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CONTROLLING ANTIBIOTIC DOSING ERRORS IN PATIENTS WITH IMPAIRED RENAL FUNCTION USING AN EMR ALERT
NKF 2014 Spring Clinical Meetings Abstracts
149 URETERAL STENT MAY NOT BE ASSOCIATED WITH THE DEVELOPMENT OF SIGNIFICANT BK VIRURIA AND/OR VIREMIA Marcos A. Hernandez Roman, Mohanram Narayanan. Scott and White Memorial Hospital, Temple, TX, USA. The incidence of BK virus infection has increased in renal transplant recipients without a definitive etiology. Some studies have identified an association with ureteral stent placement and BK viremia (BKV) or BK nephropathy (BKN), suggesting a potential role of ureteral trauma in the pathogenesis of BK infection. No studies have found an association of ureteral stent duration with significant BK viruria (BKU), BKV, or BKN. We aimed to evaluate the risk of BKU and BKV adjusted for presence and duration of ureteral stent. A total of 93 kidney transplant recipients included in this analysis were followed for at least 1 year. Surgeon A performed 48 (52%) cases and Surgeon B performed 45 (48%) cases. Surgeon B routinely places a stent and Surgeon A does not. The stent was removed at a median (minimum-maximum) time of 94 (9-964) days from the transplant. The overall incidence of BKU and BKV was 42.2% and 26.8% of tested patients respectively. There was no significant difference between subjects with and without ureteral stent placement in BKU (p= 0.72) or BKV (p= 0.97), or duration of stent for BKU (p= 0.56) or BKV (p= 0.85). Multiple risk factors have been described in association with the development of BKU and BKV without a single study accounting for all possible factors. Since it is axiomatic that the dose makes the poison, one would have expected to see a clear relationship of not only stent presence, but also its duration with BKU and BKV.
150 TRENDS IN ESRD PPS CASE-MIX PREVALENCE IN THE MEDICARE FEE-FOR-SERVICE POPULATION 2000-2008
Christopher S Hollenbeak,1 Robert J Rubin,2 Spiros Tzivelekis,3 Mark Stephens4 1 Pennsylvania State University College of Medicine, Hershey, PA, USA; 2Georgetown University School of Medicine, Washington DC, USA; 3Amgen Inc., Thousand Oaks, CA, USA; 4Prima Health Analytics, Boston, MA, USA The ESRD PPS used patient case mix from the 2006-08 Medicare fee-for-service population to set weights for each case-mix adjuster in the payment formula. The case mix used was not made public, and little is known about case-mix trends over time or how prevalence of casemix conditions may differ by industry segment. This study attempted to replicate the case mix used to set the PPS payment weights and to analyze trends and potential disparities in case-mix prevalence. USRDS claims and eligibility data from 2000-2008 were used to calculate prevalence of each PPS case-mix condition for all Medicare fee-for-service patients aged 18+ yrs who were on dialysis during the 9-year study period (N=25.7M patient months). Case-mix definitions replicated the PPS reimbursement definitions as closely as possible. Three 3-year cohorts (2000-2002, 2003-2005, 2006-2008) were analyzed for trends. Data were stratified by facility characteristics of organization size, profit status, region, and urban vs rural location. Double-digit trends were observed in many case-mix categories between 2000-2002 and 2006-2008. Large declines were observed in prevalence of low BMI patients (-33.4%), prevalence of pericarditis (-23.4%), patients in the first 4 months of dialysis (-13.0%), and patients aged 18-44 yrs (-12.5%). Large increases were observed in all chronic comorbidities (myelodysplastic syndrome [+169%], monoclonal gammopathy [+140%], hemolytic and sickle cell anemias [+94.4%]) as well as in prevalence of bacterial pneumonia (+26.7%) and patients aged 80+ yrs (+16.1%). Changes in case-mix prevalence over time suggest that the PPS payment formula should be regularly updated to reflect current case mix. CMS should publish the prevalence of each case-mix category used in setting payment rates.
A56
151 CONTROLLING ANTIBIOTIC DOSING ERRORS IN PATIENTS WITH IMPAIRED RENAL FUNCTION USING AN EMR ALERT
Tamer Hudali, Ahmad Almomani, Leah Low, Meredith Masel. University of Texas Medical Branch at Galveston, Galveston, Tx. Frequently medication dosing is not adjusted correctly in patients with CKD, resulting in many avoidable adverse outcomes such as worsening renal function, medication toxicity, and death. This problem originates from either decreased awareness of the patient’s estimated GFR and/or a lack of knowledge regarding the prescribed medication. in this QI project we aimed to reduce antibiotic dosing errors in renally impaired patients by 20% in a 3 month period through implementing an alert in our electronic medical record (EMR) at John Sealy Hospital. After discussing the possible areas of intervention and reviewing the fishbone diagram and process flow chart, we chose the EMR as the tool for intervention. Six antibiotics were chosen based on the frequency of use in our institution. These antibiotics were: Vancomycin, Piperacillin-Tazobactam, Levofloxacin, Cefepime, Ertapanem and Meropenem. Antibiotic orders were collected and reviewed to assess the rates of wrong dosing based on the GFR. The GFR was calculated using the MDRD formula. Patients with acute kidney injury were excluded from this data analysis. The clinical indications of the antibiotics were considered when assessing the appropriate dose requiring adjustment. We compared dosing error rates between the two sets of data collected before and after the intervention. Patients on dialysis were studied separately. The total error percentage decreased significantly after the alert system was launched. The percentage of errors before the intervention was 15.4%, and the percentage of errors after the intervention was 3.7%. To assess the significance of these results, a one sided Z-score test was performed. Z score: 9.5002 with a P value of < 0.000001. A successful reduction in dosing errors adjusted renally of 6 antibiotics was achieved using an EMR alert with a statistically significant results.
152 RENAL INSUFFICIENCY AND DIASTOLIC DYSFUNCTION Tamer Hudali, Sangeeta Mutnuri, Adnan Khan, Roozbeh Sharif, Van Hoang, Mohammad A Morsy, Wissam Khalife University of Texas Medical Branch at Galveston, Galveston, Tx. Reduced estimated glomerular filtration rate (eGFR) has been shown to be significantly associated with heart failure in previous studies. However, there is no studies comparing the linear association between the severity of renal insufficiency (RI) and the degree of diastolic dysfunction (DD). We aimed to investigate the association of RI with DD among patients with preserved systolic function and examine whether the severity of RI correlates with the degree of DD. In this observational retrospective study, we reviewed the echocardiograms of patients who presented to ambulatory clinics of a tertiary academic medical center. Study population included 1329 DD patients with LVEF>50% and 308 randomly selected normal controls. Demographic and clinical variables were compared between patients with DD and normal controls. Patients with impaired relaxation (grade I) were compared to those with pseudonormal (grade II) or restrictive (grade III) DD. RI was defined as eGFR<60mL/min/1.73 m2 within 6 months prior to the echocardiogram. Student’s t-test and chi-square were used for univariable analysis. We utilized logistic regression analysis with a forward hierarchical variable selection strategy to investigate independent correlation of RI with DD and its severity. Among the 1329 patients with DD, 1238 (93.2%) had grade I, & 91 (6.8%) had grade II or III. Prevalence of RI among patients with any degree of DD was 30.8%, compared to 12.4% among normal controls (Odds ratio [OR]: 2.9, 95%CI: 2.1, 4.8, p<0.001). Similarly, patients with DD had lower eGFR compared to controls (76.9 vs. 95.3, p<0.001). In the multivariable analysis, the final model showed that after adjusting for age, sex, hypertension, and DM, RI is an independent correlate of DD (OR: 1.9, 95%CI: 1.1, 4.5, p=0.023). The same pattern was observed comparing the frequency of RI (45.3% vs. 25.9%, OR: 2.2, 95%CI: 1.4, 2.9, p=0.005) and level of GFR (83.5 vs. 64.8, p=0.002) in patients with DD (grades I,II and III). Our Study indicates a clear association between RI and DD. Also the severity of RI tends to correlate with the severity of DD.
Am J Kidney Dis. 2014;63(5):A1-A121
149 URETERAL STENT MAY NOT BE ASSOCIATED WITH THE DEVELOPMENT OF SIGNIFICANT BK VIRURIA AND/OR VIREMIA Marcos A. Hernandez Roman, Mohanram Narayanan. Scott and White Memorial Hospital, Temple, TX, USA. The incidence of BK virus infection has increased in renal transplant recipients without a definitive etiology. Some studies have identified an association with ureteral stent placement and BK viremia (BKV) or BK nephropathy (BKN), suggesting a potential role of ureteral trauma in the pathogenesis of BK infection. No studies have found an association of ureteral stent duration with significant BK viruria (BKU), BKV, or BKN. We aimed to evaluate the risk of BKU and BKV adjusted for presence and duration of ureteral stent. A total of 93 kidney transplant recipients included in this analysis were followed for at least 1 year. Surgeon A performed 48 (52%) cases and Surgeon B performed 45 (48%) cases. Surgeon B routinely places a stent and Surgeon A does not. The stent was removed at a median (minimum-maximum) time of 94 (9-964) days from the transplant. The overall incidence of BKU and BKV was 42.2% and 26.8% of tested patients respectively. There was no significant difference between subjects with and without ureteral stent placement in BKU (p= 0.72) or BKV (p= 0.97), or duration of stent for BKU (p= 0.56) or BKV (p= 0.85). Multiple risk factors have been described in association with the development of BKU and BKV without a single study accounting for all possible factors. Since it is axiomatic that the dose makes the poison, one would have expected to see a clear relationship of not only stent presence, but also its duration with BKU and BKV.
150 TRENDS IN ESRD PPS CASE-MIX PREVALENCE IN THE MEDICARE FEE-FOR-SERVICE POPULATION 2000-2008
Christopher S Hollenbeak,1 Robert J Rubin,2 Spiros Tzivelekis,3 Mark Stephens4 1 Pennsylvania State University College of Medicine, Hershey, PA, USA; 2Georgetown University School of Medicine, Washington DC, USA; 3Amgen Inc., Thousand Oaks, CA, USA; 4Prima Health Analytics, Boston, MA, USA The ESRD PPS used patient case mix from the 2006-08 Medicare fee-for-service population to set weights for each case-mix adjuster in the payment formula. The case mix used was not made public, and little is known about case-mix trends over time or how prevalence of casemix conditions may differ by industry segment. This study attempted to replicate the case mix used to set the PPS payment weights and to analyze trends and potential disparities in case-mix prevalence. USRDS claims and eligibility data from 2000-2008 were used to calculate prevalence of each PPS case-mix condition for all Medicare fee-for-service patients aged 18+ yrs who were on dialysis during the 9-year study period (N=25.7M patient months). Case-mix definitions replicated the PPS reimbursement definitions as closely as possible. Three 3-year cohorts (2000-2002, 2003-2005, 2006-2008) were analyzed for trends. Data were stratified by facility characteristics of organization size, profit status, region, and urban vs rural location. Double-digit trends were observed in many case-mix categories between 2000-2002 and 2006-2008. Large declines were observed in prevalence of low BMI patients (-33.4%), prevalence of pericarditis (-23.4%), patients in the first 4 months of dialysis (-13.0%), and patients aged 18-44 yrs (-12.5%). Large increases were observed in all chronic comorbidities (myelodysplastic syndrome [+169%], monoclonal gammopathy [+140%], hemolytic and sickle cell anemias [+94.4%]) as well as in prevalence of bacterial pneumonia (+26.7%) and patients aged 80+ yrs (+16.1%). Changes in case-mix prevalence over time suggest that the PPS payment formula should be regularly updated to reflect current case mix. CMS should publish the prevalence of each case-mix category used in setting payment rates.
A56
151 CONTROLLING ANTIBIOTIC DOSING ERRORS IN PATIENTS WITH IMPAIRED RENAL FUNCTION USING AN EMR ALERT
Tamer Hudali, Ahmad Almomani, Leah Low, Meredith Masel. University of Texas Medical Branch at Galveston, Galveston, Tx. Frequently medication dosing is not adjusted correctly in patients with CKD, resulting in many avoidable adverse outcomes such as worsening renal function, medication toxicity, and death. This problem originates from either decreased awareness of the patient’s estimated GFR and/or a lack of knowledge regarding the prescribed medication. in this QI project we aimed to reduce antibiotic dosing errors in renally impaired patients by 20% in a 3 month period through implementing an alert in our electronic medical record (EMR) at John Sealy Hospital. After discussing the possible areas of intervention and reviewing the fishbone diagram and process flow chart, we chose the EMR as the tool for intervention. Six antibiotics were chosen based on the frequency of use in our institution. These antibiotics were: Vancomycin, Piperacillin-Tazobactam, Levofloxacin, Cefepime, Ertapanem and Meropenem. Antibiotic orders were collected and reviewed to assess the rates of wrong dosing based on the GFR. The GFR was calculated using the MDRD formula. Patients with acute kidney injury were excluded from this data analysis. The clinical indications of the antibiotics were considered when assessing the appropriate dose requiring adjustment. We compared dosing error rates between the two sets of data collected before and after the intervention. Patients on dialysis were studied separately. The total error percentage decreased significantly after the alert system was launched. The percentage of errors before the intervention was 15.4%, and the percentage of errors after the intervention was 3.7%. To assess the significance of these results, a one sided Z-score test was performed. Z score: 9.5002 with a P value of < 0.000001. A successful reduction in dosing errors adjusted renally of 6 antibiotics was achieved using an EMR alert with a statistically significant results.
152 RENAL INSUFFICIENCY AND DIASTOLIC DYSFUNCTION Tamer Hudali, Sangeeta Mutnuri, Adnan Khan, Roozbeh Sharif, Van Hoang, Mohammad A Morsy, Wissam Khalife University of Texas Medical Branch at Galveston, Galveston, Tx. Reduced estimated glomerular filtration rate (eGFR) has been shown to be significantly associated with heart failure in previous studies. However, there is no studies comparing the linear association between the severity of renal insufficiency (RI) and the degree of diastolic dysfunction (DD). We aimed to investigate the association of RI with DD among patients with preserved systolic function and examine whether the severity of RI correlates with the degree of DD. In this observational retrospective study, we reviewed the echocardiograms of patients who presented to ambulatory clinics of a tertiary academic medical center. Study population included 1329 DD patients with LVEF>50% and 308 randomly selected normal controls. Demographic and clinical variables were compared between patients with DD and normal controls. Patients with impaired relaxation (grade I) were compared to those with pseudonormal (grade II) or restrictive (grade III) DD. RI was defined as eGFR<60mL/min/1.73 m2 within 6 months prior to the echocardiogram. Student’s t-test and chi-square were used for univariable analysis. We utilized logistic regression analysis with a forward hierarchical variable selection strategy to investigate independent correlation of RI with DD and its severity. Among the 1329 patients with DD, 1238 (93.2%) had grade I, & 91 (6.8%) had grade II or III. Prevalence of RI among patients with any degree of DD was 30.8%, compared to 12.4% among normal controls (Odds ratio [OR]: 2.9, 95%CI: 2.1, 4.8, p<0.001). Similarly, patients with DD had lower eGFR compared to controls (76.9 vs. 95.3, p<0.001). In the multivariable analysis, the final model showed that after adjusting for age, sex, hypertension, and DM, RI is an independent correlate of DD (OR: 1.9, 95%CI: 1.1, 4.5, p=0.023). The same pattern was observed comparing the frequency of RI (45.3% vs. 25.9%, OR: 2.2, 95%CI: 1.4, 2.9, p=0.005) and level of GFR (83.5 vs. 64.8, p=0.002) in patients with DD (grades I,II and III). Our Study indicates a clear association between RI and DD. Also the severity of RI tends to correlate with the severity of DD.
Am J Kidney Dis. 2014;63(5):A1-A121