Feasibility Study of a Quasi-experimental Regional Opioid Safety Prescribing Program in Veterans Health Administration Emergency Departments.

BACKGROUND: The Veterans Health Administration (VHA) Opioid Safety Initiative (OSI) was implemented in 2013 and was associated with a 25% relative decrease in the dispensing of opioids. Although emergency department (ED) providers play a role in the initiation and continuation of opioids, the incumbent OSI did not target EDs. OBJECTIVE: The goal of this feasibility study was to leverage the existing VHA OSI and test a novel ED-based quality improvement (QI) program to decrease opioid prescribing in multiple ED settings. METHODS: This was a quasi-experimental study of phased-in implementation of a QI ED-based OSI. The general setting for this pilot were four VHA EDs across the Veterans Integrated Services Network (VISN) region 19: Denver, Oklahoma City, Muskogee, and Salt Lake City. We developed and disseminated a dashboard to assess ED-specific prescribing rates and an ED-tailored toolkit to implement the program. Academic detailing pharmacists provided focused audits and feedback with the highest prescribing providers. We measured change in ED-provider prescribing rate of opioids for patients discharged from the ED, by provider and aggregated up to facility level, pre- and postimplementation. RESULTS: Interrupted time-series analysis of provider-level data from the program implementation sites indicated a significant decrease in the trend for proportion of opioid prescriptions relative to the preintervention trend. The results of the analysis suggest that the intervention was associated with accelerating the rate at which ED provider prescribing rates decreased. CONCLUSION: Due to the high volume of patients and the vital role the ED plays in patient treatment and hospital admissions, it is evident that the ED is an important site for QI programs as well as the implementation of opioid safety measures. Given the findings of this pilot, we believe that implementation of a national Veterans Affairs ED OSI implementation is feasible practice.

Improving Transitions of Care for Veterans Transferred to Tertiary VA Medical Centers.

Veterans are often transferred from "spoke" Veterans Administration (VA) clinics or hospitals to "hub" tertiary VA hospitals for advanced inpatient care, but they face significant barriers to safe transitions home. The Transitions Nurse Program was developed as an intervention to address the unique needs of this population. A difference-in-differences (DiD) analysis was used to compare outcomes between 303 veterans enrolled in this program and veterans transferred from the same spoke sites to a second, similar tertiary VA hub. Veterans enrolled in the program had significantly increased rates of follow-up with their primary care clinic within 14 days of discharge (DiD estimate: 10.43%, 95% confidence interval = 1.20 to 19.66), and a trend toward fewer unplanned 30-day readmissions (DiD estimate: -6.9%, 95% confidence interval = -14.2 to 0.31%, P = .06). There were no significant differences in 30-day emergency department visits or costs. Lessons learned from this preliminary intervention can inform implementation at other VA and non-VA sites.

Aldosterone Does Not Predict Cardiovascular Events Following Acute Coronary Syndrome in Patients Initially Without Heart Failure.

BACKGROUND: Aldosterone may have adverse effects in the myocardium and vasculature. Treatment with an aldosterone antagonist reduces cardiovascular risk in patients with acute myocardial infarction complicated by heart failure (HF) and left ventricular systolic dysfunction. However, most patients with acute coronary syndrome do not have advanced HF. Among such patients, it is unknown whether aldosterone predicts cardiovascular risk. METHODS AND RESULTS: To address this question, we examined data from the dal-OUTCOMES trial that compared the cholesteryl ester transfer protein inhibitor dalcetrapib with placebo, beginning 4 to 12 weeks after an index acute coronary syndrome. Patients with New York Heart Association class II (with LVEF <40%), III, or IV HF were excluded. Aldosterone was measured at randomization in 4073 patients. The primary outcome was a composite of coronary heart disease death, nonfatal myocardial infarction, stroke, hospitalization for unstable angina, or resuscitated cardiac arrest. Hospitalization for HF was a secondary endpoint. Over a median follow-up of 37 months, the primary outcome occurred in 366 patients (9.0%), and hospitalization for HF occurred in 72 patients (1.8%). There was no association between aldosterone and either the time to first occurrence of a primary outcome (hazard ratio for doubling of aldosterone 0.92, 95% confidence interval 0.78-1.09, P=0.34) or hospitalization for HF (hazard ratio 1.38, 95% CI 0.96-1.99, P=0.08) in Cox regression models adjusted for covariates. CONCLUSIONS: In patients with recent acute coronary syndrome but without advanced HF, aldosterone does not predict major cardiovascular events. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00658515.