No systematic, automated process for providing feedback to acute care providers exists in the Veterans Health Administration (VHA), despite there being 432,000 acute care visits annually by Veterans seeking acute care via the emergency department (ED), urgent care clinics, or primary care clinics in the VHA. More than 144 million prescriptions are written in these VHA acute care settings each year, many for antibiotics or non-steroidal anti-inflammatory drugs (NSAIDs). More than 30% of acute care prescriptions for antibiotics or NSAIDs are inappropriate and carry associated increased risk of adverse drug events (ADEs) due to lack of patient or comorbidity familiarity, drug-drug interactions, and patient pressure to prescribe. Currently, acute outpatient care providers operate without knowledge of their own prescribing quality or patient outcomes. This absence of feedback creates a vacuum through which providers may falsely assume a positive outcome. Inadequate outcomes feedback and understanding of indications and contraindications to prescribing antibiotics and NSAIDs have hindered improvement in the quality and safety of prescriptions for Veteran in acute care settings. We will use user-centered design to develop a scalable prescribing feedback system that includes audit and feedback, academic detailing, and non-financial incentives, will be implemented to examine how this multifaceted intervention impacts potentially inappropriate prescribing and ADEs in acute outpatient care settings in the VHA. This project describes a mixed-methods proposal that addresses major HSR&D priorities to improve Veteran health and advance the VHA as a learning healthcare system. The Specific Aims are: 1) Evaluate determinants of potentially inappropriate prescribing to design intervention implementation in acute outpatient care settings.; 2) Develop and evaluate a risk-adjusted provider profiling surveillance system; 3) Refine the visual representation of the feedback system with user-centered design; and 4) Examine the impact of implementation of a multifaceted intervention on potentially inappropriate prescriptions and ADEs. The team is uniquely qualified to accomplish these aims, with expertise in healthcare operations research, informatics, human factors engineering and user-centered design, implementation science, qualitative methods, and practicing clinicians in acute care settings (emergency department and primary care). The institutional environment at the VA Tennessee Valley Healthcare System and Vanderbilt University Medical Center is outstanding, including the Geriatric Research, Education and Clinical Center (GRECC), a site for VA Quality Scholars, an innovative qualitative research center; nationally ranked graduate programs in the relevant fields of study; and the national CTSA coordinating center. This application will develop an automated feedback system for acute care providers using antibiotic and NSAID prescribing as two exemplars of the need for acute care provider feedback in the VHA. Taking a user- centered approach by placing the provider at the center of the design process will substantially advance the ability to enhance provider activities through the delivery of scalable feedback using Veteran, provider, and stakeholder input. Advancing the delivery of acute outpatient provider feedback creates a mechanism to improve provider quality and safety, and ultimately to enhance Veteran health.

Every day, thousands of Veterans are treated urgently for unexpected problems. They present to acute outpatient settings such as the emergency department, urgent care clinics, and primary care offices for infectious and pain-related complaints, and in many cases, are treated with antibiotics and non-steroidal anti- inflammatory drugs (NSAIDs). Unfortunately, 30% of these medications are inappropriately prescribed and may cause patient harm. Without a systematic process to give providers feedback on their prescribing, the opportunity to learn from experience and prevent future adverse events is lost. By placing the provider at the center of the design of a feedback system, this study seeks to develop a feedback system using potentially inappropriate antibiotic and NSAID prescribing as two primary opportunities to improve acute outpatient care delivery. This project will examine the performance of an automated system to enhance the quality and safety of medication prescribing for Veterans who seek acute care.