Nearly 3/4 of all older Veterans evaluated in VA emergency departments (EDs) are treated and released, often with prescriptions for one or more new medications. In a chart review performed at a single VAMC, problems with the quality of ED discharge medications were associated with a 32% increased risk of repeat ED visits, hospitalizations or death. There is a need to develop methods to examine the quality of ED discharge medications on a national level within VHA.
The specific aims of this pilot study were: (1) to construct and validate a national VHA dataset for identifying treat and release ED visits and ED discharge medications; and (2) to examine the feasibility of measuring the quality of ED discharge medications in a nationally representative cohort of Veterans.
The dataset was constructed by: (1) identifying all eligible Veterans aged 65 and older with a VAMC ED visit; (2) drawing a random sample of the cohort from each VAMC; and (3) extracting demographic, clinical and utilization data for these Veterans. Data were drawn from 4 national VHA sources for FY07 and FY08. Medical records were reviewed for 600 Veterans to document ED disposition (treated and released or admitted to the hospital) and ED discharge medications in order to perform validation of these measures in the constructed dataset. NCQA's HEDIS quality measures related to pharmacotherapy in older adults were applied to the ED discharge medications identified in the constructed dataset.
We assembled a nationally representative sample of 42,808 older Veterans (mean age 75.6 years) who visited one of 102 VAMC EDs between 10/1/07 and 6/30/08. In the validation subsample of 600, ED disposition was correctly classified in 94.7% of cases in the constructed dataset (compared to chart abstraction). Reasons for misclassification were: nurse only visit or telephone encounter (59%), no provider note (31%), released from ED but returned and admitted the same day (9%). Among Veterans who were treated and released, ED discharge medications were correctly classified in 77.8% of cases. Sources of error are currently being analyzed. We applied quality measures to the constructed cohort and found that among Veterans prescribed ED discharge medications, 11% received at least one drug considered high risk for elderly patients.
This pilot study generated validated methodology for identifying treat and release ED visits and ED discharge medications, as well as preliminary data about the prevalence of medication quality problems in this population. These data and methods will be used in further research to examine the association between ED medication quality problems and adverse health outcomes among older Veterans. The long-term goal of this program of research is to develop strategies to improve ED discharge pharmacotherapy and, ultimately, the health of older Veterans who receive care in VAMC EDs.
- Hastings SN, Smith VA, Weinberger M, Schmader KE, Olsen MK, Oddone EZ. Emergency department visits in Veterans Affairs medical facilities. The American journal of managed care. 2011 Jun 1; 17(6 Spec No.):e215-23.
- Hastings SN. Emergency Department Discharge Information: What is Provided and Do Patients Understand? Poster session presented at: American Geriatrics Society Annual Meeting; 2011 May 12; National Harbor, MD.
- Hastings SN. Older Veterans Treated and Released from VAMC Emergency Departments. Paper presented at: American Geriatrics Society Annual Meeting; 2011 May 12; National Harbor, MD.
- Hastings SN, Smith V, Weinberger M, Schmader K, Olsen MK, Oddone EZ. Emergency Department Discharge Information: What is provided and do patients understand. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD.
- Hastings SN, Stechuchak KM, Schmader K, Weinberger M, Oddone EZ. Older Veterans treated and released from VAMC Emergency Departments. Poster session presented at: VA HSR&D Career Development Annual Meeting; 2011 Feb 16; National Harbor, MD.