Transcript Determining the Incidence of Drug-associated AKI in Nursing Home

Determining the Incidence of Drug-Associated
Acute Kidney Injury in Nursing Home
Residents
Steven M. Handler, MD, PhD, CMD
Assistant Professor of Geriatric Medicine and Biomedical
Informatics; CMIO UPMC Community Provider Services.
U.S. Nursing Home (NH) Demographics
• Approximately 1.6 million Americans receive health care in
more than 16,000 NHs annually
• In 2006, national spending on NH care totalled 125 billion
dollars or about 5.3% of total U.S. healthcare spending
• Lifetime risk of NH placement for those over the age of 65
is ~45%
• The number of people expected to need NH services is
expected to double by the year 2020
Hanlon JT, Handler SM, et al. Brocklehurst’s Textbook of Geriatric Medicine
& Gerontology. 7th ed. London, UK. Churchill Livingstone (2010).
Potentially Avoidable Hospitalizations (PAHs)
• PAHs are defined as hospitalizations that could have been
avoided because the condition could have been prevented
or treated outside of an inpatient hospital setting.
• 26% percent of hospitalizations were considered PAHs
• Had an ALOS of 6.1 days and an estimated cost of $8 billion
• Five conditions were responsible for nearly 80% of PAHs
(CHF, COPD/asthma, UTIs, pneumonia, and
dehydration/AKI)
Medicare & Medicaid Research Review 2014;4.
Public Health Significance of Adverse Drug
Events (ADEs) in Nursing Homes
• Are the most frequent medication-related adverse event,
with ~2 million ADEs/year when all U.S. NHs are combined
Handler SM, et al. Am J Geriatr Pharmacother 2006; 4:264-72
• Are the most clinically significant medication-related adverse
events and are associated with approximately 93,000
deaths/year
Gurwitz JH, et al. J Am Geriatr Soc. 2008;56(12):2225-33.
• Are the most costly medication-related adverse events,
resulting in as much as 4 billion dollars of excess healthcare
expenditures/year
Bootman JL, et al. Arch Intern Med. 1997;157(18):2089-96.
Systems Analysis of ADEs in NHs
• Only the presence of polypharmacy has consistently
been found to increase the likelihood of developing an
ADE
Leape LL, et al. JAMA 1995;274(1):35-43.
• Approximately half of the events are considered
preventable (i.e., medication errors)
Gurwitz JH, et al. Am J Med. 2005;118(3):251-8.
• Most (80%) are associated with monitoring rather than
prescribing errors
Gurwitz JH, et al. Am J Med 2000; 109:87-94.
Active Medication Monitoring Systems
•
The Institute of Medicine recommends that all healthcare settings assess the safety of medication use
through active monitoring systems
IOM. Preventing Medication Errors. Washington, DC: National
Academies Press; 2006.
•
Active medication monitoring systems are particularly
needed to detect and prevent ADEs in priority
populations such as institutionalized elderly because of:
– concerns about the quality of pharmaceutical care,
– frequency of polypharmacy, and
– an insufficient healthcare workforce with a poorly developed
safety culture
Handler SM et al. Qual Saf Health Care. 2006 Dec;15(6):400-4.
 Seriousness
Impact of Medication Monitoring on ADEs
Steinman MA, Handler SM, Gurwitz JH, Schiff GD, Covinsky KE. J Am Geriatr Soc.
2011;59(8):13-20.
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Background/Objective
• Although acute kidney injury (AKI) is well-studied in the
acute care setting, investigation of AKI in the nursing
home (NH) setting is virtually nonexistent
• The goal of this study was to determine the incidence of
drug-associated AKI using the RIFLE (Risk, Injury,
Failure, Loss of kidney function or End-Stage kidney
disease) criteria in NH residents
Design/Setting/Measurements
• We conducted a retrospective study between February
9, 2012 and February 8, 2013 for all residents at four
UPMC NHs located in Southwest Pennsylvania
• The TheraDoc™ Clinical Surveillance System, which
monitors laboratory and medication data and fires alerts
when patients have a sufficient increase in SCr, was
used for automated case detection
Methods (Continued)
• An increase in SCr in the presence of an active
medication order identified to potentially cause AKI
triggered an alert, and drug-associated AKI was staged
according to the RIFLE criteria
– Risk: (1.5 SCr increase)
– Injury (2x SCr increase)
– Failure (3x SCr increase or increase of 0.5 if SCr ≥ 4)
• Data were analyzed by frequency and distribution of alert
type by risk, injury, and failure
Sample ADE Alert
Results (Continued)
• Of the 249 residents who had a drug-associated AKI
alert fire, 170 (68.3%) were female, and the mean age
was 74.2 years
• Using the total number of alerts (n=668), the rate of
drug-associated AKI was 0.41 events per 100 residentdays
• Based on the RIFLE criteria, there were 191, 70, and 44
residents who were classified as AKI Risk, Injury, and
Failure, respectively
• The most common medication classes included in the
AKI alerts were diuretics, ACEIs/ARBs, and antibiotics
Limitations
• The TheraDoc Clinical Surveillance Software System is
currently limited to assessing medications prescribed
• It is possible that we overestimated the attribution of
medications to the development of AKI, as no formal
causality assessment tool (e.g., Naranjo algorithm) was
used to exclude competing factors, such as comorbid
disease, polypharmacy, and volume depletion
Limitations (Continued)
• Ideally for staging purposes, patients should be staged
according to both RIFLE and Acute Kidney Injury Network
(AKIN) criteria that give them the highest stage
• Limited number of NHs which may limit generalizability
Conclusions
• This is the first study that assessed the incidence of drug
associated AKI in NHs
• Drug-associated AKI was a common cause of potential
ADEs
• Vast majority of the cases were related to the use of
diuretics, ACEIs/ARBs and antibiotics
• Future studies are needed to better understand patient,
provider and facility risk factors as well as strategies to
enhance the detection and management of drug-associated
AKI in the NH
Thank you!
QUESTIONS?
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