Reporting of estimated glomerular filtration rate: effect on physician recognition of chronic kidney disease and prescribing practices for elderly hospitalized patients

Medication decision-making for patients with renal insufficiency in inpatient and outpatient care at a US Veterans Affairs Medical Centre: a qualitative, cognitive task analysis

BACKGROUND

Many studies identify factors that contribute to renal prescribing errors, but few examine how healthcare professionals (HCPs) detect and recover from an error or potential patient safety concern. Knowledge of this information could inform advanced error detection systems and decision support tools that help prevent prescribing errors.

OBJECTIVE

To examine the cognitive strategies that HCPs used to recognise and manage medication-related problems for patients with renal insufficiency.

DESIGN

HCPs submitted documentation about medication-related incidents. We then conducted cognitive task analysis interviews. Qualitative data were analysed inductively.

SETTING

Inpatient and outpatient facilities at a major US Veterans Affairs Medical Centre.

PARTICIPANTS

Physicians, nurses and pharmacists who took action to prevent or resolve a renal-drug problem in patients with renal insufficiency.

OUTCOMES

Emergent themes from interviews, as related to recognition of renal-drug problems and decision-making processes.

RESULTS

We interviewed 20 HCPs. Results yielded a descriptive model of the decision-making process, comprised of three main stages: detect, gather information and act. These stages often followed a cyclical path due largely to the gradual decline of patients' renal function. Most HCPs relied on being vigilant to detect patients' renal-drug problems rather than relying on systems to detect unanticipated cues. At each stage, HCPs relied on different cognitive cues depending on medication type: for renally eliminated medications, HCPs focused on gathering renal dosing guidelines, while for nephrotoxic medications, HCPs investigated the need for particular medication therapy, and if warranted, safer alternatives.

CONCLUSIONS

Our model is useful for trainees so they can gain familiarity with managing renal-drug problems. Based on findings, improvements are warranted for three aspects of healthcare systems: (1) supporting the cyclical nature of renal-drug problem management via longitudinal tracking mechanisms, (2) providing tools to alleviate HCPs' heavy reliance on vigilance and (3) supporting HCPs' different decision-making needs for renally eliminated versus nephrotoxic medications.

Inappropriate prescribing in chronic kidney disease: A systematic review of prevalence, associated clinical outcomes and impact of interventions

INTRODUCTION

Adjusting doses of renally cleared medications and/or avoidance of nephrotoxic medications are standard clinical practices in chronic kidney disease (CKD), albeit the prevalence of inappropriate prescribing (IP) in these patients remains high. Therefore, this work sought to systematically review the prevalence of IP and compare the relative effectiveness of available interventions in reducing IP in CKD.

METHODS

Studies were identified searching PubMed/Medline, EMBASE, Cochrane Library, IPA, Web of Science, Ovid/Medline, CINAHL, and PsychINFO databases. Studies defining CKD based on laboratory markers and quantifying prevalence of IP were included.

RESULTS

Forty-nine studies from 23 countries met the inclusion criteria. An IP prevalence of 9.4%-81.1% and 13%-80.50% was reported in hospital and ambulatory settings, respectively; whereas, in long-term care facilities the prevalence ranged between 16% and 37.9%. Unsurprisingly, IP was associated with adverse drug events like increased hospital stay (Mean [SD] of 4.5 [4.8] vs 4.3 [4.5]) and high risk of mortality [40%]. Twenty-one studies reported the impact of interventions on IP; manual and computerised alerts were the main forms of interventions (n=19). The most significant reduction in IP was observed when physicians received immediate concurrent feedback from a clinical pharmacist (P<.001). Polypharmacy, comorbidities, and age were identified as predictors of IP.

CONCLUSION

IP has led to poor patient outcomes. Although pharmacist-based and computer-aided approaches have shown promising results, there is still room for improvement. Future studies should focus on developing a multifaceted intervention to address the widespread prevalence of IP and associated clinical outcomes in CKD patients.

Secular trends in antihyperglycaemic medication prescriptions in older adults with diabetes and chronic kidney disease: 2004-2013

AIM

To examine how antihyperglycaemic medications were prescribed to older adults with diabetes and chronic kidney disease over the last decade.

METHODS

We conducted a population-based study of 144 252 older adults with diabetes and chronic kidney disease (estimated glomerular filtration rate <60 ml/min/1.73 m(2) or receiving chronic dialysis) in Ontario, Canada. In each study quarter (3-month intervals from 1 April 2004 until 31 March 2013) we studied the proportion of treated and newly treated patients prescribed insulin, sulphonylureas, α-glucosidase inhibitors, metformin, thiazolidinediones, meglitinides and dipeptidyl peptidase-4 (DPP-4) inhibitors. We further examined prescription trends by stage of chronic kidney disease.

RESULTS

The mean age of patients increased slightly (from 76 to 78 years) over the study period and the percentage with comorbidities declined. Metformin was the predominant therapy prescribed (prescribed to a mean of 56.1% of treated patients). Glyburide (glibenclamide) and thiazolidinedione prescriptions decreased (glyburide prescriptions declined from 45.5 to 9.5%, rosiglitazone from 3.6 to 0.2% and pioglitazone from 1.9 to 1.7%), while gliclazide and DPP-4 inhibitor prescriptions increased (gliclazide prescriptions increased from 0.6 to 26.4%, sitagliptin from 0 to 15.3% and saxagliptin from 0 to 2.0%). Up to 48.6% of patients with stage 3a-5 chronic kidney disease or receiving chronic dialysis were prescribed glyburide, and up to 27.6% of patients with stage 4-5 disease or receiving chronic dialysis were prescribed metformin.

CONCLUSIONS

In patients with chronic kidney disease, there were trends towards safer antihyperglycaemic medication prescribing. A considerable number of patients, however, continue to receive medications that should be avoided.

The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial

BACKGROUND

Patients with kidney disease are at risk for adverse events due to improper medication prescribing. Few randomized controlled trials of clinical decision support (CDS) utilizing dynamic assessment of patients' kidney function to improve prescribing for patients with kidney disease have been published.

METHODS

We developed a CDS tool for 20 medications within a commercial electronic health record. Our system detected scenarios in which drug discontinuation or dosage adjustment was recommended for adult patients with impaired renal function in the ambulatory and acute settings - both at the time of the initial prescription ("prospective" alerts) and by monitoring changes in renal function for patients already receiving one of the study medications ("look-back" alerts). We performed a prospective, cluster randomized controlled trial of physicians receiving clinical decision support for renal dosage adjustments versus those performing their usual workflow. The primary endpoint was the proportion of study prescriptions that were appropriately adjusted for patients' kidney function at the time that patients' conditions warranted a change according to the alert logic. We employed multivariable logistic regression modeling to adjust for glomerular filtration rate, gender, age, hospitalized status, length of stay, type of alert, time from start of study, and clustering within the prescribing physician on the primary endpoint.

RESULTS

A total of 4068 triggering conditions occurred in 1278 unique patients; 1579 of these triggering conditions generated alerts seen by physicians in the intervention arm and 2489 of these triggering conditions were captured but suppressed, so as not to generate alerts for physicians in the control arm. Prescribing orders were appropriate adjusted in 17% of the time vs 5.7% of the time in the intervention and control arms, respectively (odds ratio: 1.89, 95% confidence interval, 1.45-2.47, P < .0001). Prospective alerts had a greater impact than look-back alerts (55.6% vs 10.3%, in the intervention arm).

CONCLUSIONS

The rate of appropriate drug prescribing in kidney impairment is low and remains a patient safety concern. Our results suggest that CDS improves drug prescribing, particularly when providing guidance on new prescriptions.

Educating Patients about CKD: The Path to Self-Management and Patient-Centered Care

Patient education is associated with better patient outcomes and supported by international guidelines and organizations, but a range of barriers prevent widespread implementation of comprehensive education for people with progressive kidney disease, especially in the United States. Among United States patients, obstacles to education include the complex nature of kidney disease information, low baseline awareness, limited health literacy and numeracy, limited availability of CKD information, and lack of readiness to learn. For providers, lack of time and clinical confidence combine with competing education priorities and confusion about diagnosing CKD to limit educational efforts. At the system level, lack of provider incentives, limited availability of practical decision support tools, and lack of established interdisciplinary care models inhibit patient education. Despite these barriers, innovative education approaches for people with CKD exist, including self-management support, shared decision making, use of digital media, and engaging families and communities. Education efficiency may be increased by focusing on people with progressive disease, establishing interdisciplinary care management including community health workers, and providing education in group settings. New educational approaches are being developed through research and quality improvement efforts, but challenges to evaluating public awareness and patient education programs inhibit identification of successful strategies for broader implementation. However, growing interest in improving patient-centered outcomes may provide new approaches to effective education of people with CKD.

Fluctuation of the renal function after discharge from hospital and its effects on drug dosing in elderly patients--study protocol

Background

Chronic kidney disease (CKD) is associated with an increased mortality rate, risk of cardiovascular events and morbidity. Impaired renal function is common in elderly patients, and their glomerular filtration rate (GFR) should be taken into account when prescribing renally excreted drugs. In a hospital care setting the GFR may fluctuate substantially, so that the renal function group and therefore the recommended dose, can change within a few days. The magnitude and prevalence of the fluctuation of renal function in daily clinical practice and its potential effects on appropriateness of drug prescriptions after discharge from the hospital is unknown.

Methods/design

This is a prospective observational study. Patients ≥ 70 years with renal impairment (eGFR <60 ml/min/1.73 m²) admitted to a geriatric ward are eligible to participate. Participants undergo blood sample collection to measure serum creatinine level at three time points: at discharge from hospital, 14 days, and 2 months after discharge. At these time points the actual medication of the participants is assessed and the number of incorrect prescriptions according to the Dutch guidelines in relation to their estimated renal function is measured. In addition, for a hypothetical selection of drugs, the need for drug dose adaptation in relation to renal function is measured. The outcome of interest is the percentage of patients that changes from renal function group after discharge from hospital compared to the renal function at discharge. In addition, the percentages of patients whose actual medications are incorrectly prescribed and for the hypothetical selection of drugs that would have required dose adaptation will be determined at discharge, 14 days and 2 months after discharge. For each outcome, risk factors which may lead to increased risk for fluctuation of renal function and/or incorrect drug prescribing will also be identified and analysed.

Discussion

This study will provide data on changes in renal function in elderly patients after discharge from the hospital with a focus on the medications used. The benefits for healthcare professionals comprise of the creation, adjustment or confirmation of recommendations for the monitoring of the renal function after discharge from hospital of elderly patients.

Adherence with Dosing Guideline in Patients with Impaired Renal Function at Hospital Discharge

Objectives

To determine the prevalence, determinants, and potential clinical relevance of adherence with the Dutch dosing guideline in patients with impaired renal function at hospital discharge.

Design

Retrospective cohort study between January 2007 and July 2011.

Setting

Academic teaching hospital in the Netherlands.

Subjects

Patients with an estimated glomerular filtration rate (eGFR) between 10-50 ml/min/1.73m² at discharge and prescribed one or more medicines of which the dose is renal function dependent.

Main Outcome Measures

The prevalence of adherence with the Dutch renal dosing guideline was investigated, and the influence of possible determinants, such as reporting the eGFR and severity of renal impairment (severe: eGFR<30 and moderate: eGFR 30-50 ml/min/1.73m²). Furthermore, the potential clinical relevance of non-adherence was assessed.

Results

1327 patients were included, mean age 67 years, mean eGFR 38 ml/min/1.73m². Adherence with the guideline was present in 53.9% (n=715) of patients. Reporting the eGFR, which was incorporated since April 2009, resulted in more adherence with the guideline: 50.7% vs. 57.0%, RR 1.12 (95% CI 1.02-1.25). Adherence was less in patients with severe renal impairment (46.0%), compared to patients with moderate renal impairment (58.1%, RR 0.79; 95% CI 0.70-0.89). 71.4% of the cases of non-adherence had the potential to cause moderate to severe harm.

Conclusion

Required dosage adjustments in case of impaired renal function are often not performed at hospital discharge, which may cause harm to the majority of patients. Reporting the eGFR can be a small and simple first step to improve adherence with dosing guidelines.

Tailoring of alerts substantially reduces the alert burden in computerized clinical decision support for drugs that should be avoided in patients with renal disease

OBJECTIVE

Electronic alerts are often ignored by physicians, which is partly due to the large number of unspecific alerts generated by decision support systems. The aim of the present study was to analyze critical drug prescriptions in a university-based nephrology clinic and to evaluate the effect of different alerting strategies on the alert burden.

METHODS

In a prospective observational study, two advanced strategies to automatically generate alerts were applied when medication regimens were entered for discharge letters, outpatient clinic letters, and written prescriptions and compared to two basic reference strategies. Strategy A generated alerts whenever drug-specific information was available, whereas strategy B generated alerts only when the estimated glomerular filtration rate of a patient was below a drug-specific value. Strategies C and D included further patient characteristics and drug-specific information to generate even more specific alerts.

RESULTS

Overall, 1012 medication regimens were entered during the observation period. The average number of alerts per drug preparation in medication regimens entered for letters was 0.28, 0.080, 0.019, and 0.011, when using strategy A, B, C, or D (P<0.001, for comparison between the strategies), leading to at least one alert in 87.5%, 39.3%, 13.5%, or 7.81 % of the regimens. Similar average numbers of alerts were observed for medication regimens entered for written prescriptions.

CONCLUSIONS

The prescription of potentially hazardous drugs is common in patients with renal impairment. Alerting strategies including patient and drug-specific information to generate more specific alerts have the potential to reduce the alert burden by more than 90 %.

Individualizing pharmacotherapy in patients with renal impairment: the validity of the Modification of Diet in Renal Disease formula in specific patient populations with a glomerular filtration rate below 60 ml/min. A systematic review

Background

The Modification of Diet in Renal Disease (MDRD) formula is widely used in clinical practice to assess the correct drug dose. This formula is based on serum creatinine levels which might be influenced by chronic diseases itself or the effects of the chronic diseases. We conducted a systematic review to determine the validity of the MDRD formula in specific patient populations with renal impairment: elderly, hospitalized and obese patients, patients with cardiovascular disease, cancer, chronic respiratory diseases, diabetes mellitus, liver cirrhosis and human immunodeficiency virus.

Methods and Findings

We searched for articles in Pubmed published from January 1999 through January 2014. Selection criteria were (1) patients with a glomerular filtration rate (GFR) < 60 ml/min (/1.73m²), (2) MDRD formula compared with a gold standard and (3) statistical analysis focused on bias, precision and/or accuracy. Data extraction was done by the first author and checked by a second author. A bias of 20% or less, a precision of 30% or less and an accuracy expressed as P₃₀% of 80% or higher were indicators of the validity of the MDRD formula. In total we included 27 studies. The number of patients included ranged from 8 to 1831. The gold standard and measurement method used varied across the studies. For none of the specific patient populations the studies provided sufficient evidence of validity of the MDRD formula regarding the three parameters. For patients with diabetes mellitus and liver cirrhosis, hospitalized patients and elderly with moderate to severe renal impairment we concluded that the MDRD formula is not valid. Limitations of the review are the lack of considering the method of measuring serum creatinine levels and the type of gold standard used.

Conclusion

In several specific patient populations with renal impairment the use of the MDRD formula is not valid or has uncertain validity.

Prioritization of patient-related factors according to renal function in antidiabetic drug selection: the REDIM Project

AIMS

Few studies have evaluated how physicians prioritize renal function among other patient-related factors when stepping-up in antidiabetic treatment.

METHODS

The REDIM Spanish national online survey included 550 internists. We firstly tested proficiency in chronic kidney disease (Agrawal's Questionnaire) and motivation in diabetes (DAS-3p Questionnaire). We then analyzed how physicians prioritized renal function, age, weight, glycemic control, non-renal co-morbidities and patient perceptions in five varying fictitious clinical scenarios (generic; ambulatory vs. high cardiovascular risk hospitalized patient, for estimated glomerular filtration rates (eGFRs)=50 vs. 25 ml/min/1.73 m(2)). We assigned every item a score (from 5 to 0, highest to lowest relevance) per-physician and compared mean values between clinical scenarios using the t-test for independent means (nominal significance at p<0.05).

RESULTS

Completion rate was 57.5% (N=316; mean age, 46.3 years; men, 71%). Average scores were 22.6 ± 3.9 (possible range [0-30]) for Agrawal's Questionnaire and 4.1 ± 0.6 (range [1-5]) for DAS-3p Questionnaire. In the generic scenario, renal function had the highest priority (mean=3.36 ± 1.66, range [0-5]). When eGFR was set at 50 ml/min/1.73 m(2), physicians prioritized glycemic control for ambulatory (mean=3.23 ± 1.59) and non-renal co-morbidities for hospitalized patients (mean=3.20 ± 1.68) over renal function (mean=3.18 ± 1.77 for ambulatory, p=0.032; mean=3.11 ± 1.65 for hospitalized patients, p=0.002). When eGFR was subsequently lowered to 25 ml/min/1.73 m(2), renal function again led priorities (mean values=3.73 ± 2.05 for ambulatory and 3.75 ± 1.96 for hospitalized patients; both p<0.001).

CONCLUSIONS

Knowledge of the degree of renal function impairment induced physicians to prioritize patient-related factors differently when adding a second antidiabetic drug. Renal function led priorities when severely impaired.

Recognition of CKD after the introduction of automated reporting of estimated GFR in the Veterans Health Administration

BACKGROUND AND OBJECTIVES

Early detection of CKD is important for slowing progression to renal failure and preventing cardiovascular events. Automated laboratory reporting of estimated GFR (eGFR) has been introduced in many health systems to improve CKD recognition, but its effect in large, United States-based health systems remains unclear.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using Veterans Affairs (VA) laboratory and administrative data, two nonoverlapping national cohorts of patients receiving care in VA medical centers before (n=66,323) and after (n=16,670) implementation of automated eGFR reporting between 2004 and 2010 were identified. Recognition was assessed by the presence of new CKD diagnostic codes, use of additional diagnostic testing, outpatient nephrology visits, or overall CKD recognition (receipt of at least one of these outcomes) for each patient during the 12-month period after their first eligible creatinine or eGFR laboratory result. Generalized estimating equations were used to assess change before and after automated eGFR reporting.

RESULTS

Overall CKD recognition increased from 22.1% of veterans before eGFR reporting to 27.5% in the post-eGFR reporting period (odds ratio [OR], 1.19; 95% CI, 1.12 to 1.27; P<0.001). Higher overall CKD recognition was driven largely by increased documentation of CKD diagnosis codes in medical records (OR, 1.31; 95% CI, 1.21 to 1.41; P<0.001) and diagnostic testing for CKD (OR, 1.13; 95% CI, 1.03 to 1.24; P<0.01) rather than outpatient nephrology consultation. Automated eGFR reporting was not associated with greater CKD recognition among black or older patients (P=0.07).

CONCLUSIONS

Automated eGFR laboratory reporting improved documentation of CKD diagnoses but had no effect on nephrology consultation. These findings suggest that to advance CKD care, further strategies are needed to ensure appropriate follow-up evaluation to confirm and effectively evaluate CKD.

Impact of vendor computerized physician order entry on patients with renal impairment in community hospitals

BACKGROUND

Adverse drug events (ADEs) are common among hospitalized patients with renal impairment.

OBJECTIVE

To determine whether computerized physician order entry (CPOE) systems with clinical decision support capabilities reduce the frequency of renally related ADEs in hospitals.

DESIGN, SETTING, AND PATIENTS

Quasi-experimental study of 1590 adult patients with renal impairment who were admitted to 5 community hospitals in Massachusetts from January 2005 to September 2010, preimplementation and postimplementation of CPOE.

INTERVENTION

Varying levels of clinical decision support, ranging from basic CPOE only (sites 4 and 5), rudimentary clinical decision support (sites 1 and 2), and advanced clinical decision support (site 3).

MEASUREMENTS

Primary outcome was the rate of preventable ADEs from nephrotoxic and/or renally cleared medications. Similarly, secondary outcomes were the rates of overall ADEs and potential ADEs.

KEY RESULTS

There was a 45% decrease in the rate of preventable ADEs following implementation (8.0/100 vs 4.4/100 admissions; P < 0.01), and the impact was related to the level of decision support. Basic CPOE was not associated with any significant benefit (4.6/100 vs 4.3/100 admissions; P = 0.87). There was a nonsignificant decrease in preventable ADEs with rudimentary clinical decision support (9.1/100 vs 6.4/100 admissions; P = 0.22). However, substantial reduction was seen with advanced clinical decision support (12.4/100 vs 0/100 admissions; P = 0.01). Despite these benefits, a significant increase in potential ADEs was found for all systems (55.5/100 vs 136.8/100 admissions; P < 0.01).

CONCLUSION

Vendor-developed CPOE with advanced clinical decision support can reduce the occurrence of preventable ADEs but may be associated with an increase in potential ADEs.

Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used; however, they are also nephrotoxic with both acute and chronic effects on kidney function. Here we determined NSAID prescribing before and after estimated GFR (eGFR) reporting and evaluate renal function in patients who used NSAIDs but stopped these after their first eGFR report. A population-based longitudinal analysis using a record-linkage database was conducted with the GFR estimated using the four-variable equation from the MDRD study and analyzed by trend test, paired t-test, and logistic regression modeling. Prescriptions for NSAIDs significantly decreased from 39,459 to 35,415 after implementation of eGFR reporting from the second quarter of 2005 compared with the first quarter of 2007. Reporting eGFR was associated with reduced NSAID prescriptions (adjusted odds ratio, 0.78). NSAID prescription rates in the 6 months before April 2006 were 18.8, 15.4, and 7.0% in patients with CKD stages 3, 4, and 5 and 15.5, 10.7, and 6.3%, respectively, after eGFR reporting commenced. In patients who stopped NSAID treatment, eGFR significantly increased from 45.9 to 46.9, 23.9 to 27.1, and 12.4 to 26.4 ml/min per 1.73 m² in 1340 stage 3 patients, 162 stage 4 patients, and 9 stage 5 patients, respectively. Thus, NSAID prescribing decreased after the implementation of eGFR reporting, and there were significant improvements in estimated renal function in patients who stopped taking NSAIDs. Hence, eGFR reporting may result in safer prescribing.

Influence of creatinine versus glomerular filtration rate on non-steroidal anti-inflammatory drug prescriptions in chronic kidney disease

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs), including cyclooxygenase-2 (COX-2) inhibitors, are generally contraindicated in chronic kidney disease (CKD). This investigation sought to identify the frequency of NSAID/COX-2 prescription and to determine the influence of serum creatinine (Cr) versus estimated glomerular filtration rate (eGFR) on this practice pattern.

METHODS

An established Veterans Health Administration CKD safety cohort (n = 70,154) was examined to determine the frequency of NSAID/COX-2 in fiscal year 2005 (FY05) for up to 30 days preceding the index hospitalization and as many as 365 days during that year. Binomial regression was used to determine adjusted prevalence ratios for prescription of NSAID/COX-2 with respect to continuous eGFR measurement and serum Cr categories. CKD was defined as eGFR <60 ml/min/1.73 m(2).

RESULTS

15.4% of the subjects had an NSAID/COX-2 prescription during the observation period. The proportion of these prescribed agents decreased with declining renal function, but remained significant at any stage of CKD given the renal harm related to these medications. At specific GFR estimates, serum Cr remained a significant predictor of NSAID/COX-2 prescription. At GFR set at 42 ml/min/1.73 m(2), the predicted proportion of prescribed NSAID/COX-2 was 0.29 (95% CI 0.24, 0.36), 0.23 (95% CI 0.22, 0.26), 0.20 (95% CI 0.19, 0.22), and 0.12 (95% CI 0.10, 0.14) for Cr strata of ≤1.3, 1.4-1.6, 1.7-2.1, and ≥2.2 mg/dl, respectively (all p < 0.05).

CONCLUSION

A significant proportion of individuals with CKD continue to be prescribed NSAID/COX-2 and serum Cr remains an influential guide to NSAID/COX-2 prescription, even in GFR ranges where these agents are ill advised.

Computerized decision support systems: improving patient safety in nephrology

Incorrect prescription and administration of medications account for a substantial proportion of medical errors in the USA, causing adverse drug events (ADEs) that result in considerable patient morbidity and enormous costs to the health-care system. Patients with chronic kidney disease or acute kidney injury often have impaired drug clearance as well as polypharmacy, and are therefore at increased risk of experiencing ADEs. Studies have demonstrated that recognition of these conditions is not uniform among treating physicians, and prescribed drug doses are often incorrect. Early interventions that ensure appropriate drug dosing in this group of patients have shown encouraging results. Both computerized physician order entry and clinical decision support systems have been shown to reduce the rate of ADEs. Nevertheless, these systems have been implemented at surprisingly few institutions. Economic stimulus and health-care reform legislation present a rare opportunity to refine these systems and understand how they could be implemented more widely. Failure to explore this technology could mean that the opportunity to reduce the morbidity associated with ADEs is missed.

Characterizing pre-dialysis care in the era of eGFR reporting: a cohort study

Background

Chronic kidney disease (CKD) is a common disorder associated with increased morbidity and mortality. Primary care physicians (PCPs) care for the majority of pre-dialysis CKD patients; however, PCPs often do not recognize the presence of CKD based on serum creatinine levels. Prior studies suggest that PCPs and nephrologists deliver suboptimal CKD care. One strategy to improve disease awareness and treatment is estimated glomerular filtration rate (eGFR) reporting. We examined PCP and nephrologist CKD practices before and after routine eGFR reporting.

Methods

We conducted a retrospective cohort study of patients with CKD 3b-4 (eGFR < 45) seen at a university-based, outpatient primary care clinic. Using a chi-square or Fisher's exact test, we compared co-management rates, renal protective strategies, CKD documentation, and laboratory processes of care in 274 patients and 266 patients seen in a 6-month period prior to and following eGFR implementation, respectively.

Results

CKD co-management increased from 22.6% pre-eGFR to 48.5% post-eGFR (P < 0.0001). eGFR reporting did not improve angiotensin converting enzyme inhibitor or angiotensin receptor blocker use or quantitative urinary testing. However, non-steroidal anti-inflammatory drug avoidance (pre-eGFR 81.8% vs. post- eGFR 90.6%, P = 0.003) and phosphorus and parathyroid hormone testing improved (pre-eGFR vs. post-eGFR: 32.5% vs. 51.5%, P < 0.0001; 12.4% vs. 36.1%, P < 0.0001 respectively).

Conclusions

A marked increase in CKD co-management was observed following eGFR implementation. Although some improvements in processes of care were noted, this did not include angiotensin converting enzyme inhibitor or angiotensin receptor blocker use. Overall care remained suboptimal despite eGFR reporting; further strategies are needed to improve PCP and nephrologist CKD care.

Effect of primary care physicians' use of estimated glomerular filtration rate on the timing of their subspecialty referral decisions

Background

Primary care providers' suboptimal recognition of the severity of chronic kidney disease (CKD) may contribute to untimely referrals of patients with CKD to subspecialty care. It is unknown whether U.S. primary care physicians' use of estimated glomerular filtration rate (eGFR) rather than serum creatinine to estimate CKD severity could improve the timeliness of their subspecialty referral decisions.

Methods

We conducted a cross-sectional study of 154 United States primary care physicians to assess the effect of use of eGFR (versus creatinine) on the timing of their subspecialty referrals. Primary care physicians completed a questionnaire featuring questions regarding a hypothetical White or African American patient with progressing CKD. We asked primary care physicians to identify the serum creatinine and eGFR levels at which they would recommend patients like the hypothetical patient be referred for subspecialty evaluation. We assessed significant improvement in the timing [from eGFR < 30 to ≥ 30 mL/min/1.73m²) of their recommended referrals based on their use of creatinine versus eGFR.

Results

Primary care physicians recommended subspecialty referrals later (CKD more advanced) when using creatinine versus eGFR to assess kidney function [median eGFR 32 versus 55 mL/min/1.73m², p < 0.001]. Forty percent of primary care physicians significantly improved the timing of their referrals when basing their recommendations on eGFR. Improved timing occurred more frequently among primary care physicians practicing in academic (versus non-academic) practices or presented with White (versus African American) hypothetical patients [adjusted percentage(95% CI): 70% (45-87) versus 37% (reference) and 57% (39-73) versus 25% (reference), respectively, both p ≤ 0.01).

Conclusions

Primary care physicians recommended subspecialty referrals earlier when using eGFR (versus creatinine) to assess kidney function. Enhanced use of eGFR by primary care physicians' could lead to more timely subspecialty care and improved clinical outcomes for patients with CKD.

Under-documentation of chronic kidney disease in the electronic health record in outpatients

OBJECTIVE

To ascertain if outpatients with moderate chronic kidney disease (CKD) had their condition documented in their notes in the electronic health record (EHR).

DESIGN

Outpatients with CKD were selected based on a reduced estimated glomerular filtration rate and their notes extracted from the Columbia University data warehouse. Two lexical-based classification tools (classifier and word-counter) were developed to identify documentation of CKD in electronic notes.

MEASUREMENTS

The tools categorized patients' individual notes on the basis of the presence of CKD-related terms. Patients were categorized as appropriately documented if their notes contained reference to CKD when CKD was present.

RESULTS

The sensitivities of the classifier and word-count methods were 95.4% and 99.8%, respectively. The specificity of both was 99.8%. Categorization of individual patients as appropriately documented was 96.9% accurate. Of 107 patients with manually verified moderate CKD, 32 (22%) lacked appropriate documentation. Patients whose CKD had not been appropriately documented were significantly less likely to be on renin-angiotensin system inhibitors or have urine protein quantified, and had the illness for half as long (15.1 vs 30.7 months; p<0.01) compared to patients with documentation.

CONCLUSION

Our studies show that lexical-based classification tools can accurately ascertain if appropriate documentation of CKD is present in a EHR. Using this method, we demonstrated under-documentation of patients with moderate CKD. Under-documented patients were less likely to receive CKD guideline recommended care. A tool that prompts providers to document CKD might shorten the time to implementing guideline-based recommendations.

Prevalence and severity of chronic kidney disease and anemia in the nursing home population

OBJECTIVES

Chronic kidney disease (CKD) is an emerging health concern and may have important implications for the management of older people with many other chronic conditions, such as the nursing home (NH) resident population. This study was designed to describe the prevalence of CKD and associated comorbidities in a representative sample of NH residents.

DESIGN

Cross-sectional descriptive study as a component of a prospective observational study of CKD and anemia in the NH population.

SETTING

Eighty-two geographically representative NHs in the United States.

PARTICIPANTS

Participants were 794 NH residents who had complete baseline data collected.

MEASUREMENTS

Residents for whom consent was obtained underwent a record review focused on identifying a predefined set of comorbid conditions, clinical assessment, and blood and urine collections. Stage of CKD was based on estimated GFR (eGFR) using the MDRD equation: no CKD (eGFR > 60 mL/min/1.73 m(2)), Stage 3a (45-59), Stage 3b (30-44), and Stage 4/5 (< 30).

RESULTS

Consent was obtained from 847 of 1626 residents screened; 32 were ineligible and 21 dropped out of the study; complete data were available for 794 residents. CKD was present in approximately 50% of residents; of these residents with CKD, 47.6% were stage 3a, 39.27% stage 3b, and 13.2% stage 4/5. Fifty percent of the population had anemia, and anemia was more common in those with CKD. The average number of comorbid conditions in the population was 5.3 (SD 2.2); the proportion of patients with multiple comorbid conditions, especially cardiovascular conditions, increased with increasing stage of CKD. Among those without CKD, 57% had 5 or more comorbidities in comparison to 87% of those with stage 4/5 CKD.

CONCLUSIONS

In this representative sample of 794 US NH residents, 50% had clinical evidence of CKD. Patients with CKD, particularly those at later stages, were more likely to have cardiovascular comorbidities and anemia. The co-occurrence of these conditions in institutionalized populations may have important implications for the clinical management of this patient population, particularly as it relates to the potential for further renal complications.

When laboratories report estimated glomerular filtration rates in addition to serum creatinines, nephrology consults increase

Serum creatinine alone can be difficult to interpret as a measure of kidney function such that chronic kidney disease might be under-recognized in the general population. In the province of Ontario, Canada, all outpatient laboratories now report estimated glomerular filtration rate (eGFR) in addition to serum creatinine. To determine the impact of this reporting on clinical practice, we linked health administrative data for more than 8 million adults of age 25 years or older over an almost 10-year period and conducted a population-based intervention analysis with seasonal time-series modeling to determine overall trends in the number and type of patients seen by nephrologists. Compared to the period when only serum creatinines were reported, the number of patients seen in consultation by nephrologists increased after eGFR reporting by an average of 24% (an absolute increase of 2.9 consults per 100,000 adults), an increase of about 23 consults per nephrologist per year. The greatest increases were seen in women (39% increase) and those 80 years of age and older (58% increase). Our study found that eGFR reporting was associated with a sudden increase in the number of nephrology consults. However, it remains to be seen whether the routine reporting of eGFR results in improved treatment and outcomes for those with chronic kidney disease.

Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency

OBJECTIVE To determine whether a computerized clinical decision support system providing patient-specific recommendations in real-time improves the quality of prescribing for long-term care residents with renal insufficiency. DESIGN Randomized trial within the long-stay units of a large long-term care facility. Randomization was within blocks by unit type. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units. Measurement The proportions of final drug orders that were appropriate were compared between intervention and control units within alert categories: (1) recommended medication doses; (2) recommended administration frequencies; (3) recommendations to avoid the drug; (4) warnings of missing information. RESULTS The rates of alerts were nearly equal in the intervention and control units: 2.5 per 1,000 resident days in the intervention units and 2.4 in the control units. The proportions of dose alerts for which the final drug orders were appropriate were similar between the intervention and control units (relative risk 0.95, 95% confidence interval 0.83, 1.1) for the remaining alert categories significantly higher proportions of final drug orders were appropriate in the intervention units: relative risk 2.4 for maximum frequency (1.4, 4.4); 2.6 for drugs that should be avoided (1.4, 5.0); and 1.8 for alerts to acquire missing information (1.1, 3.4). Overall, final drug orders were appropriate significantly more often in the intervention units-relative risk 1.2 (1.0, 1.4). CONCLUSIONS Clinical decision support for physicians prescribing medications for long-term care residents with renal insufficiency can improve the quality of prescribing decisions.

TRIAL REGISTRATION

http://clinicaltrials.gov Identifier: NCT00599209.

The epidemic challenge of chronic kidney disease in older patients

Since the introduction of estimated glomerular filtration rate (GFR), the number of patients with chronic kidney disease (CKD) has considerably increased. This is particularly true for elderly patients as the majority have a low GFR. Chronic kidney disease has a significant impact on a patient's outcome. We have reviewed important aspects of CKD in older patients, with emphasis on diagnosis and management, as well as explored decision-making regarding specialist-care referral and renal replacement therapy.

Prevalence of estimated GFR reporting among US clinical laboratories

BACKGROUND

Routine laboratory reporting of estimated glomerular filtration rate (eGFR) may help clinicians detect kidney disease. The current national prevalence of eGFR reporting in clinical laboratories is unknown; thus, the extent of the situation of laboratories not routinely reporting eGFR with serum creatinine results is not quantified.

DESIGN

Observational analysis.

SETTING

National Kidney Disease Education Program survey of clinical laboratories conducted in 2006 to 2007 by mail, web, and telephone follow-up.

PARTICIPANTS

A national random sample, 6,350 clinical laboratories, drawn from the Federal Clinical Laboratory Improvement Amendments database and stratified by 6 major laboratory types/groupings.

PREDICTORS

Laboratory reports serum creatinine results.

OUTCOMES

Reporting eGFR values with serum creatinine results.

MEASUREMENTS

Percentage of laboratories reporting eGFR along with reporting serum creatinine values, reporting protocol, eGFR formula used, and style of reporting cutoff values.

RESULTS

Of laboratories reporting serum creatinine values, 38.4% report eGFR (physician offices, 25.8%; hospitals, 43.6%; independents, 38.9%; community clinics, 47.2%; health fair/insurance/public health, 45.5%; and others, 43.2%). Physician office laboratories have a reporting prevalence lower than other laboratory types (P < 0.001). Of laboratories reporting eGFR, 66.7% do so routinely with all adult serum creatinine determinations; 71.6% use the 4-variable Modification of Diet in Renal Disease Study equation; and 45.3% use the ">60 mL/min/1.73 m(2)" reporting convention. Independent laboratories are least likely to routinely report eGFR (50.6%; P < 0.05) and most likely to report only when specifically requested (45.4%; P < 0.05). High-volume laboratories across all strata are more likely to report eGFR (P < 0.001).

LIMITATIONS

Self-reporting by laboratories, federal database did not have names of laboratory directors/managers (intended respondents), assumed accuracy of federal database for sample purposes.

CONCLUSIONS

Routine eGFR reporting with serum creatinine values is not yet universal, and laboratories vary in their reporting practices.

Recognition and management of chronic kidney disease in an elderly ambulatory population

BACKGROUND

Chronic kidney disease (CKD) is a growing problem among the elderly. Early detection is considered essential to ensure proper treatment and to avoid drug toxicity, but detection is challenging because elderly patients with CKD often have normal serum creatinine levels. We hypothesized that most cases of CKD in the elderly would go undetected, resulting in inappropriate prescribing.

OBJECTIVE

To determine whether recognition of CKD is associated with more appropriate treatment

DESIGN

Retrospective chart review

PARTICIPANTS

All patients aged >/=65 years with a measured serum creatinine in the past 3 years at 2 inner city academic health centers.

MEASUREMENTS

Estimated glomerular filtration rate (eGFR) calculated using the Modified Diet in Renal Disease equation, and for patients with eGFR < 60, documentation of CKD by the provider, diagnostic testing, nephrology referral and prescription of appropriate or contraindicated medications.

RESULTS

Of 814 patients with sufficient information to estimate eGFR, 192 (33%) had moderate (eGFR < 60 mL/min) and 5% had severe (eGFR < 30 mL/min) CKD. Providers identified 38% of moderate and 87% of severe CKD. Compared to patients without recognized CKD, recognized patients were more likely to receive an ACE/ARB (80% vs 61%, p = .001), a nephrology referral (58% vs 2%, p < .0001), or urine testing (75% vs 47%, p < .0001), and less likely to receive contraindicated medications (26% vs 40%, p = .013).

CONCLUSIONS

Physicians frequently fail to diagnose CKD in the elderly, leading to inappropriate treatment. Efforts should focus on helping physicians better identify patients with low GFR.

eGFR: is it ready for early identification of CKD?

Reporting estimated glomerular filtration rate (eGFR) with serum creatinine simply provides the information for which the serum creatinine was ordered in the first place. Mass or universal screening is not the purpose of eGFR reporting. Furthermore, such mass screening does not seem justified. Rather, testing of high-risk groups with eGFR and urinary albumin is useful. Population estimates of the prevalence of chronic kidney disease in the United States that use the Kidney Disease Outcomes Quality Initiative staging system lead to disturbingly high estimates. Many of these people are elderly with marginally depressed GFRs and for whom there are no known therapeutic implications. However, an even more disturbing fraction of people with serious and progressive renal disease are not diagnosed, counseled, or treated. Reporting of eGFR is only one tool in attempting to rectify this latter problem. Nephrologists need to educate patients and their primary care colleagues in the use of this tool.