Loreen Walker

CKD as an Underrecognized Threat to Patient Safety

Chronic kidney disease (CKD) is common, but underrecognized, in patients in the health care system, where improving patient safety is a high priority. Poor disease recognition and several other features of CKD make it a high-risk condition for adverse safety events. In this review, we discuss the unique attributes of CKD that make it a high-risk condition for patient safety mishaps. We point out that adverse safety events in this disease have the potential to contribute to disease progression; namely, accelerated loss of kidney function and increased incidence of end-stage renal disease. We also propose a framework in which to consider patient safety in CKD, highlighting the need for disease-specific safety indicators that reflect unsafe practices in the treatment of this disease. Finally, we discuss the hypothesis that increased recognition of CKD will reduce disease-specific safety events and in this way decrease the likelihood of adverse outcomes, including an accelerated rate of kidney function loss and increased incidence of end-stage renal disease.

Erythropoiesis-stimulating agents increase the risk of acute stroke in patients with chronic kidney disease.

Erythropoiesis-stimulating agents (ESAs) are effective in ameliorating anemia in chronic kidney disease (CKD). A recent trial in diabetic patients with CKD, however, suggested a greater risk of stroke associated with full correction of anemia with ESAs. Using national Veterans Affairs data we performed a case-control study examining the association of incident ESA use with acute stroke in patients with estimated glomerular filtration rate < 60 cm³/min per 1.73 m² and outpatient hemoglobin <12 g/dl. Using diagnosis codes, we identified 2071 acute hospitalized stroke cases and matched them 1:5 with controls without stroke, resulting in 12,426 total patients for analysis. Conditional logistic regression was used to estimate the association of ESA use with stroke, adjusting for potential confounders. After multivariate adjustment, ESA use in 1026 patients was associated with greater odds of stroke (odds ratio 1.30). There was significant interaction between ESA use and cancer, with greater odds of stroke among ESA-treated cancer patients (odds ratio 1.85), but not in ESA-treated patients without cancer (odds ratio 1.07). ESA-treated patients with cancer received a median initial dose 2.5-4 times greater than ESA-treated patients without cancer, but pre-ESA hemoglobin and its rate of change did not differ between these groups. Hence, in a large national sample of anemic patients with CKD, ESA treatment was associated with an increased risk of acute stroke with the greatest effect among patients with cancer.

Effect of Medications on Physical Function and Cognition in Nursing Home Residents with Dementia

To assess the effectiveness of medications used in the management of Alzheimers disease and related dementias (ADRD) on cognition and activity of daily living (ADL) trajectories and to determine whether sex modifies these effects.

A Sustainable Strategy to Prevent Misuse of Antibiotics for Acute Respiratory Infections

Backgrounds Over 50% of antibiotics prescriptions are for outpatients with acute respiratory infections (ARI). Many of them are not needed and thus contribute both avoidable adverse events and pressures toward the development of bacterial resistance. Could a clinical decision support system (CDSS), interposed at the time of electronic prescription, adjust antibiotics utilization toward consensus treatment guidelines for ARI? Methods This is a retrospective comparison of pre- (2002) and post-intervention (2003–2006) periods at two comprehensive health care systems (intervention and control). The intervention was a CDSS that targeted fluoroquinolone and azithromycin; other antibiotics remained unrestricted. 7000 outpatients visits flagged by an ARI case-finding algorithm were reviewed for congruence with the guidelines (antibiotic prescribed-when-warranted or not-prescribed-when-unwarranted). Results 3831 patients satisfied the case definitions for one or more ARI: pneumonia (537), bronchitis (2931), sinusitis (717) and non-specific ARI (145). All patients with pneumonia received antibiotics. The relative risk (RR) of congruent prescribing was 2.57 (95% CI = (1.865 to 3.540) in favor of the intervention site for the antibiotics targeted by the CDSS; congruence did not change for other antibiotics (adjusted RR = 1.18 (95% CI = (0.691 to 2.011)). The proportion of unwarranted prescriptions of the targeted antibiotics decreased from 22% to 3%, pre vs. post-intervention (p<0.0001). Conclusions A CDSS interposed at the time of e-prescription nearly extinguished unwarranted use targeted antibiotics for ARI for four years. This intervention highlights a path toward sustainable antibiotics stewardship for outpatients with ARI.

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 m2. 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 m2, 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.

A varying patient safety profile between black and nonblack adults with decreased estimated GFR.

BACKGROUND Chronic kidney disease is a high-risk condition for a variety of adverse safety events, yet little is known about differential rates of safety events across racial groups with decreased kidney function. We sought to examine the incidence of an array of disease-specific adverse safety events in black versus nonblack patients with decreased estimated glomerular filtration rate (eGFR). STUDY DESIGN Retrospective observational study of a national US Veterans Affairs cohort. SETTINGS & PARTICIPANTS Veterans with eGFR <60 mL/min/1.73 m(2) and one or more hospitalization during federal fiscal year 2005 (n = 70,154). PREDICTOR Self-reported race/ethnicity dichotomized as black or nonblack. OUTCOMES Hospital discharge coding for Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs), laboratory records for detection of hyperkalemia and hypoglycemia, and pharmacy records to determine dosing of 4 selected medications. MEASUREMENTS Relationship between race and disease-specific patient safety events. RESULTS Black veterans were more likely than nonblack veterans to experience one type of safety event (33% vs 32%, respectively) and multiple types of safety events (32% vs 23%, respectively; both P < 0.001). After adjustment, black veterans were 11% and 36% more likely to have at least one episode of hyperkalemia and hypoglycemia, respectively, than nonblack veterans, but were 14% less likely to experience a medication error (all P < 0.001). There was no association between the occurrence of AHRQ PSIs and race after adjustment. LIMITATIONS Use of administrative data has a risk of imprecision in coding; Veterans Affairs cohort may limit generalizability. CONCLUSIONS Black veterans with decreased eGFR are more likely to experience a broad array of safety events than nonblacks with decreased eGFR, with a preponderance of metabolic disturbances rather than medication errors or AHRQ PSIs. The differential safety phenotype in blacks versus nonblacks may have implications for preventive strategies to improve patient safety in an integrated health care system.

Consideration of ICD-9 Code-Derived Disease-Specific Safety Indicators in CKD

BACKGROUND AND OBJECTIVES The Agency for Healthcare and Research Quality patient safety indicators track adverse safety events in hospitalized patients but overlook safety incidents specific to CKD. This study considers candidate CKD-pertinent patient safety indicators and compares them with the Agency for Healthcare and Research Quality patient safety indicators. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using a national Veterans Health Administration database of hospitalized veterans from fiscal year 2005, 247,160 hospitalized veterans with prehospitalization measures of renal function were retrospectively examined for proposed CKD patient safety indicators versus Agency for Healthcare and Research Quality patient safety indicators using International Classification of Diseases, Ninth Revision diagnosis codes. Candidate CKD-pertinent patient safety indicators included in-hospital acute kidney failure; in-hospital congestive heart failure (and related diagnostic codes); electrolyte disturbances; and medication errors, poisoning, and intoxication. Patients with a prehospital estimated GFR<60 ml/min per 1.73 m(2) (CKD group) were compared with a non-CKD group. For CKD patient safety indicators, hospitalizations were excluded if the admitting condition was a potential cause of the secondary condition. Regression methods were used to present adjusted rates in study groups of interest. RESULTS The CKD patient safety indicators were generally more common than the Agency for Healthcare and Research Quality patient safety indicators in all groups, tended to occur in different patients than those patients who experienced Agency for Healthcare and Research Quality patient safety indicators, and were more common in the CKD group than the non-CKD group, except for hypoglycemia, hypokalemia, and hyponatremia. The adjusted composite CKD patient safety indicators rate (per 1000 patient-hospitalizations) was 398.0 (95% confidence interval, 391.2 to 405.0) for patients in the CKD group and 250.0 (95% confidence interval, 247.4 to 252.7) for patients in the non-CKD group. The prevalence ratio of CKD patient safety indicators to Agency for Healthcare and Research Quality patient safety indicators was 23.4 (95% confidence interval, 21.9 to 25.0). CONCLUSION The candidate CKD patient safety indicators that occur in hospitalized patients are distinct from the Agency for Healthcare and Research Quality patient safety indicators and tend to be more common in CKD than non-CKD patients. These measures have the potential to serve as sentinel tools for identifying patients with CKD who warrant examination for disease-pertinent safety events.