Characterizing the Quality of Evidence-based Prescribing for Hospitalized Veterans

About This Grant

Significance to VA: Each year, hundreds of thousands of Veterans are hospitalized for new presentations and acute exacerbations of complex chronic conditions, such as cardiovascular, pulmonary, neurologic, and substance use disorders. For each of these conditions, there are medications with strong evidence for improving clinical outcomes when taken long-term. Use of evidence-based, long-term medications following hospitalization is often deficient, with disparities observed in prescribing by race, ethnicity, rurality, and socioeconomic status. To date, no studies have systematically assessed the quality and equity of evidence-based prescribing at hospital discharge, a critical time to initiate guideline-recommended care. The objectives of this proposal are to detect and understand determinants of quality and equity of prescribing for hospitalized Veterans and to identify evidence-based strategies to improve prescribing. This research has been developed in partnership with the National Hospital Medicine Program, Office of Health Equity, and Center for Medication Safety and aligns with HSR priorities to apply Learning Health Systems foundational methods to achieve the VA Quintuple Aims of improving outcomes and ensuring equity. Innovation and Impact: The proposal is innovative in three ways. First, this research moves beyond disease- specific silos to examine evidence-based prescribing as a cross-cutting concept for hospitalized Veterans. Second, this research evaluates prescribing quality with an explicit health equity lens and employing a novel pharmacoequity framework. Third, it will use a complementary set of rigorous health services research methods to understand the underlying mechanisms for gaps in the quality and equity of prescribing and develop strategies with stakeholders to close gaps. This proposal will provide hospital-specific metrics to frontline clinicians and administrators to guide quality improvement efforts to advance inpatient prescribing quality and equity. Specific Aims: Aim 1: To examine the association of sociodemographic factors with receipt of evidence-based medications at hospital discharge. Aim 2: To determine mechanisms by which Veterans do not receive evidence- based medications at hospital discharge. Aim 3: To identify stakeholder perceptions of hospital prescribing performance and barriers to and facilitators of discharge prescribing quality and equity. Methodology: Aim 1 will be a retrospective cohort study using electronic health record data from the VA Corporate Data Warehouse to assess national and hospital-level rates of evidence-based medication use for Veterans hospitalized from 2022 and 2024 for five common complex chronic conditions: alcohol use disorder, atrial fibrillation, cerebrovascular disease, chronic obstructive pulmonary disease, and heart failure. Aim 2 will be a chart review study of a sample of 1,000 Veterans identified in Aim 1 as not receiving evidence-based medications at hospital discharge, oversampling for sociodemographic groups with the largest disparities in care. Aim 3 will be a qualitative study of 75 semi-structured interviews with inpatient clinicians and VA hospital leaders to identify barriers to and facilitators of equitable, high-quality discharge prescribing, recruiting from VA hospitals that are high and low performing (by quality and equity metrics) based upon Aim 1 results. Path to Translation/Implementation: This project will yield critical evidence to guide research and quality improvement efforts to equitably improve care delivery for hospitalized Veterans. The sum impact of this proposal will be the foundational data needed to initiate a Learning Health System Translation-to-Policy Learning Cycle to urgently transform current prescribing practices and test the implementation of data-informed strategies to improve hospital discharge prescribing quality and equity. Findings from all aims will be synthesized and reviewed with Operations partners, Veterans, and a longitudinal Expert Stakeholder Panel of frontline hospital- based clinicians to inform the co-design of implementation strategies to increase prescribing of evidence-based therapies for hospitalized Veterans that will be studied in future QUERI and Merit proposals.