GenIC "Primary Care Provider - Stopping Elderly Accidents, Deaths, and Injuries (STEADI)"

Attachment B: Focus Group Moderators Guide

Form Approved

OMB No. 0920-1009

Exp. Date: 3/31/2017

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Introduction Hello, my name is ______________. I will be moderating this focus group today. Thank you for agreeing to participate. I would also like to introduce _______________. He/she is here to take notes. He/she will not use any names; all responses will be kept confidential outside this room.

Provide basic description of project and project aims

I am a researcher at Altarum Institute. We are partners on a project funded by CDC to help reduce falls among persons 65 and older. This CDC initiative, called STEADI: Stopping Elderly Accidents Deaths and Injuries, has several goals. One of them is to improve services and tools focused on fall preventions that are offered to primary care providers. Specifically, we are interested in tools that are utilized by providers in their decisions to start, alter or stop medications that may increase or decrease fall risk for patients 65 and older, who we will call “older adults.”

To do so effectively, it is important to have an accurate understanding of your experiences with older adult patients, and what influences your decisions about medication regimens for them in general, and regarding fall prevention in particular. These are the issues this focus group is designed to address.

I am looking forward to hearing your insights and opinions. What we learn from this focus group and others we are conducting will greatly assist the CDC in advancing clinical fall prevention. The findings from this focus group will assist the CDC in delivering effective services and information to primary care providers to reduce their patients’ fall risk.

Ask if participants understand the project and their role

Does anyone have any questions about the STEADI initiative?

Do any of you have any questions about your role in the focus group?

Initial Questions

Before we begin, I would like to ask you some background questions.

1. Age: Please indicate your age range.

____ 25-34 years of age

____ 35-44 years of age

____ 45-54 years of age

____ 55-64 years of age

____ 65+ years of age

2. Practice Area: How would you describe yourself?

____Physician

____Nurse Practitioner

____Physician Assistant

____Other (Please specify): _____________________________________________

4. Are you board-certified? If yes, in what specialty?

____ Yes (Specialty: ___________________________________________________)

____ No

5. How many years have you been practicing as a primary care provider (excluding residency)?

_____ Years _____Months

6. What environment/practice type do you work in currently (check all that apply)

______ Private practice (solo) _______ Employed (other)

______ Private practice (group) ________ Academic

______ Employed by health system ________ Urgent Care

___________________________________ Other (describe)

Explain how the focus group will operate, including guidelines

This focus group should take no more than 90 minutes.

I’d like to quickly go over some guidelines for how we’ll conduct this session. First, I value everyone’s input, and I hope to hear from each of you throughout the focus group. However, no one is required to speak.

If at any time you must leave the room, you are free to do so.

I encourage everyone to help maintain an open, polite, and orderly environment. Try not to speak over each other. Please, also, silence your cellphones and other electronic devices.

It is likely there will be varied experiences and opinions expressed today. This is actually what we are hoping to hear; we are not looking for everyone to agree.

The focus group will be centered on six main themes. I will introduce each theme by asking a question, and will take some time to ask follow-up questions before moving on to the next theme.

Does anyone have any questions about how the focus group will run?

With your permission, we would also like to use an audio recorder for this session, so that we can go back to it as we analyze the information we learn today. Does anyone object to our recording this conversation?

Introductory activity

Great. First, I’m going to ask each of you to state your name, where you practice, and one observation you have made regarding older adults and falls.

Thematic and follow-up questions

Primary Care Provider Changes in Practice

I’d like to start by talking about health care information you find particularly impactful. Please think about a time when you changed your clinical approach or practice. (pause – most important question, allow plenty of time for responses)

What was it that inspired you to make that change?

Probe: You heard about the severity of the problem at a conference or continuing education event? You received information from a professional association or government agency? You noticed it was an issue affecting patients in your own practice? You received information on new treatment options or guidelines? You received information from a listserv or read a compelling journal article?

What kind of information would lead you to adjust medications to reduce older adult patients’ fall risk?

Probe: Are statistics (like rates of falls) more effective? What about messages with specific guidelines from trusted professional associations/organizations, agencies? Or those with stories from patients and providers about medication and falls?

What are some of the resources or tools you use when deciding which medications to select for your patients?
Probe: clinical decision support, electronic health records,

Where are you most likely to get information on medication side effects?

Probe: Examples: Epocrates? Medscape? Up-to-Date? Pharmacists or other providers? Any other tools or resources?

Similarly, what sources do you use most frequently to stay up-to-date on the field of medicine in general?

Probe: Any particular journals? Conferences you are likely to attend? Association websites or other online resources? Any others?

Input on STEADI SAFE Tool

Distribute the SAFE document for viewing by the focus group members. Introduce it as a tool for prescribers to help them understand the steps involved in a medication review, standardize the process across care settings, and encourage them to work collaboratively with pharmacists.

Now I’d like to hear your thoughts on this resource. What do you find most helpful in this SAFE document?

What could be added to increase its effectiveness?

What strategies do you think would be most effective in promoting this and other STEADI materials to primary care providers?

Fall Risk among Older Adult Patients

Thank you. Now I’d like to discuss your older adult patients. What percentage of your patient population is comprised of older adults?

Given the range of health issues your older patients face, where do you rank fall risk?

How often do you speak with your older adult patients about their risk of falls? (what percentage of the time)

Medication Change Barriers and Influences

I’m going to ask you to share your experiences with medication modification in general. Do you find it difficult to make medication changes for older adult patients?

What are some of the barriers to changing a medication regimen for older patients that you have encountered?

Probe: Time? Cost for patient? Lack of alternative medications? Conflicting guidelines (e.g., blood pressure guidelines)? Patient resistance? Concern in changing a medication that another provider or specialist started?

What resources would help address these barriers?

What influences you when you make decisions about prescribing medications to your older patients?

Probe: How do conversations with pharmacists impact your prescribing decisions? What kinds of conversations are most effective?

Do EHR alerts affect your prescribing? If so, how?

Would it be helpful to receive an EHR alert or clinical decision support to change medications? When would the prompt be most helpful?

Probe: When prescribing a new medication? When lab result indicates a change, in renal function for example?

How do you communicate with patients about medication changes? What have you found works best?

Provider Emphasis on Fall Risk among Older Adult Patients

The next questions pertain specifically to your experiences with medication modification to reduce fall risk. Have you ever made changes based on a patient’s fall risk, or a patient having a fall? How frequently? What specifically prompted the change? (emphasize last question)

Probe: EHR clinical decision support? Side effects? Concern about polypharmacy? Blood pressure too low, dizziness, changes in renal function? Patient input? Patient experiences a fall? Other provider input?

Which classes of drugs would you be most likely to consider reducing, stopping, or switching to reduce your patients’ fall risk?

Probe: Sleeping medications, anti-hypertensives, benzodiazapines, opioids, anticholinergics, antidepressants, sedatives and hypnotics

Think about the ways you could manage your patients’ medications to reduce fall risk. What would be easiest: changing the dose, recommending an alternative, or asking the patient to stop a specific drug? What would be most difficult? Are there other strategies that would be easier to implement?

Do you ever consult with other providers before making medication changes? What types of other providers?

Probe: Specialists? Pharmacists?

How often do you make changes to medications that other providers initiated? Does this create any challenges?

Vitamin D

We’re going to talk briefly now about Vitamin D. What have you heard about the use of vitamin D to prevent falls?

(If asked, moderator clarifies: not for osteoporosis, but for primary fall prevention. The USPSTF recommends daily vitamin D supplements to improve bone, muscle, and nerve function and reduce falls)

Where have you learned about vitamin D and its use for fall prevention?

What would lead you to routinely recommend vitamin D for primary fall prevention (not for osteoporosis)? (skip to this question if lacking time)

Wrap-up

That was extremely informative. Does anyone have any additional comments or questions before we conclude?

Thank you again for giving us your time.