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Omary C, Wright P, Kumarasamy MA, Franks N, Esper G, Mouzon HB, Barrolle S, Horne K, Cranmer J. Using Routinely Collected Electronic Health Record Data to Predict Readmission and Target Care Coordination. J Healthc Qual 2022; 44:11-22. [PMID: 34294659 DOI: 10.1097/jhq.0000000000000318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Patients with chronic renal failure (CRF) are at high risk of being readmitted to hospitals within 30 days. Routinely collected electronic health record (EHR) data may enable hospitals to predict CRF readmission and target interventions to increase quality and reduce readmissions. We compared the ability of manually extracted variables to predict readmission compared with EHR-based prediction using multivariate logistic regression on 1 year of admission data from an academic medical center. Categorizing three routinely collected variables (creatinine, B-type natriuretic peptide, and length of stay) increased readmission prediction by 30% compared with paper-based methods as measured by C-statistic (AUC). Marginal effects analysis using the final multivariate model provided patient-specific risk scores from 0% to 44.3%. These findings support the use of routinely collected EHR data for effectively stratifying readmission risk for patients with CRF. Generic readmission risk tools may be evidence-based but are designed for general populations and may not account for unique traits of specific patient populations-such as those with CRF. Routinely collected EHR data are a rapid, more efficient strategy for risk stratifying and strategically targeting care. Earlier risk stratification and reallocation of clinician effort may reduce readmissions. Testing this risk model in additional populations and settings is warranted.
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Potentially inappropriate primary care prescribing in people with chronic kidney disease: a cross-sectional analysis of a large population cohort. Br J Gen Pract 2021; 71:e483-e490. [PMID: 33947664 PMCID: PMC8103925 DOI: 10.3399/bjgp.2020.0871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background Many drugs should be avoided or require dose-adjustment in chronic kidney disease (CKD). Previous estimates of potentially inappropriate prescribing rates have been based on data on a limited number of drugs, and mainly in secondary care settings. Aim To determine the prevalence of contraindicated and potentially inappropriate primary care prescribing in a complete population of people with known CKD. Design and setting Cross-sectional study of prescribing patterns in a complete geographical population of people with CKD, defined using laboratory data. Method Drugs were organised by British National Formulary advice — contraindicated drugs: ‘avoid’; potentially high-risk (PHR) drugs: ‘avoid if possible’; and dose-inappropriate (DI) drugs: ‘dose exceeded recommended maximums’. CKD was defined as estimated glomerular filtration rate (eGFR) ≤60 ml/min/1.73 m2 for >3 months. Results In total, 28 489 people with CKD were included in the analysis, of whom 70.1% had CKD stage 3a, 22.4% CKD stage 3b, 5.9% CKD stage 4, and 1.5% CKD stage 5. A total of 3.9% (95% confidence interval [CI] = 3.7 to 4.1) of people with CKD stages 3a–5 were prescribed ≥1 contraindicated drug, 24.3% (95% CI = 23.8 to 24.8) ≥1 PHR drug, and 15.2% (95% CI = 14.8 to 15.6) ≥1 DI drug. Contraindicated drugs differed in prevalence by CKD stage and were most commonly prescribed in CKD stage 4, with a prevalence of 36.0% (95% CI = 33.7 to 38.2). PHR drugs were commonly prescribed in all CKD stages, ranging from 19.4% (95% CI = 17.6 to 21.3) in CKD stage 4 to 25.1% (95% CI = 24.5 to 25.7) in CKD stage 3a. DI drugs were most commonly prescribed in CKD stage 4 (26.4%, 95% CI = 24.3 to 28.6). Conclusion Potentially inappropriate prescribing is common at all stages of CKD. Development and evaluation of interventions to improve prescribing safety in this high-risk population are needed.
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Kharrazi H, Ma X, Chang HY, Richards TM, Jung C. Comparing the Predictive Effects of Patient Medication Adherence Indices in Electronic Health Record and Claims-Based Risk Stratification Models. Popul Health Manag 2021; 24:601-609. [PMID: 33544044 DOI: 10.1089/pop.2020.0306] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Multiple indices are available to measure medication adherence behaviors. Medication adherence measures, however, have rarely been extracted from electronic health records (EHRs) for population-level risk predictions. This study assessed the value of medication adherence indices in improving predictive models of cost and hospitalization. This study included a 2-year retrospective cohort of patients younger than age 65 years with linked EHR and insurance claims data. Three medication adherence measures were calculated: medication regimen complexity index (MRCI), medication possession ratio (MPR), and prescription fill rate (PFR). The authors examined the effects of adding these measures to 3 predictive models of utilization: a demographics model, a conventional model (Charlson index), and an advanced diagnosis-based model. Models were trained using EHR and claims data. The study population had an overall MRCI, MPR, and PFR of 14.6 ± 17.8, .624 ± .310, and .810 ± .270, respectively. Adding MRCI and MPR to the demographic and the morbidity models using claims data improved forecasting of next-year hospitalization substantially (eg, AUC of the demographic model increased from .605 to .656 using MRCI). Nonetheless, such boosting effects were attenuated for the advanced diagnosis-based models. Although EHR models performed inferior to claims models, adding adherence indices improved EHR model performances at a larger scale (eg, adding MRCI increased AUC by 4.4% for the Charlson model using EHR data compared to 3.8% using claims). This study shows that medication adherence measures can modestly improve EHR- and claims-derived predictive models of cost and hospitalization in non-elderly patients; however, the improvements are minimal for advanced diagnosis-based models.
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Affiliation(s)
- Hadi Kharrazi
- Center for Population Health IT, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Division of Health Sciences Informatics, Johns Hopkins School of Medicine, Baltimore Maryland, USA
| | - Xiaomeng Ma
- Dalla Lana School of Public Health, Institute of Health Policy Management and Evaluations, University of Toronto, Toronto, Canada
| | - Hsien-Yen Chang
- Center for Population Health IT, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Thomas M Richards
- Center for Population Health IT, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Changmi Jung
- Carey Business School, Johns Hopkins University, Baltimore, Maryland, USA
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Neumiller JJ, Daratha KB, Alicic RZ, Short RA, Miller HM, Gregg L, Gates BJ, Corbett CF, McPherson SM, Tuttle KR. Medication use, renin-angiotensin system inhibitors, and acute care utilization after hospitalization in patients with chronic kidney disease. J Renin Angiotensin Aldosterone Syst 2020; 21:1470320320945137. [PMID: 32762427 PMCID: PMC7418245 DOI: 10.1177/1470320320945137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objectives: The aims of this secondary analysis were to: (a) characterize medication use following hospital discharge for patients with chronic kidney disease (CKD), and (b) investigate relationships of medication use with the primary composite outcome of acute care utilization 90 days after hospitalization. Methods: The CKD-Medication Intervention Trial (CKD-MIT) enrolled acutely ill hospitalized patients with CKD stages 3–5 not dialyzed (CKD 3–5 ND). In this post hoc analysis, data for medication use were characterized, and the relationship of medication use with the primary outcome was evaluated using Cox proportional hazards models. Results: Participants were taking a mean of 12.6 (standard deviation=5.1) medications, including medications from a wide variety of medication classes. Nearly half of study participants were taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB). ACE inhibitor/ARB use was associated with decreased risk of the primary outcome (hazard ratio=0.51; 95% confidence interval 0.28–0.95; p=0.03) after adjustment for baseline estimated glomerular filtration rate, age, sex, race, blood pressure, albuminuria, and potential nephrotoxin use. Conclusions: A large number, variety, and complexity of medications were used by hospitalized patients with CKD 3–5 ND. ACE inhibitor or ARB use at hospital discharge was associated with a decreased risk of 90-day acute care utilization.
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Affiliation(s)
- Joshua J Neumiller
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, USA
| | | | - Radica Z Alicic
- Providence Medical Research Center, Providence Health Care, USA.,Department of Medicine, University of Washington School of Medicine, USA
| | - Robert A Short
- Providence Medical Research Center, Providence Health Care, USA
| | | | - Liza Gregg
- Sacred Heart Medical Center, Providence Health Care, USA
| | - Brian J Gates
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, USA
| | | | - Sterling M McPherson
- Providence Medical Research Center, Providence Health Care, USA.,Elson S. Floyd College of Medicine, Washington State University, USA.,Nephrology Division, Kidney Research Institute and Institute of Translational Health Sciences, University of Washington, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care, USA.,Department of Medicine, University of Washington School of Medicine, USA.,Nephrology Division, Kidney Research Institute and Institute of Translational Health Sciences, University of Washington, USA
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Sluggett JK, Hopkins RE, Chen EYH, Ilomäki J, Corlis M, Van Emden J, Hogan M, Caporale T, Ooi CE, Hilmer SN, Bell JS. Impact of Medication Regimen Simplification on Medication Administration Times and Health Outcomes in Residential Aged Care: 12 Month Follow Up of the SIMPLER Randomized Controlled Trial. J Clin Med 2020; 9:E1053. [PMID: 32276360 PMCID: PMC7231224 DOI: 10.3390/jcm9041053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 12/02/2022] Open
Abstract
In the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial, we evaluated the impact of structured medication regimen simplification on medication administration times, falls, hospitalization, and mortality at 8 residential aged care facilities (RACFs) at 12 month follow up. In total, 242 residents taking ≥1 medication regularly were included. Opportunities for simplification among participants at 4 RACFs were identified using the validated Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE). Simplification was possible for 62 of 99 residents in the intervention arm. Significant reductions in the mean number of daily medication administration times were observed at 8 months (-0.38, 95% confidence intervals (CI) -0.69 to -0.07) and 12 months (-0.47, 95%CI -0.84 to -0.09) in the intervention compared to the comparison arm. A higher incidence of falls was observed in the intervention arm (incidence rate ratio (IRR) 2.20, 95%CI 1.33 to 3.63) over 12-months, which was primarily driven by a high falls rate in one intervention RACF and a simultaneous decrease in comparison RACFs. No significant differences in hospitalizations (IRR 1.78, 95%CI 0.57-5.53) or mortality (relative risk 0.81, 95%CI 0.48-1.38) over 12 months were observed. Medication simplification achieves sustained reductions in medication administration times and should be implemented using a structured resident-centered approach that incorporates clinical judgement.
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Affiliation(s)
- Janet K. Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia; (J.K.S.); (R.E.H.); (E.Y.C.); (J.I.); (C.E.O.)
- School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide, SA 5005, Australia
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
| | - Ria E. Hopkins
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia; (J.K.S.); (R.E.H.); (E.Y.C.); (J.I.); (C.E.O.)
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
| | - Esa YH Chen
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia; (J.K.S.); (R.E.H.); (E.Y.C.); (J.I.); (C.E.O.)
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia; (J.K.S.); (R.E.H.); (E.Y.C.); (J.I.); (C.E.O.)
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Megan Corlis
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
- Helping Hand Aged Care, Adelaide, SA 5006, Australia;
| | - Jan Van Emden
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
- Helping Hand Aged Care, Adelaide, SA 5006, Australia;
| | - Michelle Hogan
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
- Helping Hand Aged Care, Adelaide, SA 5006, Australia;
| | | | - Choon Ean Ooi
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia; (J.K.S.); (R.E.H.); (E.Y.C.); (J.I.); (C.E.O.)
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
| | - Sarah N. Hilmer
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
- Kolling Institute of Medical Research, Royal North Shore Hospital, Northern Clinical School, School of Medicine, University of Sydney, Sydney, NSW 2050, Australia
| | - J. Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia; (J.K.S.); (R.E.H.); (E.Y.C.); (J.I.); (C.E.O.)
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
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Tesfaye WH, McKercher C, Peterson GM, Castelino RL, Jose M, Zaidi STR, Wimmer BC. Medication Adherence, Burden and Health-Related Quality of Life in Adults with Predialysis Chronic Kidney Disease: A Prospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17010371. [PMID: 31935851 PMCID: PMC6981524 DOI: 10.3390/ijerph17010371] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 12/16/2022]
Abstract
This study examines the associations between medication adherence and burden, and health-related quality of life (HRQOL) in predialysis chronic kidney disease (CKD). A prospective study targeting adults with advanced CKD (estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2) and not receiving renal replacement therapy was conducted in Tasmania, Australia. The actual medication burden was assessed using the 65-item Medication Regimen Complexity Index, whereas perceived burden was self-reported using a brief validated questionnaire. Medication adherence was assessed using a four-item Morisky-Green-Levine Scale (MGLS) and the Tool for Adherence Behaviour Screening (TABS). The Kidney Disease and Quality of Life Short-Form was used to assess HRQOL. Of 464 eligible adults, 101 participated in the baseline interview and 63 completed a follow-up interview at around 14 months. Participants were predominantly men (67%), with a mean age of 72 (SD 11) years and eGFR of 21 (SD 6) mL/min/1.73 m2. Overall, 43% and 60% of participants reported medication nonadherence based on MGLS and TABS, respectively. Higher perceived medication burden and desire for decision-making were associated with nonadherent behaviour. Poorer HRQOL was associated with higher regimen complexity, whereas nonadherence was associated with a decline in physical HRQOL over time. Medication nonadherence, driven by perceived medication burden, was prevalent in this cohort, and was associated with a decline in physical HRQOL over time.
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Affiliation(s)
- Wubshet H. Tesfaye
- Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Hobart 7005, Tasmania, Australia; (G.M.P.); (B.C.W.)
- Correspondence: ; Tel.: +61-469033062
| | | | - Gregory M. Peterson
- Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Hobart 7005, Tasmania, Australia; (G.M.P.); (B.C.W.)
| | - Ronald L. Castelino
- Sydney Nursing School, The University of Sydney, Sydney 2006, New South Wales, Australia; (R.L.C.); (M.J.)
| | - Matthew Jose
- Sydney Nursing School, The University of Sydney, Sydney 2006, New South Wales, Australia; (R.L.C.); (M.J.)
- Royal Hobart Hospital, Hobart 7000, Tasmania, Australia
| | | | - Barbara C. Wimmer
- Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Hobart 7005, Tasmania, Australia; (G.M.P.); (B.C.W.)
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Chronic Kidney Disease: The Silent Epidemy. J Clin Med 2019; 8:jcm8111795. [PMID: 31717778 PMCID: PMC6912263 DOI: 10.3390/jcm8111795] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 12/19/2022] Open
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