title: Impact of Clinical Pharmacy Specialists on the Design and Implementation of a Quality Improvement Initiative to Decrease Inappropriate Medications in a Veterans Affairs Emergency Department.
abstract: BACKGROUND
  As the proportion of older adult patients who interface with the health care system grows, clinical pharmacy specialists (CPS) have a pivotal role in reducing potentially inappropriate medication (PIM) use in this population.
  
  
  OBJECTIVE
  To (a) describe CPS involvement in the design and implementation of a quality improvement (QI) initiative to decrease PIM prescribing in a Veterans Affairs (VA) emergency department (ED) and (b) report on changes in PIM prescribing before and after the initiative.
  
  
  METHODS
  Enhancing Quality of Prescribing Practices for Veterans Discharged from the Emergency Department (EQUiPPED) is an ongoing multisite QI project that aims to decrease ED PIM prescribing. We used a mixed-method approach that applied qualitative and quantitative measures in describing the CPS role and evaluating PIM rates. PIMs were defined using the 2012 Beers Criteria. We reported monthly PIM rates in patients aged 65 years and older who were discharged from the ED from January 2012 to November 2014. A piecewise, nonlinear regression model evaluated the pattern in PIM prescriptions over time.
  
  
  RESULTS
  At the Durham, North Carolina, VA Medical Center, a total of 4 CPS were involved with tailoring the design and implementation of the EQUiPPED intervention for local use. CPS input led to 3 key innovations: academic detailing performed by a physician-CPS pair, medication alert messages identifying medications as PIMs in the computerized patient record system, and automated reports describing the frequency and type of PIMs prescribed by each ED provider. Between February 2013 and November 2014, 73 ED providers received the academic detailing. The ED facility experienced a relative reduction of 47.5% in the rate of PIM prescribing over the observation period.
  
  
  CONCLUSIONS
  This QI project resulted in a meaningful decrease in PIM prescribing in older ED adults. CPS contributions to QI can extend beyond pharmacotherapy and provider education to also include information technology tools using formulary management expertise.
authors.affiliation: 1 Assistant Professor of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, and Clinical Pharmacy Specialist, Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina.
authors.forename: Jason M
authors.initials: JM
authors.lastname: Moss
authors.affiliation: 2 Clinical Pharmacy Specialist, Pharmacy Service, Veterans Affairs Medical Center, Durham, North Carolina.
authors.forename: William E
authors.initials: WE
authors.lastname: Bryan
authors.affiliation: 3 Medical Instructor, Duke University School of Medicine, Durham, North Carolina.
authors.forename: Loren M
authors.initials: LM
authors.lastname: Wilkerson
authors.affiliation: 4 Research Health Scientist, Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, and Associate Professor, Duke University School of Medicine, Durham, North Carolina.
authors.forename: George L
authors.initials: GL
authors.lastname: Jackson
authors.affiliation: 2 Clinical Pharmacy Specialist, Pharmacy Service, Veterans Affairs Medical Center, Durham, North Carolina.
authors.forename: Ryan K
authors.initials: RK
authors.lastname: Owenby
authors.affiliation: 5 Associate Professor, Duke University School of Medicine, and Research Scientist, Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, North Carolina.
authors.forename: Courtney
authors.initials: C
authors.lastname: Van Houtven
authors.affiliation: 6 Assistant Professor, Emory University School of Medicine, and Affiliate Investigator, Birmingham/Atlanta Geriatric Research Education and Clinical Center, Atlanta VA Medical Center, Atlanta, Georgia.
authors.forename: Melissa B
authors.initials: MB
authors.lastname: Stevens
authors.affiliation: 7 Associate Clinical Director, Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, and Associate Professor, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: James S
authors.initials: JS
authors.lastname: Powers
authors.affiliation: 8 Assistant Professor, Emory University School of Medicine, and Investigator, Birmingham/Atlanta Geriatric Research Education and Clinical Center, Atlanta VA Medical Center, Atlanta, Georgia.
authors.forename: Camille P
authors.initials: CP
authors.lastname: Vaughan
authors.affiliation: 9 Assistant Professor, Icahn School of Medicine at Mount Sinai, and Associate Director/Clinical (Acting), Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Bronx, New York.
authors.forename: William W
authors.initials: WW
authors.lastname: Hung
authors.affiliation: 9 Assistant Professor, Icahn School of Medicine at Mount Sinai, and Associate Director/Clinical (Acting), Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Bronx, New York.
authors.forename: Ula
authors.initials: U
authors.lastname: Hwang
authors.affiliation: 10 Investigator, Department of Veterans Affairs Birmingham, Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center, and Assistant Professor, University of Alabama School of Medicine at Birmingham.
authors.forename: Alayne D
authors.initials: AD
authors.lastname: Markland
authors.affiliation: 11 Investigator, Department of Veterans Affairs Birmingham, Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Professor and Vice Chairman, Department of Epidemiology; and Director, Biostatistics, Epidemiology and Research Design, Center for Clinical and Translational Science, University of Alabama at Birmingham.
authors.forename: Gerald
authors.initials: G
authors.lastname: McGwin
authors.affiliation: 12 Investigator, Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina; Associate Professor, Duke University School of Medicine; and Investigator, Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, North Carolina.
authors.forename: Susan Nicole
authors.initials: SN
authors.lastname: Hastings
mesh_terms: D000368:Aged; D004636:Emergency Service, Hospital; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control*; D009657:North Carolina; D010607:Pharmacy Service, Hospital; D058996:Quality Improvement; D014728:Veterans