EVOLV-Rx VA: Evaluating Opportunities to Decrease Low-Value Prescribing in Community Living Centers

Background: More than half of Veterans aged 65 years who reside in Community Living Centers (CLCs) are subject to low-value prescribing, placing them at increased risk of adverse drug events, hospitalization, and death. CLCs represent an ideal setting to safely reduce low-value prescribing; however, no intervention to broadly reduce low-value prescribing has been successfully integrated into routine care or implemented at scale across CLCs. In response, we developed EVOLV-Rx (Evaluating Opportunities to Decrease Low-Value Prescrib- ing), a novel clinical support tool to detect 18 evidence-based and clinically useful low-value prescribing practices in older adults per an expert Delphi panel and further informed by patient, caregiver, and clinician input. Significance: Our objective is to conduct a hybrid study to assess the effectiveness and implementation of an EVOLV-Rx-based intervention to reduce LVP among older Veterans who reside in CLCs in VISN 4. This study will support VA's evolution as a learning healthcare system and is aligned with VA's key strategic healthcare priority of becoming the most age-friendly healthcare system in the United States. It also aligns with two VA HSR topic areas of interest, including improving healthcare quality and value and long-term care and aging. Innovation & Impact: EVOLV-Rx is a novel tool to detect low-value prescribing. Its unique characteristics and automated application will enable pharmacists to provide detailed recommendations to clinicians to prioritize medications for deprescribing with high clinical impact and that may be acceptably deprescribed from the per- spective of patients and caregivers. EVOLV-Rx represents a substantial departure from the status quo, and its use will enhance deprescribing in CLCs and overcome several previously described implementation barriers. Specific Aims: 1) To finalize the adaptable elements of, and implementation playbook for, the EVOLV-Rx inter- vention to reduce low-value prescribing for older Veterans residing in CLCs, 2) To assess the effectiveness of the EVOLV-Rx intervention to reduce low-value prescribing, 3) To evaluate and iteratively improve the implemen- tation of the EVOLV-Rx intervention. Methodology: Using the Theradoc clinical support platform, our intervention is an electronic EVOLV-Rx dash- board used by pharmacists to provide deprescribing recommendations to clinicians to reduce LVP as part of each Veteran's required medication review. Our intervention will be translated into clinical practice in VISN 4 CLCs using a playbook of core implementation strategies previously employed in VA and additional strategies determined by key shareholders to address specific implementation barriers identified as part of the study. In Aim 1, we will conduct focus groups of VISN 4 CLC leaders, clinicians, Veterans, and family caregivers, where we will characterize the patient, clinician, and CLC-level barriers to and facilitators of implementation; and identify and tailor strategies to optimize the intervention's adoption and implementation. In Aim 2, we will conduct a hybrid type 2 effectiveness implementation trial to compare the intervention to usual care, using a stepped wedge de- sign in five VISN 4 CLCs. Our primary effectiveness outcome is the count of low-value prescribing practices per 100 Veterans. In Aim 3, we will conduct an embedded process evaluation to study implementation processes, their impact on outcomes, and iteratively improve the implementation of the intervention. We will also conduct semi-structured interviews of clinicians, Veterans, and family caregivers to characterize the appropriateness, feasibility, acceptability, and perceived effectiveness of the intervention and implementation strategies employed. Next Steps/Implementation: Leveraging VA infrastructure, the commitment of our operational partners, and the deep expertise of our research team, this proposal will result in a scalable intervention and accompanying i Project Number: 1I01HX003849-01A2 | Fiscal Year: 2025 | NIH Institute/Center: Veterans Affairs (VA) | Principal Investigator: Thomas Radomski | Institution: VETERANS HEALTH ADMINISTRATION, PITTSBURGH, PA | Activity Code: I01 | Study Section: HSR-6 Aging and Recovery; Workforce Performance; and Rural Health[HSR6] View on NIH RePORTER: https://reporter.nih.gov/project-details/11100552