Among veterans dually enrolled in VA and Medicare Part D, dual use of opioids was associated with more than 2 to 3 times the risk of high-dose opioid exposure.

OBJECTIVES Shared decision making is essential to deprescribing unnecessary or harmful medications in older adults, yet patients' and caregivers' perspectives on medication value and how this affects their willingness to discontinue a medication are poorly understood. We sought to identify the most significant factors that impact the perceived value of a medication from the perspective of patients and caregivers. DESIGN Qualitative study using focus groups conducted in September and October 2018. SETTING Participants from the Pepper Geriatric Research Registry (patients) and the Pitt+Me Registry (caregivers) maintained by the University of Pittsburgh. PARTICIPANTS Six focus groups of community‐dwelling adults aged 65 years or older, or their caregivers, prescribed five or more medications in the preceding 12 months. MEASUREMENTS We sought to identify (1) general views on medication value and what makes medication worth taking; (2) how specific features such as cost or side effects impact perceived value; and (3) reactions to clinical scenarios related to deprescribing. RESULTS We identified four themes. Perceived effectiveness was the primary factor that caused participants to consider a medication to be of high value. Participants considered a medication to be of low value if it adversely affected quality of life. Participants also cited cost when determining value, especially if it resulted in material sacrifices. Participants valued medications prescribed by providers with whom they had good relationships rather than valuing level of training. When presented with clinical scenarios, participants ably weighed these factors when determining the value of a medication and indicated whether they would adhere to a deprescribing recommendation. CONCLUSION We identified that perceived effectiveness, adverse effects on quality of life, cost, and a strong relationship with the prescriber influenced patients' and caregivers' views on medication value. These findings will enable prescribers to engage older patients in shared decision making when deprescribing unnecessary medications and will allow health systems to incorporate patient‐centered assessment of value into systems‐based deprescribing interventions. J Am Geriatr Soc 68:746–753, 2020

BACKGROUND/OBJECTIVES Prostate‐specific antigen (PSA) screening can be of low value in older adults. Our objective was to quantify the prevalence and variation of low‐value PSA screening across the Veterans Health Administration (VA), which has instituted programs to reduce low‐value care. DESIGN Retrospective cohort. SETTING VA administrative data, 2014 to 2015. PARTICIPANTS National random sample (N = 214 480) of male veterans, aged 75 years or older. MEASUREMENTS We defined PSA screening in men aged 75 years or older without a history of prostate cancer as low value, per established definitions in Medicare. We calculated screening rates overall and by VA Medical Center (VAMC), adjusting for patient and VAMC‐level factors. We characterized variation across VAMCs using the adjusted median odds ratio (OR) and compared the adjusted OR of screening between VAMCs in different deciles of low‐value screening rates. In separate sensitivity analyses, we assessed screening in veterans at greatest risk of 1‐year mortality and among veterans after excluding those who underwent prostatectomy, had a prior PSA elevation, or had a clinical indication for testing. RESULTS Overall, 37 867 (17.7%) of veterans underwent low‐value PSA screening (VAMC range = 3.3%‐38.2%). The adjusted median OR was 1.88, meaning the median odds of screening would increase by 88% were a veteran to transfer his care to a VAMC with higher screening rates. Veterans at VAMCs in the top decile had an adjusted OR of 12.9 (95% confidence interval = 11.0‐15.2) compared to those veterans in the lowest decile. Among veterans with the greatest mortality risk (n = 23 377), 3496 (15.0%) underwent screening (VAMC range = 1.7%‐46.3%). After excluding veterans with a prior prostatectomy, PSA elevation, or a potential clinical indication, 31 556 (14.7%) underwent screening (VAMC range = 2.0%‐49.9%). CONCLUSIONS In a national cohort of older veterans, more than one in six received low‐value PSA screening, with greater than 10‐fold variation across VAMCs and high rates of screening among those with the greatest mortality risk. J Am Geriatr Soc 67:1922–1927, 2019

Despite the time and administrative burdens associated with their use, VA physicians in our study broadly supported PDMPs. The application of our findings to ongoing PDMP implementation efforts may strengthen PDMP use both within and outside VA and improve the safe prescribing of opioids.