Determining the Incidence of Drug-Associated Acute Kidney Injury in Nursing Home

Residents

Steven M. Handler, MD, PhD, CMDAssistant 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).

• 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)

Potentially Avoidable Hospitalizations (PAHs)

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.

• The Institute of Medicine recommends that all health-care 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.

Active Medication Monitoring Systems

Steinman MA, Handler SM, Gurwitz JH, Schiff GD, Covinsky KE. J Am Geriatr Soc. 2011;59(8):13-20.

Impact of Medication Monitoring on ADEs

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• 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

Background/Objective

• 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

Design/Setting/Measurements

• 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

Methods (Continued)

Sample ADE Alert

• 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 resident-days

• 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

Results (Continued)

• 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

• 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

Limitations (Continued)

• 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

Conclusions

QUESTIONS?

HANDLERSM@PITT.EDU

Thank you!