BACKGROUND/RATIONALE:
Roughly 1.5 million preventable adverse drug events occur in the US annually at a cost in excess of $4 billion. Many of these events result from inappropriate prescribing and efforts to improve prescribing practices would have a major impact on outcomes. This is particularly true for the many older adult veterans who suffer from multiple comorbid conditions and require complex medication regimens. The ability to improve prescribing depends on valid methods for measuring medication appropriateness.

OBJECTIVE(S):
The goal of this CDA-2 award was to build the applicant's methodological skills in several key areas related to the development of prescribing quality indicators. A series of incremental studies was conducted to examine the frequency and validity of these measures, and used to develop an investigator-initiated grant to determine the utility of an automated triage algorithm for targeting clinical pharmacy services.

METHODS:
The career development goals of this CDA were to develop expertise in the following areas: 1) theoretical frameworks and practical approaches to health care quality measurement; 2) advanced biostatistics and multivariable risk adjustment methods; 3) instrumental variable methods for addressing selection bias in observational studies; 4) grantsmanship and scientific writing; and 5) intervention research design and implementation.

Research Aim 1 used national VA data from 2003 to 2012 to determine the prevalence and incidence of a selected panel of prescribing quality indicators, including drugs to avoid, drug-drug interactions, therapeutic duplication, and noncompliance. Aim 2 identified sources of variation in prescribing quality indicator violations, with variables selected according to a conceptual framework based on the Donabedian quality model of structure, process and outcome. Aim 3 compared the performance of prevalence and incidence-based prescribing quality indicators in predicting adverse outcomes, adjusting for patient complexity using traditional multivariable regression and propensity scores approaches. Aim 4 determined the impact of selection bias on the relationship between prescribing quality indicators and adverse health outcomes using instrumental variable methods.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
We anticipate the results of this study will have three specific impacts. First, our findings provide a detailed characterization of prescribing quality in VA across multiple clinical domains, over time, and between regions and facilities. Second, we have established a methodological framework for examining the validity of prescribing quality in VA, with a particular emphasis on incident prescribing events, as opposed to prevalent events. Most importantly, these findings were used to inform the development of a healthcare informatics tool called the Triage Algorithm for PACT Pharmacy Services (TAPPS). TAPPS was designed to help PACT pharmacists efficiently target primary care patients most likely to benefit from clinical pharmacy series. The effectiveness of this tool is currently being studied in an HSR&D funded Merit grant.

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External Links for this Project

NIH Reporter

Grant Number: IK2HX000761-01A1
Link: https://reporter.nih.gov/project-details/8275333

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PUBLICATIONS:

Journal Articles

1. Abrams TE, Lund BC, Bernardy NC, Friedman MJ. Aligning clinical practice to PTSD treatment guidelines: medication prescribing by provider type. Psychiatric services (Washington, D.C.). 2013 Feb 1; 64(2):142-8. [view]
2. Goedken AM, Lund BC, Cook EA, Schroeder MC, Brooks JM. Application of a framework for determining number of drugs. BMC research notes. 2016 May 13; 9(1):272. [view]
3. Mosher HJ, Lund BC, Kripalani S, Kaboli PJ. Association of health literacy with medication knowledge, adherence, and adverse drug events among elderly veterans. Journal of Health Communication. 2012 Dec 12; 17 Suppl 3:241-51. [view]
4. Lund BC, Steinman MA, Chrischilles EA, Kaboli PJ. Beers criteria as a proxy for inappropriate prescribing of other medications among older adults. The Annals of pharmacotherapy. 2011 Nov 1; 45(11):1363-70. [view]
5. Lund BC, Abrams TE, Bernardy NC, Alexander B, Friedman MJ. Benzodiazepine prescribing variation and clinical uncertainty in treating posttraumatic stress disorder. Psychiatric services (Washington, D.C.). 2013 Jan 1; 64(1):21-7. [view]
6. Goodson AB, Cantrell MA, Shaw RF, Lund BC. Comparative Effectiveness of Anticholinergic Agents for Lower Urinary Tract Symptoms. Journal of managed care & specialty pharmacy. 2018 Jan 1; 24(1):65-72. [view]
7. Lund BC, Bernardy NC, Alexander B, Friedman MJ. Declining benzodiazepine use in veterans with posttraumatic stress disorder. The Journal of clinical psychiatry. 2012 Mar 1; 73(3):292-6. [view]
8. Lund BC, Bernardy NC, Alexander B, Friedman MJ. Dr. Lund and colleagues reply. The Journal of clinical psychiatry. 2013 Aug 1; 74(8):852-3. [view]
9. Alexander B, Lund BC, Bernardy NC, Christopher ML, Friedman MJ. Early discontinuation and suboptimal dosing of prazosin: a potential missed opportunity for veterans with posttraumatic stress disorder. The Journal of clinical psychiatry. 2015 May 1; 76(5):e639-44. [view]
10. Lund BC, Schroeder MC, Middendorff G, Brooks JM. Effect of hospitalization on inappropriate prescribing in elderly Medicare beneficiaries. Journal of the American Geriatrics Society. 2015 Apr 1; 63(4):699-707. [view]
11. Billingsley-Marshall RL, Basso MR, Lund BC, Hernandez ER, Johnson CL, Drevets WC, McKee PA, Yates WR. Executive function in eating disorders: the role of state anxiety. The International Journal of Eating Disorders. 2013 May 1; 46(4):316-21. [view]
12. Bernardy NC, Lund BC, Alexander B, Jenkyn AB, Schnurr PP, Friedman MJ. Gender differences in prescribing among veterans diagnosed with posttraumatic stress disorder. Journal of general internal medicine. 2013 Jul 1; 28 Suppl 2:S542-8. [view]
13. Abrams TE, Lund BC, Alexander B, Bernardy NC, Friedman MJ. Geographical diffusion of prazosin across Veterans Health Administration: Examination of regional variation in daily dosing and quality indicators among veterans with posttraumatic stress disorder. Journal of rehabilitation research and development. 2015 Sep 1; 52(5):619-27. [view]
14. Meyer HE, Lund BC, Heintz BH, Alexander B, Egge JA, Livorsi DJ. Identifying Opportunities to Improve Guideline-Concordant Antibiotic Prescribing in Veterans with Acute Respiratory Infections or Cystitis. Infection control and hospital epidemiology. 2017 Jun 1; 38(6):724-728. [view]
15. Lund BC, Carrel M, Gellad WF, Chrischilles EA, Kaboli PJ. Incidence- Versus Prevalence-Based Measures of Inappropriate Prescribing in the Veterans Health Administration. Journal of the American Geriatrics Society. 2015 Aug 1; 63(8):1601-7. [view]
16. Bernardy NC, Lund BC, Alexander B, Friedman MJ. Increased polysedative use in veterans with posttraumatic stress disorder. Pain medicine (Malden, Mass.). 2014 Jul 1; 15(7):1083-90. [view]
17. Lund BC, Bernardy NC, Vaughan-Sarrazin M, Alexander B, Friedman MJ. Patient and facility characteristics associated with benzodiazepine prescribing for veterans with PTSD. Psychiatric services (Washington, D.C.). 2013 Feb 1; 64(2):149-55. [view]
18. Patterson BJ, Solimeo SL, Stewart KR, Rosenthal GE, Kaboli PJ, Lund BC. Perceptions of pharmacists' integration into patient-centered medical home teams. Research in social & administrative pharmacy : RSAP. 2015 Jan 1; 11(1):85-95. [view]
19. Lund BC, Charlton ME, West AN. Pharmacy use by dual-eligible non-elderly veterans with private healthcare insurance. BMC health services research. 2016 Sep 23; 16(1):515. [view]
20. Mosher HJ, Hofmeyer BA, Hadlandsmyth K, Richardson KK, Lund BC. Predictors of Long-Term Opioid Use After Opioid Initiation at Discharge From Medical and Surgical Hospitalizations. Journal of hospital medicine. 2018 Apr 1; 13(4):243-248. [view]
21. Barnett ER, Bernardy NC, Jenkyn AB, Parker LE, Lund BC, Alexander B, Friedman MJ. Prescribing clinicians' perspectives on evidence-based psychotherapy for posttraumatic stress disorder. Behavioral sciences (Basel, Switzerland). 2014 Oct 21; 4(4):410-22. [view]
22. Lund BC, Abrams TE, Gravely AA. Rebuttal to Gravely et al. Validity of PTSD diagnoses in VA administrative data: comparison of VA administrative PTSD diagnoses to self-reported PTSD Checklist scores. J Rehabil Res Dev. 2011; 48(1):21-30. Available from: http://www.rehab.research.va.gov/jour/11/481/pdf/gravely.pdf. Journal of rehabilitation research and development. 2011 Dec 7; 48(5):vii-ix. [view]
23. Lund BC, Charlton ME, Steinman MA, Kaboli PJ. Regional differences in prescribing quality among elder veterans and the impact of rural residence. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2012 Aug 27; 29(2):172-9. [view]
24. Hadlandsmyth K, Vander Weg MW, McCoy KD, Mosher HJ, Vaughan-Sarrazin MS, Lund BC. Risk for Prolonged Opioid Use Following Total Knee Arthroplasty in Veterans. Journal of Arthroplasty. 2018 Jan 1; 33(1):119-123. [view]
25. Moga DC, Carnahan RM, Lund BC, Pendergast JF, Wallace RB, Torner JC, Li Y, Chrischilles EA. Risks and benefits of bladder antimuscarinics among elderly residents of Veterans Affairs Community Living Centers. Journal of The American Medical Directors Association. 2013 Oct 1; 14(10):749-60. [view]
26. Patterson BJ, Kaboli PJ, Tubbs T, Alexander B, Lund BC. Rural access to clinical pharmacy services. Journal of the American Pharmacists Association : JAPhA. 2014 Sep 1; 54(5):518-25. [view]
27. Mosher HJ, Richardson KK, Lund BC. Sedative Prescriptions Are Common at Opioid Initiation: An Observational Study in the Veterans Health Administration. Pain medicine (Malden, Mass.). 2018 Apr 1; 19(4):788-792. [view]
28. Mosher HJ, Richardson KK, Lund BC. The 1-Year Treatment Course of New Opioid Recipients in Veterans Health Administration. Pain medicine (Malden, Mass.). 2016 Jul 1; 17(7):1282-1291. [view]
29. Lund BC, Ernst ME. The comparative effectiveness of hydrochlorothiazide and chlorthalidone in an observational cohort of veterans. Journal of clinical hypertension (Greenwich, Conn.). 2012 Sep 1; 14(9):623-9. [view]
30. Mosher HJ, Krebs EE, Carrel M, Kaboli PJ, Weg MW, Lund BC. Trends in prevalent and incident opioid receipt: an observational study in Veterans Health Administration 2004-2012. Journal of general internal medicine. 2015 May 1; 30(5):597-604. [view]

Journal Other

1. Lund BC. Adverse drug events in older adults: will risk factor algorithms translate into effective clinical interventions? [Editorial]. Expert review of clinical pharmacology. 2011 Nov 1; 4(6):655-7. [view]

Conference Presentations

1. Lund BC, Kaboli PJ. Adverse Outcomes of High Risk Medication in Older Adult Veterans. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA. [view]
2. Lund BC. Adverse Outcomes of Polysedative Use in Veterans with PTSD. Paper presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 27; Denver, CO. [view]
3. Abrams T, Lund BC, Alexander B, Bernardy N, Friedman M. Dissemination of Prazosin use for PTSD in the Veterans Health System. Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 4; Miami, FL. [view]
4. Lund BC, Vaughan-Sarrazin MS, Katz DA. Lack of Continuity in VA Primary Care Predicts Lapses in Prescribing Quality. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 17; National Harbor, MD. [view]
5. Lund BC. Rural Access to Clinical Pharmacy Services. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 9; San Diego, CA. [view]
6. Lund BC, Ernst ME. The Comparative Effectiveness of Chlorthalidone versus Hydrochlorothiazide Veterans: Nurse Attitudes and Performance. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD. [view]
7. Mosher HJ, Richardson KK, Lund BC. The One Year Treatment Course of New Opioid Recipients in Veterans Health Administration. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2016 May 11; Hollywood, FL. [view]
8. Abrams T, Richardson KK, Lund BC. Variations in Pharmacotherapy Associated with a Diagnosis of PTSD. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD. [view]

DRA: Health Systems Science
DRE: Prevention, Technology Development and Assessment
Keywords: none
MeSH Terms: none