provide a reply sample as a DNP student. 300 words. NO AI or plagiarism

tam 

 

Among healthcare providers prescribing medications for adults aged 65 years and older in a primary care clinic (P), how does implementation of the 2023 American Geriatrics Society Beers Criteria through provider education, a clinical decision-making tool, and audit and feedback (I), compared with current prescribing practices (C), affect provider knowledge and adherence to evidence-based prescribing recommendations and reduce potentially inappropriate medications (O) over eight weeks (T)?

1. Objectives for the first week

The primary objective for the first week of implementation was to inform all participating providers about the DNP project and to develop a standard methodology for identifying potentially inappropriate medication use in adults aged 65 years and older. The DNP project objectives included developing a method to improve prescribing practices through incorporation of the 2023 American Geriatric Society Best Practices criteria into the clinic's medication-review process. Education and the distribution of project tools were also priorities for the first week along with administering the preimplementation knowledge survey and initiating the audit and feedback process.

In addition to increasing awareness among providers regarding the differences between polypharmacy and inappropriate polypharmacy, another main priority was to increase providers' awareness that having five or more prescribed medications does not necessarily equate to poor prescribing practices. Multiple medications can be clinically necessary for individuals with many chronic conditions; however, there is an increased likelihood of adverse outcomes due to the cumulative medication burden. Adverse outcomes include drug-drug interactions, drug-disease interactions, therapeutic duplication, medication non-adherence, falls, cognitive decline, and adverse drug reactions. Thus, the focus of the project is on the appropriateness of each medication rather than just counting the number of medications.

The 2023 AGS Beers Criteria update outlines evidence-based recommendations relative to medications that generally should be avoided, medications that may exacerbate specific disease states or syndromes, medications that should be used with caution, clinically significant drug interactions, and medications requiring avoidance or dose adjustment based upon renal function (American Geriatrics Society Beers Criteria update expert panel, 2023). As such, one of the important objectives of Week 1 was to ensure that the providers understand how to utilize the Beers Criteria as a clinical decision support tool rather than a definitive "do not prescribe" criterion.

Other priorities for Week 1 included confirmation of provider participation in the study, protection of participant confidentiality, establishment of a uniform mechanism for analyzing clinical encounters, and ensuring that any activities implemented would not negatively impact the quality of patient care. Since the providers are considered part of the population of interest for the project, no patients were recruited or enrolled in the study. The only identifiable information recorded in the study database would relate to provider prescribing behavior.

2. Activities completed during this week

Prior to the start of the week, I met with the project preceptor and clinic leadership to review the implementation timeline and discuss roles and responsibilities of all stakeholders. During this meeting, we discussed the project schedule, provider education plan, preimplementation survey, clinical decision-making tool, and audit-and-feedback tracking tool. The meeting also allowed me to confirm the procedure for selecting eligible medication management encounters for analysis involving patients aged 65 years and older.

Structured provider education occurred during a previously scheduled clinic time. The educational program introduced clinicians to the clinical implications of polypharmacy and potentially inappropriate medication use in older adults. Clinicians were informed that age-related changes in both pharmacokinetic properties and pharmacodynamic responses to drugs may result in increased susceptibility to various types of adverse effects related to specific classes of drugs. The presentation highlighted common medications that can cause adverse effects in older adults, including centrally acting anti-cholinergics, sedatives/hypnotics, certain types of pain medications, selected diabetes therapies, and medications that may cause falls or bleeding.

Practical patient examples were presented to illustrate the application of the Beers Criteria and assist clinicians in making evidence-based clinical decisions. Clinicians were directed to analyze the reason each medication was ordered; evaluate whether each medication was still medically necessary; assess potential therapeutic duplication; examine possible adverse effects resulting from drug-drug or drug-disease interactions; and consider safer alternative treatments (either pharmacological or non-pharmacological) whenever possible. The educational presentation emphasized that treatment decisions should be individualized and take into account factors including prior treatment responses; life expectancy; patient preferences; patient-specific diagnoses; patient-specific treatment goals; etc.

Following completion of the educational presentation, participating clinicians completed a preimplementation knowledge survey. Study identification codes were assigned to protect participant anonymity and facilitate pairing with subsequent surveys. The surveys were reviewed for completeness. Individual clinician survey results were not disseminated to clinic administrators or other clinicians.

Participating clinicians also received a BEERS criteria-based clinical decision-making tool. This resource was created to provide a simple-to-use tool that can be integrated into typical ambulatory practice encounters. It prompts clinicians to assess the necessity for continued medication therapy; identify potential adverse effects of medication therapy; identify patient-specific considerations for dosing adjustments due to decreased renal function; identify duplicate prescriptions; identify possible harmful drug-drug or drug-disease interactions; identify necessary monitoring requirements; and identify opportunities for either de-prescription or substitution of prescription therapies.

Audit-and-feedback tracking began during this week. Data collected via this tool will include whether a review of the medication list has occurred; whether a potentially inappropriate medication was identified; whether the clinician documented a medical justification for continuation of therapy; and whether any type of intervention was initiated. Interventions may include discontinuing therapy, reducing dosage, substituting one medication with another, increasing monitoring frequency, educating patients about medications, and referring patients for a comprehensive medication review by a specialist pharmacist.

Initial reviews of charts were performed to verify whether the approved variables could be uniformly extracted from clinical documentation. No patient names, medical record numbers, birthdays, or other unique identifiers were captured in the tracking tool. All information collected was maintained under strict confidential procedures outlined within the project protocol.

A recent systematic review demonstrated that polypharmacy and multimorbidity are common among older adults. However, since studies employ varying definitions and samples of populations examined, considerable variability exists across studies (Nicholson et al., 2024). This variability reinforces why it is essential for projects to employ well-defined project measures. For example, while medication count may be informative regarding the description of the quantity of medication usage, quantification is secondary to determination as to whether medications conform to the project-established definition of potentially inappropriate medication utilization.

3. Positive features of this week

Positive features included high levels of enthusiasm among participating clinicians relative to enhancing safety of medication use among older adults. Productive discussions occurred during educational presentations when clinicians presented examples where medications appeared to be contraindicated based on criteria, yet were determined to be medically necessary for their patient. Such discussions supported emphasis on individualized decision-making processes and documentation.

Support from clinic leadership and the project preceptor regarding developmentally supportive approaches toward implementation efforts assisted with facilitating schedules, distributing educational materials, providing access to information necessary for evaluations purposes, and describing the Beer's criteria-based tool as concise and clinically applicable—possibly leading to greater consistency in its use throughout the remaining duration of project implementation.

Additionally, success was achieved regarding dissemination of the preimplementation knowledge survey. Participating clinicians completed the survey without major difficulty. Review of survey items revealed that they were easily understandable. Initial audit findings suggested that most variables studied could be obtained from existing documentation.

4. Unforeseen challenges experienced this week

One unforeseen challenge encountered was that several participating clinicians missed originally scheduled educational sessions due to changes in patient schedules or competing clinical obligations. Educational materials were distributed; however, a follow-up educational session will need to occur so that all participating clinicians receive similar training materials, as well as an opportunity to ask questions.

Unforeseen challenges encountered included variability in documentation related to medication reconciliation. Documentation varied widely depending on the areas where information was located. For example, documentation existed regarding assessments of both the necessity and safety of continued medication therapy; however, some clinical notes simply indicated that the medication list had been reviewed. Due to a lack of supporting rationale, it is unclear whether continuation of a PIM represents intentional clinical decision-making or inadequate review.

Similarly, audit activities took longer than expected because the location of pertinent information within EHRs varied. Identification of an indication for a particular medication often requires reference back to previous notes or a problem list. While these challenges necessitated neither modification nor deviation from approved project protocol, they represented opportunities for improvement in data collection efficiency and consistency.

5. Changes required for next week

During next week I will conduct a brief educational session specifically designed for clinicians who were unable to participate in the initial session. The same educational slides, examples, survey instructions, and decision-support tools will be utilized so that identical material is delivered regardless of timing.

I will emphasize the importance of clinicians documenting rationales for continuing PIMs. Clinicians will be asked to document reasons for continuing PIMs, including whether benefits exceed risks; whether previous alternatives were ineffective or intolerable; and what monitoring plan is being followed. Clinical decisions regarding continuation/discontinuation/substitution/depression of PIMs will not be required by project protocol. Instead, the project will evaluate whether the clinician has acknowledged concern regarding PIMs and made evidence-supported decision.

With regard to improvements in the chart-review process, I intend to assign discrete timeslots for collecting data and specify a consistent sequence for reviewing medication lists, diagnoses, lab values, and clinical documentation. I will collaborate with the project preceptor regarding any uncertain cases without entering patient identifiers into the database. Each week will continue to provide constructive feedback based on aggregate trends rather than individual clinician performance.

6. Practicum Hours

Approximately 12 hours will be spent at the practicum site this week. These site hours will encompass conducting an educational session for clinicians; meeting with clinic leadership and the project preceptor regarding implementation timelines and role assignments; distributing instructional materials; administering the preimplementation knowledge survey; and distributing the clinical decision-making tool based on the 2023 AGS Beers Criteria: conducting chart reviews and data collection; and providing technical assistance and support to participating clinicians.

A total of 18 hours will be reported in the practicum log. These hours consist of 12 hours completed at the practicum site and 6 additional hours dedicated to practicum-related activities outside the site. The additional activities will include meeting with the DNP mentor, preceptor, faculty, or Associate Dean; reviewing the evidence supporting the project; preparing instructional materials; maintaining project documentation; reviewing weekly implementation metrics and procedures; and planning modifications or enhancements for subsequent weeks.

Overall, the first week provided an excellent foundation for the remainder of the eight-week implementation period. Participation/engagement from clinicians, support from clinic leadership/project preceptor, and success in initiating educational/audit processes were notable achievements. Identified site-level scheduling/documentation/workflow issues will serve as the basis for practical adjustments aimed at enhancing implementation fidelity/data validity.

References:

American Geriatrics Society Beers Criteria update expert panel. (2023). American geriatrics society 2023 updated ags beers criteria(r) for potentially inappropriate medication use in older Adults. Journal of the American Geriatrics Society, 71(7), 2052–2081. Doi:10.1111/jgs.18372

Nicholson, K., Liu, W., Fitzpatrick, D., Hardacre, K. A., Roberts, S., Salerno, J., Stranges, S., Fortin, M., & Mangin, D. (2024). Prevalence of multimorbidity and polypharmacy among adults and older adults: a systematic review. The lancet. Healthy longevity, 5(4), e287–e296. https://doi.org/10.1016/S2666-7568(24)00007-2