Can Value Champions Reduce Inappropriate Prescribing for People With Dementia?

December 12, 2023 updated by: Kaiser Permanente

Impact Collaboratory Transforming Dementia Care - Can Value Champions Reduce Inappropriate Prescribing for People With Dementia?

The primary objective is to assess the effectiveness of training a clinician to be a 'value champion' within clinical settings to decrease the use of three classes of potentially inappropriate prescription medications (PIMs) among people living with dementia (PLWD). Secondary objectives include determining if the intervention is associated with a reduction in emergency department (ED) visits or hospitalizations due to a fall, and examining five implementation outcomes: appropriateness, feasibility, fidelity, penetration, and equity.

This study is a pragmatic cluster-randomized trial to test the effectiveness of a primary care clinician value champion for de-implementing PIMs among patients 65 years of age and older with a diagnosis of dementia. Medicare Part D pharmacy claims data will be analyzed at the end of the 12-month intervention for the primary outcome, the medication possession rates (MPR) for three groups of potentially inappropriate medications: antipsychotic medications, benzodiazepines, and hypoglycemic medications (sulfonylureas and insulin). In a similar fashion, a hospital admission, or an emergency department visit for a fall will be assessed at the end of the intervention using Medicare claims data. Finally, the five implementation outcomes will be evaluated at the end of the intervention from notes entered by the value champions in project workbooks.

Primary care clinics within each of the two participating ACOs will be randomized to either the intervention or control arms of the study. Prior to random assignment, the investigators will stratify practices based on high versus low historic prescribing rates. A primary care clinician from each clinic selected for the trial in the intervention arm (n=30 across the two ACOs) will be recruited as a clinician value champion for each intervention clinic. The clinician value champion will participate in twice monthly value champion web-based training sessions for six months and then launch a 12-month initiative within the clinician value champions' clinics to reduce PIM prescribing among PLWD. Study outcomes will be assessed 12 months after the clinician value champions launch the initiative.

The hypothesis is that for each medication class, the intervention will produce clinically relevant decreases in mean possession rates of 10% of a standard deviation in patients seen in intervention clinics compared to those who are seen in control group clinics.

Study Overview

Detailed Description

Background on Condition, Disease, or Other Primary Study Focus:

For people living with dementia (PLWD) the overuse of Potentially Inappropriate Medications (PIMs), those for which the potential for harm outweighs benefit, remains a persistent problem despite evidence-based guidelines supporting de-adoption. A group of geriatric experts convened by the Choosing Wisely initiative identified three classes of PIMs for PLWD: antipsychotics, benzodiazepines, and hypoglycemics (sulfonylureas and insulin) with adequate glycemic control. In a systematic review the prevalence of PIMs when cognitive impairment was reported ranged from 20.6% to 80.5%. Approximately 14.3% of Medicare Part D enrollees with dementia residing in the general community are prescribed an antipsychotic. The prevalence of potentially inappropriate benzodiazepine prescriptions has been reported to be as high as 20% among elderly persons with dementia living in the community. The proportion of elderly patients with an A1c < 7% who received a prescription for sulfonylurea, insulin or combined insulin and sulfonylurea therapies was 35.2%, 24.2% and 16.3% respectively and was as prevalent in those with dementia as in those without. Park and colleagues compared rates of prescribing low-value medications in the elderly from 2006-2015 in both traditional Medicare and Medicare Advantage. Not only was there no difference in rates between the two groups, there was also no evidence of any decline in rates of prescribing over time, including use of benzodiazepines in PLWD.

Study Rationale:

The rationale for decreasing the use of PIMs is that use in this population of patients results in a greater likelihood of harm than benefit. Documented harms in the medical literature includes falls, worsening cognitive impairment, hospital admission, functional impairment, and death.

Name and Description of the Intervention:

One clinician value champion from each clinic randomized to the intervention arm will complete a value champion training program led by the P.I. and then implement care redesign activities in the clinical practice setting to reduce the use of low value prescribing in older adults with dementia. The 6-month training phase will consist of twice monthly web-based training sessions. A recently completed Robert Wood Johnson Foundation (RWJF)-funded Value Champion Fellowship program resulted in the development of a training curriculum comprised of 10 learning modules for the training phase of the intervention and a project workbook to guide clinician value champions during the 12-month project phase. Following the 6 months of training, clinician value champions will participate in a monthly 1-hour shared learning sessions via video conference to share successes, challenges, and brainstorm solutions for 12 months (months 10-22 of the study). The investigators will invite former value champion fellows and faculty from the RWJF fellowship to participate in these meetings to support this new cohort of value champions.

Study Type

Interventional

Enrollment (Actual)

2147

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

    • Washington
      • Seattle, Washington, United States, 98101
        • Kaiser Permanente Washington Health Research Institute
        • Contact:
        • Contact:
        • Principal Investigator:
          • Michael Parchman, MD

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

65 years and older (Older Adult)

Accepts Healthy Volunteers

No

Description

Inclusion Criteria - clinician practices:

  • Clinical practices with 3 or more primary care providers (defined as a primary care physician (specialty code of 08 or 11), nurse practitioner (specialty code = 50) or physician's assistant (specialty code = 97), and
  • Clinical practices with clinical encounters with 10 or more Medicare beneficiaries with Alzheimer's or Alzheimer's related dementia in the base years (2019-2020).

Inclusion Criteria - Medicare beneficiaries:

  • Seen by a clinician at a participating practice as evidenced by one or more evaluation and management claim,
  • Continuous coverage in Medicare Parts A, B and D and no months of Part C (Medicare Advantage),
  • Two or more claims with an International Statistical Classification of Diseases (ICD-10) diagnosis for Alzheimer's or Alzheimer's related dementia 30 days apart or 1 inpatient stay with a principal diagnosis of Alzheimer's.

Exclusion Criteria- Medicare beneficiaries:

  • Medicare beneficiaries with a diagnosis of metastatic cancer or
  • Medicare beneficiaries enrolled in hospice any time in the 6 months before the start of the intervention

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Value Champion Training Program
Intervention arm.
Clinicians from primary care clinic sites randomized to the intervention arm of the study will complete a 6-month clinician value champion training program by participating in a series of 12 web-based training sessions. No intervention will be conducted at clinics in the control arm.
Active Comparator: Standard Care
Control group.
Usual clinical care - no value champion present at this clinical setting

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Medication Possession Ratio for any medication in these three classes: antipsychotics, benzodiazepines, or hypoglycemic medication (sulfonylureas or insulin).
Time Frame: 1 year
The Medication Possession Ratio is calculated from Medicare Part D claims data as quotients with denominator equal to the length of the quarter and the numerators equal to the days supply for prescriptions within the medication class filled during the quarter, plus excess days-supply from the previous period minus excess days-supply remaining at the end.
1 year

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Number of Emergency Department or Hospitalizations attributed to a fall.
Time Frame: Every 3 months for 18 months
The presence of fall in the 'reason for visit' code on Emergency Department or inpatient visit as indicated by a clinician bill (Medicare art B claims data).
Every 3 months for 18 months
Proportion of stakeholders identified by clinician champions as opponents of their improvement project - recoded in Stakeholder log.
Time Frame: 12 months
This is a measure of Appropriateness. The clinician champions will record stakeholders and whether they are opponents of the improvement project in the Stakeholder Log.
12 months
Number of milestones completed by the clinician champions during the "design and implement" phase of their improvement project- recorded in the Value Champions Project Workbook
Time Frame: 12 months
This is a measure of Feasibility, defined as "…the extent to which a new innovation, can be successfully used or carried out within a given agency or setting." "Design and Implement" milestones are recorded by clinician champions in the Value Champions Project Workbook: Test and Implement section/ milestones.
12 months
Total Number of Milestones achieved by each clinician champion during their improvement project. - Recorded in Value Champions Project Workbook.
Time Frame: 12 months
This is our measure of fidelity, defined as "…the degree to which an intervention was implemented as it was prescribed in the original protocol." Milestone achievement is recorded by clinician champions in the Value Champions Project Workbook. (The workbook is broken into sections by phases of work, and each section has a list of milestones to achieve.)
12 months
Total number of stakeholders engaged by each clinician champion within their clinic. - recorded in Stakeholder Log.
Time Frame: 12 months
This is our measure of penetration, defined as "…the integration of a practice within a service setting and its subsystems."
12 months
Number of equity related milestones achieved by each clinician champion during their project. Recorded in the Value Champions Project Workbook.
Time Frame: 12 months
This is our measure of Equity, defined as "…proactive tailoring of de-implementation strategies to address healthcare inequities and unintended consequences for vulnerable populations." Milestones are recorded by clinician champions in the Value Champions Project Workbook, and several of the milestones throughout the sections are related to equity.
12 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Investigators

  • Principal Investigator: Lorella Palazzo, PhD, Kaiser Permanente

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

August 30, 2023

Primary Completion (Actual)

October 31, 2023

Study Completion (Actual)

October 31, 2023

Study Registration Dates

First Submitted

March 14, 2022

First Submitted That Met QC Criteria

April 28, 2022

First Posted (Actual)

May 4, 2022

Study Record Updates

Last Update Posted (Estimated)

December 13, 2023

Last Update Submitted That Met QC Criteria

December 12, 2023

Last Verified

December 1, 2023

More Information

Terms related to this study

Keywords

Other Study ID Numbers

  • FY21_Demo2_Parchman
  • 5U54AG063546-03 (U.S. NIH Grant/Contract)

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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