Transcript MS-TRIP 2 Indicator Set

The MS-TRIP 2 Indicator Set
The Dissemination of the PPRNet Model for Improving
Medication Safety in Primary Care Practice Project
AHRQ Grant Number 1 R18HS019593
©©PPRNet,
PPRNet,2007
2008
Purpose
• Define PPRNet Medication Safety
indicators
• Review available safety evidence behind
each indicator
• Illustrate use of decision support tools
within McKesson-Practice Partner® EHR
Organization
• Measure description
• Safety evidence
• References
• Supplemental
information
General Definitions
• PPRNet reports
– Active patient: progress note recorded within 1
year (not indicated as “Cancelled” or “No
Show”) and not designated as deceased,
transferred or inactive status
– Active prescription: written within the last 365
days and lacks a discontinuation date
• If duration available, discontinuation date is
calculated
© PPRNet, 2010.
Potentially Inappropriate Therapy
• Antibiotics within 3 days of an upper
respiratory infection
– Excluding patients with COPD exacerbation, otitis
media, pneumonia, strep pharyngitis or sinusitis
• Rarely appropriate and inappropriate
medications in the elderly
© PPRNet, 2010.
Antibiotics in URI
• Upper respiratory infection = the common
cold, pharyngitis or bronchitis
• Antibiotics are ineffective for viral URI and
may lead to increased bacterial resistance
www.cdc.gov/getsmart; Annals of Internal Medicine. 2001;134(6):487-9; AHRQ National Healthcare
Quality Report.
Defining Potentially Inappropriate
Medication Use
Beers Criteria
Expert Panel
1991, 1992, 1997
1996
1996 Medical Expenditure Panel Survey Categories
• Inappropriate
• Rarely appropriate
• Appropriate for some indications but often misused
JAMA 2001;286:2823-29; AHRQ National Healthcare Quality Report.
Potentially Inappropriate
Medications in the Elderly
• Barbiturates
• Flurazepam (Dalmane)
• Meprobamate (Miltown,
Equanil)
• Chlorpropamide
(Diabinese)
• Meperidine (Demerol)
• Pentazocine (Talwin)
• Trimethobenzamide
(Tigan)
• Belladonna alkaloids
(Donnatal and others)
• Dicyclomine (Bentyl)
• Hyoscyamine (Levsin,
Levsinex)
• Propantheline (ProBanthine)
JAMA 2001;286:2823-29; Amer J Geri Pharm 2008; 6(1):21-27.
Rarely Appropriate
Medications in the Elderly
•
•
•
•
•
•
•
•
Chlordiazopoxide (Librium)
Diazepam (Valium)
Propoxyphene (Darvocet)
Carisoprodol (Soma)
Chlorzoxazone (Paraflex)
Cyclobenzaprine (Flexeril)
Metaxalone (Skelaxin)
Methocarbamol (Robaxin)
JAMA 2001;286:2823-29; Amer J Geri Pharm 2008; 6(1):21-27.
© PPRNet, 2010.
Potentially Inappropriate Dosages
• Allopurinol based on renal function
• Short-acting benzodiazepines in the elderly
• Digoxin in the elderly with CHF
• H-2 blockers based on renal function
© PPRNet, 2010.
How is renal function
defined in MS-TRIP?
For pts w/Serum Creatinine recorded in the last year:
Calculated CrCl/GFR by Cockcroft-Gault estimate
(140 – age) * wt (kg) *0.85 females
72 * SCr (mg/dl)
•
•
Same estimate used in PP Dose Advisor
Limitations: Overweight patients, SCr < 0.7 mg/dl,
fluctuating SCr
What about eGFR from the
lab?
• Estimated GFR by MDRD Study Equation
170 * (SCr-0.999) * (Age-0.176) * Sex (0.762 if female)
* Race (1.18 if black) * (BUN-0.170) * (Albumin0.318)
• Recommended by National Kidney Foundation
for CKD evaluation/staging
• Limitations: Young patients w/o kidney disease, age >
85 yrs, pregnant women, Hispanic subgroups
National Kidney Foundation, www.kdoqi.org.
GFR estimates: Which is
better for drug dosing?
• No evidence-based answer
• C-G is recommended if differences exist since
this estimate is used in standardized dosing
recommendations
• Bottom line: Use ‘Dose advisor’ calculations
instead of eGFR to estimate renal function and
medication adjustments
© PPRNet, 2010.
Allopurinol in
Renal Impairment
• Avoidance of daily dose over 200 mg for GFR
20-60 ml/min, over 100 mg for < 20 ml/min
• Safety concern
– Potential toxicity due to accumulation of metabolite
• Skin rash, fever, hepatotoxicity, worsening renal function
• Reduced doses are effective for most patients
• Newer agents should also be used cautiously
American Journal of Medicine 1984;76(1):47-56.
Benzodiazepines in
the Elderly
• Avoidance of daily dose over 2 mg alprazolam,
3 mg lorazepam (Ativan), 60 mg oxazepam
(Serax), 15 mg temazepam (Restoril), 0.25 mg
triazolam (Halcion) in patients > 65 yrs
• Safety concern
– Greater sensitivity to effects and adverse reactions
– Increased risk of falls, memory impairment and
cognitive decline
Archives of Internal Medicine. 2003;163(22):2716-24; Journal of the American Geriatrics Society
2007;55(s2):S373-S82.
Digoxin in the Elderly
with CHF
• Avoidance of daily dose >0.125 mg/day in
patients > 65 yrs with CHF
• Safety concerns
– Adverse reactions from decreased renal clearance:
nausea, vomiting, anorexia
• Efficacy in CHF established with low doses
Archives of Internal Medicine. 2003;163(22):2716-24.
H2 blockers in Renal
Impairment
• Avoidance of maximum dose for GFR < 50 ml/min
–
–
–
–
Cimetidine (Tagamet) > 1200 mg
Nizatidine (Axid) > 150 mg
Famotidine (Pepcid) > 20 mg
Ranitidine (Zantac) > 150 mg
• Safety concerns
– Potential adverse reactions include delirium, confusion and
agitation
– Mechanism unclear, possibly due to histamine receptors in
the CNS and/or anticholinergic effects
Nephrology Dialysis Transplantation. 2005;20(11):2376-84.
Potential Drug – Drug Interactions
• Macrolide antibiotics (excluding azithromycin)
and digoxin
• Tetracycline and digoxin
• Itraconazole and statin
• Lithium and thiazide diuretic
• Methotrexate and trimethoprim
• Sulfonylurea and sulfamethoxazole in patients
> 65 yrs
© PPRNet, 2010.
Potential Drug-Drug
Interactions
• Definition of eligible patients for reports
– Patients with active prescriptions
for either medication
Macrolides + Digoxin
• Safety concern
– Increased absorption of digoxin and potential toxicity
– Older patients admitted to the hospital for digoxin
toxicity were 12 times more likely to have received
clarithromycin in the past week
• Indicator excludes patients on azithromycin
• Management recommendations
– Use alternative antibiotic
– No clear guidance on reducing digoxin dose
JAMA 2003;289:1652-1658.
Statins + Itraconazole
• Safety concern
– Increased risk of rhabdomyolysis due to inhibition of
statin metabolism
• Management recommendations
– Use alternative(s) to itraconazole
– Some data suggest lower interaction risk with
pravastatin or rosuvastatin
Lithium + Thiazide
diuretics
• Safety concern
– Decreased lithium clearance  lithium toxicity
(confusion, weakness, GI)
• Management recommendations
– Use non-diuretic HTN treatment
– Reduce lithium dose and monitor regularly
Methotrexate + TMP/SMX
• Safety concern
– Pancytopenia via displaced protein binding of MTX
and additive antifolate activity
• Management recommendation
– Use alternative to TMP/SMX
Sulfonylurea + SMX
in the Elderly
• Safety concern
– Hypoglycemia via displacement of sulfonylurea from
protein binding sites
– Older patients admitted to the hospital for
hypoglycemia on glyburide were 6 times more likely
to have received SMX in the past week
• Management recommendations
– Use alternative antibiotic
– Depending on glycemic control, hold sulfonylurea
during SMX course
JAMA. 2003;289:1652-1658.
Drug Interaction Alerts
Improving the accuracy of
interaction alerts
Potential Drug – Disease Interactions
• Anticholinergics in dementia
• Bupropion in epilepsy
• Metformin in pts with SCr >1.4 (female),
1.5 (male)
• Metoclopramide in Parkinson’s Disease
• NSAID or COX2 Inhibitor in CHF, HTN or GFR
< 20 ml/min
• NSAID in peptic ulcer disease
• Thiazolidinediones in CHF
Anticholinergics in
Dementia
• Antihistamines, skeletal muscle relaxants, urinary
incontinence, GI antispasmodics
– Indicator excludes tricyclic antidepressants
• Safety concern
– Disorientation, confusion, delirium by further
reduction of acetylcholine in CNS
– Increased potential for problems in patients on
acetylcholinesterase inhibitors for dementia
J Am Geriatr Soc 2002;50:1165-1166.
Am J Geriatr Psychiatry 2003;11:458-461. .
Bupropion in Seizures
• Safety concern
– Antidepressants are associated with seizures to
varying degrees
– Bupropion carries higher risk than SSRIs
Biological Psychiatry 2007;62(4):345-354.
Metformin in Renal
Impairment
• Avoidance in men with SCr > 1.5 mg/dl
and women > 1.4 mg/dl
• Safety concern: lactic acidosis
– Conclusion from analysis of ~200 studies: “No
evidence to date…an increased risk of lactic acidosis
compared to other antihyperglycemic treatments if
the drug is prescribed under study conditions”
• Consistent with contraindications from
product labeling
Arch Int Med 2003;163:2594-2602.
Metoclopramide in
Parkinson’s Disease
• Safety concern
– Tardive dyskinesia through metoclopramide’s
antagonism of dopamine receptors
Clinical Therapeutics 2006;28(8):1133-43.
NSAIDs, COX2 Inhibitors
in CHF
• Safety concerns
– Fluid retention and risk of exacerbation
– Association established across classes for increased
cardiovascular morbidity and mortality
• Published warnings through FDA “black box” and
public health advisories
• American Heart Association and American Geriatrics
Society panels include CHF as contraindication to
NSAID, COX2 therapy
Circulation 2007; 115:1634-1642; Journal of the American Geriatrics Society 2009;57:1331–1346;
Arch Intern Med. 2009;169(2):141-9.
NSAIDs, COX2 Inhibitors
in HTN
• Safety concerns
– Increased BP (+5 mmHg) by inhibiting vasodilation from
prostaglandins
– May interfere w/antihypertensive efficacy
• Longer rx duration = greater likelihood of adverse
drug reaction
• Unknown if effect is agent or class-specific
JAMA 1994;272:781-786; Annals of Pharmacotherapy 2003;37(3):442-446.
NSAIDs, COX2 Inhibitors in
GFR < 20 ml/min
• Safety concerns
– Decreased renal blood flow via prostaglandin inhibition
• 12% of Medicare beneficiaries with renal failure
received an NSAID or COX2 in 2009
• American Geriatrics Society panel includes CKD as
contraindication to NSAID, COX2 therapy
Journal of the American Geriatrics Society 2009;57:1331–1346; 2009 NCQA State of Health Care
Quality Report.
NSAIDs, COX2 Inhibitors in
Peptic ulcer disease
• Safety concerns
– Decreased renal blood flow via prostaglandin inhibition
• American Geriatrics Society panel includes CKD as
contraindication to NSAID, COX2 therapy
Journal of the American Geriatrics Society 2009;57:1331–1346; 2009 NCQA State of Health Care
Quality Report.
TZDs in CHF
• Safety concerns
– Cautions published by American Heart Association
and American Diabetes Association in 2004
– Potential fluid retention and weight gain (+ 2-5 kg)
– Increased risk of developing CHF established vs
placebo in >20,000 pts (RR 1.72)
Diabetes Care 2004; 27:256-263.
Lancet 2007;9593:1129-1136.
Disease Interaction Alerts
Monitoring of Potential
Adverse Drug Events
• Serum creatinine monitoring
– Annual
• ACEI or ARB
• Digoxin
• Diuretic
• Metformin
• NSAID or COX-2 Inhibitor
– Every 6 months
• Pts > 65 yrs or GFR < 50 ml/min on ACEI/ARB and Ksparing diuretic
© PPRNet, 2010.
Monitoring of Potential
Adverse Drug Events
• Potassium monitoring
– Annual
• ACEI or ARB
• Digoxin
• Diuretic
– Every 6 months
• Pts > 65 yrs or GFR < 50 ml/min on ACEI/ARB and Ksparing diuretic
– Most recent value > 3.5 meq/L in pts on thiazide
diuretics
© PPRNet, 2010.
Diuretics
• Adverse reactions: hypokalemia, decreased
renal function
• Monitoring may prevent potential adverse
events from drug-drug interactions
• Lack of monitoring is commonly cited as cause
of preventable ADRs
• Potassium target > 3.5 meq/L
– Pts with hypokalemia after 1 year of chlorthalidone
for HTN had a similar risk of CV and CHD events as
pts on placebo
Hypertension 2000;35:1025-1030.
ACEI/ARB + K-sparing
diuretic
• Elevations in serum creatinine and potassium are
two most common adverse reactions
• Admissions for and mortality from hyperkalemia
significantly increased when spironolactone was
added to ACEI in heart failure pts
• Older pts admitted to the hospital for
hyperkalemia on an ACEI were 20 times more
likely to have received a K-sparing diuretic in the
past week
Arch Intern Med 2000;685–693. JAMA 2003;289:1652-1658. NEJM 2004;351:543-551.
NSAIDs, COX2 Inhibitors
• Renal toxicity occurs in up to 20% of high
risk patients
• Evidence-based guidelines for monitoring are
lacking
– American Heart Association panel
recommends SCr for patients on chronic rx
• Class is commonly identified as a cause of
preventable ADEs
West J Med 1991;155:39-42; Circulation 2007; 115:1634-1642
Annual Glucose and
Weight for Antipsychotics
• Includes typical and atypical antipsychotics
• Safety concern: weight gain and related
complications of diabetes mellitus and
dyslipidemia are on the rise in this population
• Both mechanism and understanding agentspecific versus class effect are unclear
Diabetes Care 2004;27(2):596-601.
Annual Hemoglobin and Platelet Count
for Antiplatelets and Anticoagulants
• Includes new agents and excludes aspirin
• Safety concern: Major and minor bleeding
complications, thrombocytopenia
• Evidence for monitoring benefit on outcomes
is lacking
• Availability of trends may improve ability to
detect minor bleeding episodes
CHEST 2008;133(6) suppl:199S-233S.
Annual Glucose and
Weight for Antipsychotics
• Includes typical and atypical antipsychotics
• Safety concern: weight gain and related
complications of diabetes mellitus and
dyslipidemia are on the rise in this population
• Both mechanism and understanding agentspecific versus class effect are unclear
Diabetes Care 2004;27(2):596-601.
Warfarin
• Two indicators: INR within 45 days and most
recent INR < 5
• 2008 American College of Chest Physician
guidelines recommend INR every 4 weeks in
stable patients
• Correlation between major bleeding events
and INRs > 5 in ambulatory clinics
CHEST 2008;133(6) suppl:160S-198S.
Folic Acid and Methotrexate
• Adverse reactions of MTX: GI intolerance,
hepatotoxicity, pancytopenia
• Cochrane review
– Folic acid 5 mg/week (or less) decreased mucosal
and GI adverse events by 80% in patients on lowdose MTX for rheumatoid arthritis
• Use of folic acid improves MTX continuation rates
by reducing LFT changes and GI intolerance
Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD000951; Rheumatology
2004;43(3):267-71.
HM Monitoring Prompts
HM Monitoring Prompts