Frequency of laboratory monitoring of chronic medications administered to nursing facility residents: results of a national Internet-based study

Determining the incidence of drug-associated acute kidney injury in nursing home residents

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/PARTICIPANTS/MEASUREMENTS

We conducted a retrospective study between February 9, 2012, and February 8, 2013, for all residents at 4 UPMC NHs located in southwest Pennsylvania. The TheraDoc™ Clinical Surveillance Software System, which monitors laboratory and medication data and fires alerts when patients have a sufficient increase in serum creatinine, was used for automated case detection. An increase in serum creatinine 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. Data were analyzed by frequency and distribution of alert type by risk, injury, and failure.

RESULTS

Of the 249 residents who had a drug-associated AKI alert fire, 170 (68.3%) were women, 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, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEIs/ARBs), and antibiotics.

CONCLUSION

Drug-associated AKI was a common cause of potential adverse drug events. The vast majority of 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.

Introduction to the medication regimen review--part 3

Part 1 of this series provided an introduction and overview of the medication regimen review (MRR) process (Consult Pharm 2010;25:710-20). In Part 2, a framework for MRR was presented (Consult Pharm 2010;25:778-802). This article reviews and expands on the elements of the MRR framework and provides examples of implementation.

Introduction to medication regimen review-part 2

Drug therapy is one of a variety of tools used by clinicians to manage symptoms and diseases in patients. To understand the medication regimen review process, it is important to understand the big picture of patient care and how medications fit into this overall scheme. The framework for patient management is known as "the care process."

The quality of warfarin prescribing and monitoring in Veterans Affairs nursing homes

OBJECTIVES

To describe the quality of warfarin prescribing and monitoring in Veterans Affairs (VA) nursing homes and to assess the factors associated with maintaining a therapeutic international normalized ratio (INR).

DESIGN

Retrospective cohort.

SETTING

Five VA nursing homes.

PARTICIPANTS

All veterans who received warfarin between January 1 and June 30, 2008, at the nursing homes.

MEASUREMENTS

Using medical records, the percentage of person-time spent in the target INR range, the proportion of patients with INRs in the therapeutic range on 50% or more of their person-days, and the frequency of INR monitoring were estimated. Multivariable logistic regression was used to identify factors associated with maintaining a therapeutic INR 50% or more of the time.

RESULTS

Over 6 months, 160 patients received 10,380 person-days of warfarin. INRs were in the therapeutic range for 55% of the person-days, and 99% of the INR tests were repeated within 4 weeks of the previous result. On an individual level, 49% of patients had INRs in the target range for 50% or more of their person-days. Achieving this outcome was more likely in patients with prevalent warfarin use than with new use (adjusted odds ratio (AOR)=2.86, 95% confidence interval (CI)=1.06-7.72). Conversely, patients with a history of a stroke (AOR=0.38, 95% CI =0.18-0.80) were less likely to have therapeutic INRs for 50% or more of their days.

CONCLUSION

Warfarin appears to be prescribed and monitored effectively in VA nursing home patients. Future studies should focus on increasing time in therapeutic range in patients with poor INR control.

Assessing the quality of prescribing and monitoring erythropoiesis-stimulating agents in the nursing home setting

INTRODUCTION

As many as 50% of all nursing home (NH) residents meet the World Health Organization criteria for anemia. The objectives of this study were to determine the prevalence and appropriateness of prescribing and monitoring of erythropoiesis-stimulating agents (ESAs) used to treat anemia in the NH setting.

METHODS

Cross-sectional, 1-month study of all NH residents in 4 community-based, university-affiliated NHs between January and February 2008. Residents were included in the analysis if they received at least 1 dose of an ESA during the study duration. Data collected through chart review included basic demographic information, ESA indication, ESA dosage, concurrent administration of iron supplements, hemoglobin (Hgb) monitoring, and blood pressure measurements.

RESULTS

A total of 4.5% (22/485) of NH residents received at least 1 dose of an ESA. Residents who received ESAs had a mean age of 80.4 (+/- 14.5) years. Most residents who received ESAs were female (64% [14/22]), white (68% [15/22]), and had a mean weight of 72.0 (+/- 20.84) kg. Only 27% (6/22) of residents were prescribed an ESA for an FDA-approved indication. Darbepoetin alfa was the most commonly prescribed ESA (64% [14/22]) with a mean weekly dose of 70.8 (+/- 68.1) mug, followed by epoetin alfa (37% [8/22]) with a mean weekly dose of 22,625 (+/- 21,232) units. More than one quarter (27% [6/22]) of those who received an ESA had an Hgb value of 12g/dL or more, the maximum recommended threshold for use of these medications. Of the 18 residents who had blood pressure measurements, 11% (2/18) were hypertensive.

CONCLUSION

Suboptimal prescribing and monitoring of ESAs were common in the NHs we studied. Future studies are needed to determine if the development and use of computerized decision support systems can improve prescribing and monitoring of ESAs in the NH setting.