrity of secondary data sources. Health systems and researchers should increase trust-building efforts with patients to engender trust in data access and use.

Variation in Nevada primary care clinicians' use of urine drug testing to mitigate opioid harm.

INTRODUCTION: The prescription opioid epidemic led to federal, state, and health system guidelines and policies aimed at mitigating opioid misuse, including presumptive urine drug testing (UDT). This study identifies whether a difference exists in UDT use among different primary care medical license types. METHODS: The study used January 2017-April 2018 Nevada Medicaid pharmacy and professional claims data to examine presumptive UDTs. We examined correlations between UDTs and clinician characteristics (medical license type, urban/rural status, care setting) along with clinician-level measures of patient mix characteristics (proportions of patients with behavioral health diagnoses, early refills). Adjusted odds ratios (AORs) and predicted probabilities (PPs) from a logistic regression with a binomial distribution are reported. The analysis included 677 primary care clinicians (medical doctors [MD], physician assistants [PA], nurse practitioners [NP]). RESULTS: Of those in the study, 85.1 % of clinicians did not order any presumptive UDTs. NPs had the highest proportion of UDT use (21.2 % of NPs), followed by PAs (20.0 % of PAs), and MDs (11.4 % of MDs). Adjusted analyses showed that being a PA or NP was associated with higher odds of UDT (PA: AOR: 3.6; 95 % CI: 3.1-4.1; NP: AOR: 2.5; 95 % CI: 2.2-2.8) compared to being an MD. PAs had the highest PP for ordering UDTs (2.1 %, 95 % CI: 0.5 %-8.4 %). Among clinicians who ordered UDTs, midlevel clinicians had higher mean and median UDT use (PA and NP mean: 24.3 % vs. MDs: 19.4 %; PA and NP median: 17.7 % vs. MDs: 12.5 %). CONCLUSION: In Nevada Medicaid, UDTs are concentrated among 15 % of primary care clinicians who are frequently non-MDs. More research should include PAs and NPs when examining clinician variation in mitigating opioid misuse.

Identifying barriers and facilitators to deprescribing benzodiazepines and sedative hypnotics in the hospital setting using the Theoretical Domains Framework and the Capability, Opportunity, Motivation and Behaviour (COM-B) Model: a qualitative study.

OBJECTIVES: Geriatric guidelines strongly recommend avoiding benzodiazepines and non-benzodiazepine sedative hypnotics in older adults. Hospitalisation may provide an important opportunity to begin the process of deprescribing these medications, particularly as new contraindications arise. We used implementation science models and qualitative interviews to describe barriers and facilitators to deprescribing benzodiazepines and non-benzodiazepine sedative hypnotics in the hospital and develop potential interventions to address identified barriers. DESIGN: We used two implementation science models, the Capability, Opportunity and Behaviour Model (COM-B) and the Theoretical Domains Framework, to code interviews with hospital staff, and an implementation process, the Behaviour Change Wheel (BCW), to codevelop potential interventions with stakeholders from each clinician group. SETTING: Interviews took place in a tertiary, 886-bed hospital located in Los Angeles, California. PARTICIPANTS: Interview participants included physicians, pharmacists, pharmacist technicians, and nurses. RESULTS: We interviewed 14 clinicians. We found barriers and facilitators across all COM-B model domains. Barriers included lack of knowledge about how to engage in complex conversations about deprescribing (capability), competing tasks in the inpatient setting (opportunity), high levels of resistance/anxiety among patients to deprescribe (motivation), concerns about lack of postdischarge follow-up (motivation). Facilitators included high levels of knowledge about the risks of these medications (capability), regular rounds and huddles to identify inappropriate medications (opportunity) and beliefs that patients may be more receptive to deprescribing if the medication is related to the reason for hospitalisation (motivation). Potential modes of delivery included a seminar aimed at addressing capability and motivation barriers in nurses, a pharmacist-led deprescribing initiative using risk stratification to identify and target patients at highest need for deprescribing, and the use of evidence-based deprescribing education materials provided to patients at discharge. CONCLUSIONS: While we identified numerous barriers and facilitators to initiating deprescribing conversations in the hospital, nurse- and pharmacist-led interventions may be an appropriate opportunity to initiate deprescribing.

Effect of the population health inpatient Medicare Advantage pharmacist intervention on hospital readmissions: A quasi-experimental controlled study.

BACKGROUND: The population health inpatient Medicare Advantage pharmacist (PHIMAP) intervention is a pharmacist-led, transitions-of-care intervention that aims to reduce hospital readmissions among Medicare Advantage beneficiaries. PHIMAP includes inpatient pharmacist participation in interdisciplinary rounds, admission and discharge medication reconciliation, pharmacy staff delivery of discharge medications to the bedside, personalized discharge medication lists and counseling, and communication with outpatient pharmacists through an electronic health record. OBJECTIVE: To evaluate the effect of the PHIMAP intervention on unplanned 30-day same-hospital readmissions among Medicare Advantage patients. METHODS: Those included were patients admitted to a large urban academic medical center between May 2018 and March 2020 who had a Medicare Advantage plan and were aged at least 18 years. A 2-group, quasi-experimental design was utilized. Control patients received the usual care, which included a best possible medication history and a postdischarge phone call. A multivariable logistic regression model was estimated to predict unplanned 30-day same-hospital readmissions. This study was a Hypothesis Evaluating Treatment Effectiveness study. RESULTS: In total, 884 patients were included. The majority were White (59.0%), non-Hispanic (87.7%), English speaking (90.5%), and older adults (median age, 75 years; interquartile range, 70-83 years). We detected no statistically significant association between the PHIMAP intervention and unplanned 30-day same-hospital readmissions (odds ratio [OR] = 0.91, 95% CI = 0.56-1.52). After adjusting for patient demographics and clinical covariates, significant predictors of 30-day readmissions included the number of emergency department/inpatient visits within 180 days prior to index admission (OR = 1.40, 95% CI = 1.11-1.77); discharge to a post-acute care facility, such as an inpatient rehabilitation facility, long-term acute care facility, or skilled nursing facility (OR = 1.69, 95% CI = 1.06-2.66); hospital length of stay in days (OR = 1.04, 95% CI=1.01-1.07); and the Agency for Healthcare Research and Quality Elixhauser Comorbidity Index score (OR = 1.01, 95% CI = 1.01-1.02). CONCLUSIONS: Significant predictors of readmissions among Medicare Advantage beneficiaries were consistent with greater illness severity, including a recent history of prior hospital utilization, a discharge to post-acute care facility (vs home), a longer length of hospital stay, and a higher comorbidity burden. Although we detected no statistically significant association between PHIMAP and unplanned 30-day same-hospital readmissions, differences in study group assignment based on the day of hospital discharge (weekend vs weekday) was a noted limitation of this study. Future studies of inpatient pharmacist-led interventions should plan to minimize the risk of selection bias due to differences in the time of patient discharge. DISCLOSURES: This study was supported in part by the National Institute on Aging under award number R01AG058911 (to Pevnick) and the UCLA Clinical Translational Science Institute (UL1 TR001881). The sponsor had no role in the design and conduct of the study, nor the writing of this report.

Comparing risk prediction models aimed at predicting hospitalizations for adverse drug events in community dwelling older adults: a protocol paper.

Background: The objective of this paper is to describe the creation, validation, and comparison of two risk prediction modeling approaches for community-dwelling older adults to identify individuals at highest risk for adverse drug event-related hospitalizations. One approach will use traditional statistical methods, the second will use a machine learning approach. Methods: We will construct medication, clinical, health care utilization, and other variables known to be associated with adverse drug event-related hospitalizations. To create the cohort, we will include older adults (≥ 65 years of age) empaneled to a primary care physician within the Cedars-Sinai Health System primary care clinics with polypharmacy (≥ 5 medications) or at least 1 medication commonly implicated in ADEs (certain oral hypoglycemics, anti-coagulants, anti-platelets, and insulins). We will use a Fine-Gray Cox proportional hazards model for one risk modeling approach and DataRobot, a data science and analytics platform, to run and compare several widely used supervised machine learning algorithms, including Random Forest, Support Vector Machine, Extreme Gradient Boosting (XGBoost), Decision Tree, Naïve Bayes, and K-Nearest Neighbors. We will use a variety of metrics to compare model performance and to assess the risk of algorithmic bias. Discussion: In conclusion, we hope to develop a pragmatic model that can be implemented in the primary care setting to risk stratify older adults to further optimize medication management.

Pharmacists, nurses, and physicians' perspectives and use of formal and informal interpreters during medication management in the inpatient setting.

OBJECTIVE: Language barriers during inpatient medication management can occur during medication reconciliation on admission and discharge, and during the hospitalization. Understanding inpatient clinicians' experiences with language barriers and use of interpreters can help inform interventions aimed at improving medication management with Limited English Proficient (LEP) patients. Our objective was to examine clinicians' experiences with language barriers around inpatient medication management. METHODS: We used semi-structured interviews with pharmacist technicians, pharmacists, nurses, and physicians working in a tertiary care hospital. We used the constant comparison method to guide data collection and analysis. RESULTS: We interviewed 14 providers. Nurses and physicians perceived lack of time to use formal interpreters, particularly during busy or night shifts. Clinicians strongly preferred virtual and in-person interpreter services over telephonic services, and highlighted communication challenges with patients with low health literacy, concerns about the quality of interpretation, and inconsistencies in the use of translated materials. CONCLUSIONS: Ensuring access to formal interpreters during all shifts, translation of materials into the patient/caregiver's language, and access to in-person/virtual services would improve quality of care for LEP patients. PRACTICE IMPLICATIONS: Current laws require use of interpreters, but do not provide for their reimbursement, resulting in suboptimal use. Reimbursement for interpreter services may increase their availability.

Design, implementation, and evaluation of a pharmacist-led outpatient benzodiazepine-tapering clinic.

BACKGROUND: Benzodiazepines are commonly used among older adults, despite well-known risks. Clinical pharmacists can lead tapering efforts, leveraging their clinical expertise and relieving time-pressured primary care providers. OBJECTIVES: The objective of this study is to describe the design, implementation, and evaluation of an outpatient pharmacist-led benzodiazepine-tapering clinic. PRACTICE DESCRIPTION: The clinic is based within a community medical group associated with a large academic health system in Los Angeles, California. PRACTICE INNOVATION: The clinic is staffed by clinical pharmacists and supervised by a psychiatrist. The initial visit consists of patient education, design of patient-driven tapering schedule, and medical history review. Follow-up phone/video visits are used to monitor withdrawal symptoms and provide support. EVALUATION METHODS: We used chart review to assess tapering status among those enrolled in the tapering clinic versus those who did not enroll. We compared outcomes across the 2 groups using bivariate statistics. RESULTS: From March 2017 to May 2019, 176 patients were referred to the clinic; 17 were deemed ineligible. Of the 159 patients contacted, 62 patients enrolled in the clinic; 97 patients did not enroll. Among patients in the clinic, 13 (27%) of patients were tapered down, 29 (60%) completely tapered off, 6 (13%) were unable to taper, and 14 (23%) were in the process of tapering. In contrast, among patients who did not enroll, 3 (4%) of patients were tapered down, 15 (20%) completely tapered off, 57 (76%) were unable to taper, and 22 (22%) were in the process of tapering. Ninety percent of patients had at least some benzodiazepine tapering when enrolled in the clinic compared to 41% among not enrolled in the clinic (P<0.001). CONCLUSION: A pharmacist-led benzodiazepine-tapering clinic can be an effective way to engage patients motivated to taper down. Lessons learned include the importance of ensuring referring providers adequately counsel patients prior to referral.

Geriatric fracture program centering age-friendly care associated with lower length of stay and lower direct costs.

OBJECTIVE: To evaluate outcomes associated with an integrated inpatient and outpatient program aimed at optimizing the care of geriatric fracture patients in a mixed community and academic health system setting. DATA SOURCES AND STUDY SETTING: This study took place at a tertiary-care, 886-bed hospital system. The Geriatric Fracture Program (GFP) was designed in 2018 using the 4Ms Framework (What Matters, Medication, Mentation, and Mobility). Patients ≥65 years old with non-spine fractures managed by orthopedic faculty surgeons and participating hospitalist groups were included. A fracture liaison team educated patients regarding bone health and ensured ambulatory geriatrics follow-up. Outpatient geriatric visits focused on mobility, fall risk, bone health imaging, and medications. STUDY DESIGN: We compared GFP-enrolled patients (n = 746) to patients seen by non-GFP-participating physicians (n = 852) and used a generalized estimating equations approach and Poisson models to analyze associations between participation in the GFP program and four inpatient outcomes (time to surgery, length of stay, Vizient length of stay index, and total direct costs). We examined outcomes across all fractures and also stratified them by fracture type (hip vs. non-hip). We descriptively examined post-discharge care outcomes: fall, gait, and balance assessments; bone health imaging; and medications. DATA COLLECTION/EXTRACTION METHODS: We collected data through chart reviews/electronic health record extracts from July 2018 to June 2021. PRINCIPAL FINDINGS: GFP-enrolled patients with all fracture types had a significantly lower length of stay (marginal effect [ME]: -2.12, 95%CI: -2.61, -1.63), length of stay index (ME: -0.33, 95%CI: -0.42, -0.25), and total direct costs (ME: -$5316, 95%CI: -$6806, -$3826); the magnitude of the effects was greater for non-hip fractures. There was no significant difference in time to surgery. Of 746 GFP patients, 170 (23%) had a post-discharge visit with a participating geriatrician ≥6 months. CONCLUSIONS: A systematic approach to improving care for older adults with fractures improved length of stay and total direct costs.

A qualitative dual-site analysis of the pharmacist discharge care (PHARM-DC) intervention using the CFIR framework.

INTRODUCTION: Older adults face several challenges when transitioning from acute hospitals to community-based care. The PHARMacist Discharge Care (PHARM-DC) intervention is a pharmacist-led Transitions of Care (TOC) program intended to reduce 30-day hospital readmissions and emergency department visits at two large hospitals. This study used the Consolidated Framework for Implementation Research (CFIR) framework to evaluate pharmacist perceptions of the PHARM-DC intervention. METHODS: Intervention pharmacists and pharmacy administrators were purposively recruited by study team members located within each participating institution. Study team members located within each institution coordinated with two study authors unaffiliated with the institutions implementing the intervention to conduct interviews and focus groups remotely via telecommunication software. Interviews were recorded and transcribed, with transcriptions imported into NVivo for qualitative analysis. Qualitative analysis was performed using an iterative process to identify "a priori" constructs based on CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation) and to create overarching themes as identified during coding. RESULTS: In total, ten semi-structured interviews and one focus group were completed across both hospitals. At Site A, six interviews were conducted with intervention pharmacists and pharmacists in administrative roles. Also at Site A, one focus group comprised of five intervention pharmacists was conducted. At Site B, interviews were conducted with four intervention pharmacists and pharmacists in administrative roles. Three overarching themes were identified: PHARM-DC and Institutional Context, Importance of PHARM-DC Adaptability, and Recommendations for PHARM-DC Improvement and Sustainability. Increasing pharmacist support for technical tasks and navigating pharmacist-patient language barriers were important to intervention implementation and delivery. Identifying cost-savings and quantifying outcomes as a result of the intervention were particularly important when considering how to sustain and expand the PHARM-DC intervention. CONCLUSION: The PHARM-DC intervention can successfully be implemented at two institutions with considerable variations in TOC initiatives, resources, and staffing. Future implementation of PHARM-DC interventions should consider the themes identified, including an examination of institution-specific contextual factors such as the roles that pharmacy technicians may play in TOC interventions, the importance of intervention adaptability to account for patient needs and institutional resources, and pharmacist recommendations for intervention improvement and sustainability. TRIAL REGISTRATION: NCT04071951 .

Challenges and Successes of Global Deprescribing Networks: A Qualitative Key Informant Study.

The landscape of deprescribing has been rapidly evolving and expanding globally with the formation of regional and national deprescribing networks. The work of these networks is primarily focused on older adults and high-risk medications. The purpose of the current qualitative study is to describe successes and challenges of deprescribing from thought-leaders across the world. Fourteen key informant interviews were conducted from various disciplines, levels of experiences, and regions around the globe. From the interviews, six major themes across two domains were identified: (a) network structure, (b) public perception, (c) policy implications, (d) implementation, (e) challenges, and (f) recommendations. These domains, themes, and insight provided by deprescribing leaders contribute to the advancement of deprescribing networks as global efforts continue to focus on optimizing medication management. Collaboration among interprofessional team members will be critical to the expansion as well as sustainability of this important work. [Journal of Gerontological Nursing, 48(1), 7-14.].

Accessing Patient Electronic Health Record Portals Safely Using Social Credentials: Demonstration Pilot Study.

BACKGROUND: Patient portals allow communication with clinicians, access to test results, appointments, etc, and generally requires another set of log-ins and passwords, which can become cumbersome, as patients often have records at multiple institutions. Social credentials (eg, Google and Facebook) are increasingly used as a federated identity to allow access and reduce the password burden. Single Federated Identity Log-in for Electronic health records (Single-FILE) is a real-world test of the feasibility and acceptability of federated social credentials for patients to access their electronic health records (EHRs) at multiple organizations with a single sign-on (SSO). OBJECTIVE: This study aims to deploy a federated identity system for health care in a real-world environment so patients can safely use a social identity to access their EHR data at multiple organizations. This will help identify barriers and inform guidance for the deployment of such systems. METHODS: Single-FILE allowed patients to pick a social identity (such as Google or Facebook) as a federated identity for multisite EHR patient portal access with an SSO. Binding the identity to the patient's EHR records was performed by confirming that the patient had a valid portal log-in and sending a one-time passcode to a telephone (SMS text message or voice) number retrieved from the EHR. This reduced the risk of stolen EHR portal credentials. For a real-world test, we recruited 8 patients and (or) their caregivers who had EHR data at 2 independent health care facilities, enrolled them into Single-FILE, and allowed them to use their social identity credentials to access their patient records. We used a short qualitative interview to assess their interest and use of a federated identity for SSO. Single-FILE was implemented as a web-based patient portal, although the concept can be readily implemented on a variety of mobile platforms. RESULTS: We interviewed the patients and their caregivers to assess their comfort levels with using a social identity for access. Patients noted that they appreciated only having to remember 1 log-in as part of Single-FILE and being able to sign up through Facebook. CONCLUSIONS: Our results indicate that from a technical perspective, a social identity can be used as a federated identity that is bound to a patient's EHR data. The one-time passcode sent to the patient's EHR phone number provided assurance that the binding is valid. The patients indicated that they were comfortable with using their social credentials instead of having to remember the log-in credentials for their EHR portal. Our experience will help inform the implementation of federated identity systems in health care in the United States.