Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

VA Health Systems Research

Go to the VA ORD website
Go to the QUERI website

IIR 17-236 – HSR Study

IIR 17-236
Reducing Potentially Inappropriate Medication Prescribing for Older Patients: Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUIPPED)
Elizabeth Camille Vaughan, MD MS
Atlanta VA Medical and Rehab Center, Decatur, GA
Decatur, GA
George Jackson PhD MHA
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: October 2018 - September 2022


Older Veterans are a vulnerable population at high risk of medication adverse drug events (ADE) especially when they are discharged from the Emergency Department (ED). More than half of older adults discharged from the ED leave with a new prescription medication. Multiple studies show that between 5.6%-13% of prescriptions written for older adults at ED discharge represent a potentially inappropriate medication (PIM). Prescribing new medications for older Veterans outside the setting of primary care increases the opportunity for suboptimal prescribing as well as adverse drug events (ADEs), both major reasons for repeat ED visits, hospitalization or death. In order to inform a Veterans Affairs (VA) system-wide approach to improve prescribing safety for older Veterans, we propose a study to determine best practices for influencing provider prescribing behavior in order to decrease PIMs prescribed for older Veterans at the time of ED discharge. EQUIPPED (Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department) was initially established as an innovative quality improvement initiative designed to reduce PIM prescribing for adults aged 65 years and older. The EQUIPPED QI initiative provides preliminary data supporting this proposal written in response to the Learning Health System Provider Behavior Change RFA. Initially funded by the Office of Geriatrics and Extended Care, the EQUIPPED QI intervention has three components aimed at influencing provider prescribing behavior: a) provider education; b) electronic clinical decision support via specialized geriatric pharmacy order sets at the point of prescribing; and c) academic detailing including audit and feedback and peer benchmarking. EQUIPPED is informed by the Beers Criteria, which indicate drugs that should be avoided in older adults because of the increased risk of ADEs. The Beers Criteria are widely used by government agencies and supported by research in various settings as a marker of prescribing quality. The EQUIPPED QI intervention has been implemented in 10 VA EDs. Results from 4 of the initial EQUIPPED sites with in-person academic detailing demonstrated sustained pre-post improvement (reduction) in PIM prescribing rates by nearly 50% at 6 months, suggesting the possibility of culture change with regard to provider prescribing behavior. The EQUIPPED QI intervention typically involves in-person academic detailing using audit and feedback with peer benchmarking, which is more resource intensive. The VA already uses both passive feedback (i.e. dashboards to report psychotropic medication use in community living center residents) and active feedback (i.e. implementation of a national academic detailing pharmacy program); however, there is little guidance on which strategy is most effective in the ED. In order to inform the optimal EQUIPPED strategy for improving provider prescribing behavior toward older Veterans in ED, we propose a trial comparing EQUIPPED with active provider feedback including academic detailing to EQUIPPED with passive provider feedback using individual electronic reports via a clinical dashboard. In a parallel cluster randomized trial, we will randomize 8 VA facilities to implement EQUIPPED with either passive provider feedback or active provider feedback. Specifically, all sites will implement EQUIPPED components including: didactic education concerning the Beers Criteria; decision support by order sets; and monthly provider prescribing feedback. However, passive provider feedback sites will implement monthly electronic provider feedback via individual prescribing reports using a novel clinical dashboard with audit, feedback and peer benchmarking, while active provider feedback sites will implement one-to-one (1:1) in- person academic detailing that includes in-person audit, feedback, and peer benchmarking and engagement with an on-site champion. In order to inform the eventual dissemination strategy, we will also include formative evaluation and micro-costing of the two methods of implementing provider feedback as part of EQUIPPED.

External Links for this Project

NIH Reporter

Grant Number: I01HX002527-01A1

Dimensions for VA

Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.

Learn more about Dimensions for VA.

VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address.
    Search Dimensions for this project


Journal Articles

  1. Lewinski AA, Crowley MJ, Miller C, Bosworth HB, Jackson GL, Steinhauser K, White-Clark C, McCant F, Zullig LL. Applied Rapid Qualitative Analysis to Develop a Contextually Appropriate Intervention and Increase the Likelihood of Uptake. Medical care. 2021 Jun 1; 59(Suppl 3):S242-S251. [view]
  2. Passey D, Healy R, Qualls J, Hamilton CJ, Tilley E, Burningham Z, Sauer B, Halwani A. Development and implementation of a pharmacist-led telehealth medication management program for veterans receiving oral antineoplastic therapies through the MISSION Act. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2022 May 24; 79(11):835-843. [view]
  3. Friedman DR, Patil V, Li C, Rassmussen KM, Burningham Z, Hamilton-Hill S, Kelley MJ, Halwani AS. Integration of Patient-Reported Outcome Measures in the Electronic Health Record: The Veterans Affairs Experience. JCO clinical cancer informatics. 2022 Feb 1; 6:e2100086. [view]
  4. Burningham Z, Jackson GL, Kelleher J, Stevens M, Morris I, Cohen J, Maloney G, Vaughan CP. The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUIPPED) Potentially Inappropriate Medication Dashboard: A Suitable Alternative to the In-person Academic Detailing and Standardized Feedback Reports of Traditional EQUIPPED? Clinical therapeutics. 2020 Apr 1; 42(4):573-582. [view]
  5. Chien HC, Morreall D, Patil V, Rasmussen KM, Yong C, Li C, Passey DG, Burningham Z, Sauer BC, Halwani AS. Treatment Patterns and Outcomes in a Nationwide Cohort of Older and Younger Veterans with Waldenström Macroglobulinemia, 2006-2019. Cancers. 2021 Apr 4; 13(7). [view]
  6. Burningham Z, Jackson GL, Kelleher JL, Morris I, Stevens MB, Cohen J, Maloney G, Sauer BC, Halwani AS, Chen W, Vaughan CP. Use of a Medication Safety Audit and Feedback Tool in the Emergency Department Is Affected by Prescribing Characteristics. Applied clinical informatics. 2023 Aug 1; 14(4):684-692. [view]
  7. Burningham Z, Chen W, Sauer BC, Richter Lagha R, Hansen J, Huynh T, Patel S, Leng J, Halwani A, Kramer BJ. VA Geriatric Scholars Program's impact on prescribing potentially inappropriate medications. The American journal of managed care. 2019 Sep 1; 25(9):425-430. [view]
  8. Peters CB, Hansen JL, Halwani A, Cho ME, Leng J, Huynh T, Burningham Z, Caloyeras J, Matsuda T, Sauer BC. Validation of Algorithms Used to Identify Red Blood Cell Transfusion Related Admissions in Veteran Patients with End Stage Renal Disease. EGEMS (Washington, DC). 2019 Jul 3; 7(1):23. [view]

DRA: Aging, Older Veterans' Health and Care, Other Conditions
DRE: Prevention, TRL - Development
Keywords: Medication Management, Practice Patterns/Trends
MeSH Terms: None at this time.

Questions about the HSR website? Email the Web Team

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.