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Health Services Research & Development

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2012 HSR&D/QUERI National Conference Abstract

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2012 National Meeting

1040 — Facility-Level Variation in the Quality of Prescribing for Older Veterans

Gellad WF, and Good CB, Pittsburgh VA Medical Center; Amuan ME, Edith Nourse Rogers Memorial Veterans Hospital; Marcum ZA, and Hanlon JT, Pittsburgh VA Medical Center; Pugh MJ, South Texas Veterans Healthcare System;

Objectives:
The National Committee for Quality Assurance (NCQA) developed two measures of potentially inappropriate prescribing: exposure to high-risk medications in the elderly (HRME) and drug-disease interactions (Rx-DIS). Both HRME and Rx-DIS exposures are prevalent in Veterans Affairs (VA) facilities, but the extent to which they vary by facility is unknown. We describe facility-level variation in these quality measures and identify facility characteristics associated with high-quality prescribing.

Methods:
We obtained inpatient, outpatient, and pharmacy data for years 2005-2006 for all Veterans who were 65 or older and had at least one inpatient or outpatient visit in both years (n = 2,023,477). We identified a sub-sample of individuals (n = 305,059) with a history of falls or hip fractures, dementia, or chronic renal failure, which are the three conditions specified by NCQA in which Rx-DIS exposures are examined. Our primary outcomes were the incident use (in 2006) of any high-risk medication (iHRME) and incident drug-disease interactions (iRx-DIS). We used multivariable logistic regression models and hierarchical models to obtain facility rates of iHRME and iRx-DIS exposure adjusting for differences in patient characteristics across facilities and to examine facility predictors of iHRME and iRx-DIS exposure.

Results:
Overall, 94,692 (4.7%) Veterans had iHRME exposure. At the facility level, iHRME exposure ranged from 1.56% at the lowest facility to 12.76% at the highest (median 4.73%). In the sub-sample, 9,803 (3.2%) Veterans had iRx-DIS exposure, with a facility-level range from 1.30% to 5.85% (median 3.21%). In adjusted analyses, patients seen in facilities with formal geriatric education had lower odds of iHRME (OR = 0.86, 95%CI = 0.77-0.96) and iRx-DIS (OR = 0.95, 95%CI = 0.88-1.01). Patients seen in facilities caring for fewer older patients had greater odds of iHRME (OR = 1.54, 95%CI = 1.35-1.75) and iRx-DIS (OR = 1.22, 95%CI = 1.11-1.33).

Implications:
Substantial variation in the quality of prescribing for older adults exists across VA facilities, even after adjusting for patient characteristics. Patients seen in facilities with formal geriatric education and caring for a larger proportion of older patients have higher quality prescribing.

Impacts:
The highest and lowest performing facilities on these HEDIS measures can provide valuable guidance for intervention development to improve prescribing. The implementation of geriatric education programs may be one such intervention.


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