A deprescribing medication program to evaluate falls in older adults: methods for a randomized pragmatic clinical trial.

BACKGROUND: Opioids and benzodiazepines (BZDs) are some of the most commonly prescribed medications that contribute to falls in older adults. These medications are challenging to appropriately prescribe and monitor, with little guidance on safe prescribing of these medications for older patients. Only a handful of small studies have evaluated whether reducing opioid and BZD use through deprescribing has a positive impact on outcomes. Leveraging the strengths of a large health system, we evaluated the impact of a targeted consultant pharmacist intervention to deprescribe opioids and BZDs for older adults seen in primary care practices in North Carolina. METHODS: We developed a toolkit and process for deprescribing opioids and BZDs in older adults based on a literature review and guidance from an interprofessional team of pharmacists, geriatricians, and investigators. A total of fifteen primary care practices have been randomized to receive the targeted consultant pharmacist service (n = 8) or usual care (n = 7). The intervention consists of several components: (1) weekly automated reports to identify chronic users of opioids and BZDs, (2) clinical pharmacist medication review, and (3) recommendations for deprescribing and/or alternate therapies routed to prescribers through the electronic health record. We will collect data for all patients presenting one of the primary care clinics who meet the criteria for chronic use of opioids and/or BZDs, based on their prescription order history. We will use the year prior to evaluate baseline medication exposures using morphine milligram equivalents (MMEs) and diazepam milligram equivalents (DMEs). In the year following the intervention, we will evaluate changes in medication exposures and medication discontinuations between control and intervention clinics. Incident falls will be evaluated as a secondary outcome. To date, the study has enrolled 914 chronic opioid users and 1048 chronic BZD users. We anticipate that we will have 80% power to detect a 30% reduction in MMEs or DMEs. DISCUSSION: This clinic randomized pragmatic trial will contribute valuable evidence regarding the impact of pharmacist interventions to reduce falls in older adults through deprescribing of opioids and BZDs in primary care settings. TRIAL REGISTRATION: Clinicaltrials.gov NCT04272671 . Registered on February 17, 2020.

Educational Interventions to Improve Advance Care Planning Discussions, Documentation and Billing.

BACKGROUND/OBJECTIVES: To determine the impact of educational interventions, clinic workflow redesign, and quality improvement coaching on the frequency of advance care planning (ACP) activities for patients over the age of 65. DESIGN: Nonrandomized before-and-after study. SETTING: 13 ambulatory care clinics with 81 primary care providers in eastern and central North Carolina. PARTICIPANTS: Patients across 13 primary care clinics staffed by 66 physicians, 8 physician assistants and 7 family nurse practitioners. INTERVENTIONS: Interprofessional, interactive ACP training for the entire interprofessional team and quality improvement project management with an emphasis on workflow redesign. MEASUREMENTS: From July 2017 through June 2018-number of ACP discussions, number of written ACP documents incorporated into the electronic medical record (EMR), number of ACP encounters billed. RESULTS: Following the interventions, healthcare providers were more than twice as likely to conduct ACP discussions with their patients. Patients were 1.4 times more likely to have an ACP document included in their electronic medical record. Providers were significantly (p < 0.05) more likely to bill for an ACP encounter in only one clinic. CONCLUSIONS: Implementing ACP education for all clinic staff, planning for workflow changes to involve the entire interprofessional team and supporting ACP activities with quality improvement coaching leads to statistically significant improvements in the frequency of ACP discussions, the number of ACP documents included in the electronic medical record and number of ACP encounters billed.

A modern-day purgatory: older adults in the emergency department with nonoperative injuries.

Older adults frequently present to the emergency department (ED) with injuries that do not require operative treatment but are sufficiently severe to make it unsafe for them to return home. These individuals typically do not meet criteria for hospital admission, but because of limited reimbursement for observation, admitting physicians are often reluctant to accept these individuals for observation. Admission to a skilled nursing or assisted living facility from the ED or rapid access to additional in-home care is also often difficult or impossible. As a result, older adults with nonoperative injuries often spend a long time in the ED waiting for an appropriate disposition. The challenges of identifying an appropriate disposition for these individuals, the consequences for patients, and some potential solutions to this commonly encountered problem are described.

Development and testing of a decision aid on goals of care for advanced dementia.

OBJECTIVES: Decision aids are effective to improve decision-making, yet they are rarely tested in nursing homes (NHs). Study objectives were to (1) examine the feasibility of a goals of care (GOC) decision aid for surrogate decision-makers (SDMs) of persons with dementia; and (2) to test its effect on quality of communication and decision-making. DESIGN: Pre-post intervention to test a GOC decision aid intervention for SDMs for persons with dementia in NHs. Investigators collected data from reviews of resident health records and interviews with SDMs at baseline and 3-month follow-up. SETTING: Two NHs in North Carolina. PARTICIPANTS: Eighteen residents who were over 65 years of age, had moderate to severe dementia on the global deterioration scale (5, 6, or 7), and an English-speaking surrogate decision-maker. INTERVENTION: (1) GOC decision aid video viewed by the SDM and (2) a structured care plan meeting between the SDM and interdisciplinary NH team. MEASUREMENTS: Surrogate knowledge, quality of communication with health care providers, surrogate-provider concordance on goals of care, and palliative care domains addressed in the care plan. RESULTS: Eighty-nine percent of the SDMs thought the decision aid was relevant to their needs. After viewing the video decision aid, SDMs increased the number of correct responses on knowledge-based questions (12.5 vs 14.2; P < .001). At 3 months, they reported improved quality of communication scores (6.1 vs 6.8; P = .01) and improved concordance on primary goal of care with NH team (50% vs 78%; P = .003). The number of palliative care domains addressed in the care plan increased (1.8 vs 4.3; P < .001). CONCLUSIONS: The decision-support intervention piloted in this study was feasible and relevant for surrogate decision-makers of persons with advanced dementia in NHs, and it improved quality of communication between SDM and NH providers. A larger randomized clinical trial is underway to provide further evidence of the effects of this decision aid intervention.