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IMPLEMENTATION OF ELECTRONIC HEALTH RECORD (EHR) AND PATIENT SA TISF ACTION IN OUTPATIENT NEPHROLOGY SETTING
NKF 2014 Spring Clinical Meetings Abstracts
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91 IMPLEMENTATION OF ELECTRONIC HEALTH RECORD (EHR) AND PATIENT SATISFACTION IN OUTPATIENT NEPHROLOGY SETTING: Annie Culver, Tarik Noureldeen, Neeharika Muddana, Jones John, Mahboob Khan, Swati Arora, Kalathil K. Sureshkumar, Richard J. Marcus and Barbara A. Clark. Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, Pennsylvania, United States The goal of EHR implementation is to improve healthcare quality by reducing medical errors and increasing overall patient satisfaction. We aimed to assess patient satisfaction in the setting of EHR implementation. Anonymous cross-sectional patient surveys were conducted from Nov 2011 to Dec 2012 during 3 phases of EHR implementation (pre, start and post-EHR) in the domains of exam room wait, MD charting, visit length/satisfaction, and perception of improved care. A total of 187 surveys were obtained. There was an increase in exam room wait time (P=0.01) and visit length (P=0.03) with a decrease in patient satisfaction (P=0.02) as shown in the table. Pre-EHR Start-EHR Post-EHR P value (n=52) (n=41) (n=94) Exam room wait 9±6 12±9 15±15 0.01 (min) MD Charting 10±10 13±13 14±12 0.21 (min) Visit Length 33±19 37±17 42±19 0.03 (min) Visit Satisfaction 1.9±0.6 1.7±0.4 1.6±0.7 0.02 (-2 to 2) Improved Care .04±1.2 0.8±1.1 0.8±1.1 0.12 (-2 to 2) After implementation of EHR in our nephrology outpatient clinic, patient's wait time and length of visit increased significantly, resulting in decreased patient satisfaction. This could be related to inexperience of staff with the EHR. We plan to do a follow up study in one year to get past the learning curve. Despite these observations, there was a trend towards improved patient perception regarding overall care.
A NON-VASCULAR TREATMENT FOR RESISTANT HYPERTENSION: PRECLINICAL AND EARLY CLINICAL EXPERIENCE Randy Cooper, Terrence J. Buelna, Winton L. Berci, Brad S. Hubbard, DVM, Mihir Desai, Richard R. Heuser, University of Arizona, Phoenix, Arizona, USA Interruption of renal afferent nerve activity attenuates systemic sympathetic tone, thereby lowering blood pressure. The natural orifice denervation system developed by Verve Medical directs radiofrequency energy to the renal pelvis where the preponderance of afferent nerves are closely accessible. We present our early porcine studies evaluating histopathology of the renal pelvis following local delivery of radiofrequency energy. Assessment of nerve ablation as well as HPLC determination of norepinephrine concentration was performed. At the time of the presentation, we will present our first-in-man experience. Sixteen female domestic swine weighing 60-65kg underwent renal pelvic denervation via ureteral access. Three animals were euthanized immediately after delivery of RF energy; five animals at 7 days, 6 animals at 14 days and 2 animals at 30 days. Renal cortical norepinephrine levels were measured in all groups of animals. Histopathology of the treated zone was performed to confirm nerve damage. The Verve Medical device was passed retrograde over a 0.035" guidewire from the bladder to the renal pelvis and RF ablation was performed in both kidneys. In 2 animals, RF energy was not applied to the contralateral kidney (sham procedure). Bilateral pyelogram, ureterogram, and renal angiography were performed prior to euthanasia in 2 of the 7 day animals and all of the 14 and 30 day animals. Renal cortical tissue was harvested for determination of tissue norepinephrine concentration by HPLC. The kidneys were then perfusion fixed and harvested for histopathologic analysis. Mean reduction of norepinephrine levels was 57%, compared to control. Histopathology confirmed nerve ablation in the treated zone with no parenchymal or vascular thermal injury. In this small series of acute and chronic animals, we see a promising non-vascular alternative for renal denervation. The first in man experience will be available at the time of the presentation.
90 RANDOMIZED MULTICENTER TRIAL OF PARICALCITOL VERSUS CALCITRIOL FOR TREATMENT OF SECONDARY HYPERPARATHYROIDISM (SHPT) IN STAGE 3 AND 4 CKD Daniel Coyne, Seth Goldberg, Mark Faber, Cybele Ghossein, Stuart Sprague. Washington University, St. Louis, MO, Henry Ford Hospital, Detroit MI, Northwestern University, Chicago IL, and Northshore University Health System, Evanston IL, USA Purpose: Calcitriol and paricalcitol are used to treat SHPT but can induce hypercalcemia and hyperphosphatemia. Paricalcitol is less calcemic and phosphatemic in preclinical studies and in some trials in dialysis patients, but head-to-head comparisons of these agents in nondialysis patients is lacking. Methods: We randomized 110 CKD patients with PTH >120pg/ml to 0.25 mcg/day of calcitriol or 1 mcg/day of paricalcitol. Subsequent dose adjustments were by protocol to achieve 40 – 60% PTH suppression. Results: Forty-five patients in each group completed the 24 weeks of treatment. Both agents suppressed PTH effectively, (-52% with paricalcitol, -46% with calcitriol, p = 0.17), though the paricalcitol group tended to reach 40% reduction in PTH sooner (p=0.08), and with lower pill burden (p=0.01). The primary endpoint, confirmed hypercalcemia of >10.5 mg/dL, was very low in both groups (3 with paricalcitol; 1 with calcitriol) and not significantly different (p = 0.36). Both groups had small increases in calcium and phosphorus levels (0.30.4 mg/dL in each electrolyte), and significant decreases in alkaline phosphatase, a marker of high bone turnover, with no significant differences between groups. Conclusion: Both calcitriol and paricalcitol achieve sustained PTH and alkaline phosphatase suppression in CKD stage 3 and 4, with small effects on serum calcium and phosphorus, and a low incidence of hypercalcemia when targeting PTH to 40-60% below pretreatment levels.
Am J Kidney Dis. 2014;63(5):A1-A121
92 OUTCOMES OF ACUTE KIDNEY INJURY (AKI) IN BLOODLESS MEDICINE COMPARED WITH TRANSFUSION ELIGIBLE PATIENTS. Annie Culver, Liliana Osadchuk, Mahboob Khan, Richard Marcus, Barbara Clark. Allegheny General Hospital, Pittsburgh, PA AKI can occur in bloodless medicine patients who elect management without transfusions for anemia. To determine if outcomes were different in AKI in these patients, a two-year retrospective chart review of patients with AKI managed with intravenous iron revealed 71 patients. 14 of these were bloodless and 56 were transfusion eligible. We compared outcomes after matching for severity of AKI. Bloodless Transfusion Eligible Age,gender 74± 4yr, 7M/7F 61± 2yr, 36M/20F AKI stage 1 2 3 1 2 3 AKI # 6/14 5/14 3/14 11/56 13/56 33/56 los (days) 11±3 8± 8 23±3 12± 3 16± 4 34± 6 ICU days 8±4 3±1 4±3 4±2 5±3 19±4 sCr: baseln 1.0±.2 1.7±.5 0.7±.2 1.8±.2 1.6± .2 1.1± .1 admission
1.2±.2
2.2±.4
2.2±1
2.6±.4
2.8±0.4
2.7±.3
peak
1.7±.2
2.9±.5
4.2±1
2.8±.4
3.4±.3
5.8±.5
1.1±.2 2.0±.5 1.5±.3 10±1 7.6±1 6±2* 7±.2 6.5±1 4±2* 8±.3 7±1* 7±2* 2 2 1 10426±3309*
2.0±.4 9±.6 7.6±.5 9.2±.4 1
2.4±.3 10±.5 7.8±.2 9±.3 1 2701±721
2.8±.4 10.6±.4 7.3±.1 9.1±.2 11
D/C Hb: adm lowest D/C mortality
Epo (Hb= hemoglobin, mg/dl; sCr=serum creatinine, mg/dl) Anemia was more severe in bloodless (*p<0.05). No significant difference in mortality (5/14 vs 13/56, p= 0.265), length of stay (los) or ICU days when matched for AKI disease severity was seen. Epo use (units/los) was greater in these bloodless patients (*p<0.05). In summary, despite more severe anemia, AKI has similar outcomes in patients managed exclusively without transfusion compared with similar severity of AKI in those who are transfusion eligible but utilizes more erythropoietin (Epo).
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91 IMPLEMENTATION OF ELECTRONIC HEALTH RECORD (EHR) AND PATIENT SATISFACTION IN OUTPATIENT NEPHROLOGY SETTING: Annie Culver, Tarik Noureldeen, Neeharika Muddana, Jones John, Mahboob Khan, Swati Arora, Kalathil K. Sureshkumar, Richard J. Marcus and Barbara A. Clark. Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, Pennsylvania, United States The goal of EHR implementation is to improve healthcare quality by reducing medical errors and increasing overall patient satisfaction. We aimed to assess patient satisfaction in the setting of EHR implementation. Anonymous cross-sectional patient surveys were conducted from Nov 2011 to Dec 2012 during 3 phases of EHR implementation (pre, start and post-EHR) in the domains of exam room wait, MD charting, visit length/satisfaction, and perception of improved care. A total of 187 surveys were obtained. There was an increase in exam room wait time (P=0.01) and visit length (P=0.03) with a decrease in patient satisfaction (P=0.02) as shown in the table. Pre-EHR Start-EHR Post-EHR P value (n=52) (n=41) (n=94) Exam room wait 9±6 12±9 15±15 0.01 (min) MD Charting 10±10 13±13 14±12 0.21 (min) Visit Length 33±19 37±17 42±19 0.03 (min) Visit Satisfaction 1.9±0.6 1.7±0.4 1.6±0.7 0.02 (-2 to 2) Improved Care .04±1.2 0.8±1.1 0.8±1.1 0.12 (-2 to 2) After implementation of EHR in our nephrology outpatient clinic, patient's wait time and length of visit increased significantly, resulting in decreased patient satisfaction. This could be related to inexperience of staff with the EHR. We plan to do a follow up study in one year to get past the learning curve. Despite these observations, there was a trend towards improved patient perception regarding overall care.
A NON-VASCULAR TREATMENT FOR RESISTANT HYPERTENSION: PRECLINICAL AND EARLY CLINICAL EXPERIENCE Randy Cooper, Terrence J. Buelna, Winton L. Berci, Brad S. Hubbard, DVM, Mihir Desai, Richard R. Heuser, University of Arizona, Phoenix, Arizona, USA Interruption of renal afferent nerve activity attenuates systemic sympathetic tone, thereby lowering blood pressure. The natural orifice denervation system developed by Verve Medical directs radiofrequency energy to the renal pelvis where the preponderance of afferent nerves are closely accessible. We present our early porcine studies evaluating histopathology of the renal pelvis following local delivery of radiofrequency energy. Assessment of nerve ablation as well as HPLC determination of norepinephrine concentration was performed. At the time of the presentation, we will present our first-in-man experience. Sixteen female domestic swine weighing 60-65kg underwent renal pelvic denervation via ureteral access. Three animals were euthanized immediately after delivery of RF energy; five animals at 7 days, 6 animals at 14 days and 2 animals at 30 days. Renal cortical norepinephrine levels were measured in all groups of animals. Histopathology of the treated zone was performed to confirm nerve damage. The Verve Medical device was passed retrograde over a 0.035" guidewire from the bladder to the renal pelvis and RF ablation was performed in both kidneys. In 2 animals, RF energy was not applied to the contralateral kidney (sham procedure). Bilateral pyelogram, ureterogram, and renal angiography were performed prior to euthanasia in 2 of the 7 day animals and all of the 14 and 30 day animals. Renal cortical tissue was harvested for determination of tissue norepinephrine concentration by HPLC. The kidneys were then perfusion fixed and harvested for histopathologic analysis. Mean reduction of norepinephrine levels was 57%, compared to control. Histopathology confirmed nerve ablation in the treated zone with no parenchymal or vascular thermal injury. In this small series of acute and chronic animals, we see a promising non-vascular alternative for renal denervation. The first in man experience will be available at the time of the presentation.
90 RANDOMIZED MULTICENTER TRIAL OF PARICALCITOL VERSUS CALCITRIOL FOR TREATMENT OF SECONDARY HYPERPARATHYROIDISM (SHPT) IN STAGE 3 AND 4 CKD Daniel Coyne, Seth Goldberg, Mark Faber, Cybele Ghossein, Stuart Sprague. Washington University, St. Louis, MO, Henry Ford Hospital, Detroit MI, Northwestern University, Chicago IL, and Northshore University Health System, Evanston IL, USA Purpose: Calcitriol and paricalcitol are used to treat SHPT but can induce hypercalcemia and hyperphosphatemia. Paricalcitol is less calcemic and phosphatemic in preclinical studies and in some trials in dialysis patients, but head-to-head comparisons of these agents in nondialysis patients is lacking. Methods: We randomized 110 CKD patients with PTH >120pg/ml to 0.25 mcg/day of calcitriol or 1 mcg/day of paricalcitol. Subsequent dose adjustments were by protocol to achieve 40 – 60% PTH suppression. Results: Forty-five patients in each group completed the 24 weeks of treatment. Both agents suppressed PTH effectively, (-52% with paricalcitol, -46% with calcitriol, p = 0.17), though the paricalcitol group tended to reach 40% reduction in PTH sooner (p=0.08), and with lower pill burden (p=0.01). The primary endpoint, confirmed hypercalcemia of >10.5 mg/dL, was very low in both groups (3 with paricalcitol; 1 with calcitriol) and not significantly different (p = 0.36). Both groups had small increases in calcium and phosphorus levels (0.30.4 mg/dL in each electrolyte), and significant decreases in alkaline phosphatase, a marker of high bone turnover, with no significant differences between groups. Conclusion: Both calcitriol and paricalcitol achieve sustained PTH and alkaline phosphatase suppression in CKD stage 3 and 4, with small effects on serum calcium and phosphorus, and a low incidence of hypercalcemia when targeting PTH to 40-60% below pretreatment levels.
Am J Kidney Dis. 2014;63(5):A1-A121
92 OUTCOMES OF ACUTE KIDNEY INJURY (AKI) IN BLOODLESS MEDICINE COMPARED WITH TRANSFUSION ELIGIBLE PATIENTS. Annie Culver, Liliana Osadchuk, Mahboob Khan, Richard Marcus, Barbara Clark. Allegheny General Hospital, Pittsburgh, PA AKI can occur in bloodless medicine patients who elect management without transfusions for anemia. To determine if outcomes were different in AKI in these patients, a two-year retrospective chart review of patients with AKI managed with intravenous iron revealed 71 patients. 14 of these were bloodless and 56 were transfusion eligible. We compared outcomes after matching for severity of AKI. Bloodless Transfusion Eligible Age,gender 74± 4yr, 7M/7F 61± 2yr, 36M/20F AKI stage 1 2 3 1 2 3 AKI # 6/14 5/14 3/14 11/56 13/56 33/56 los (days) 11±3 8± 8 23±3 12± 3 16± 4 34± 6 ICU days 8±4 3±1 4±3 4±2 5±3 19±4 sCr: baseln 1.0±.2 1.7±.5 0.7±.2 1.8±.2 1.6± .2 1.1± .1 admission
1.2±.2
2.2±.4
2.2±1
2.6±.4
2.8±0.4
2.7±.3
peak
1.7±.2
2.9±.5
4.2±1
2.8±.4
3.4±.3
5.8±.5
1.1±.2 2.0±.5 1.5±.3 10±1 7.6±1 6±2* 7±.2 6.5±1 4±2* 8±.3 7±1* 7±2* 2 2 1 10426±3309*
2.0±.4 9±.6 7.6±.5 9.2±.4 1
2.4±.3 10±.5 7.8±.2 9±.3 1 2701±721
2.8±.4 10.6±.4 7.3±.1 9.1±.2 11
D/C Hb: adm lowest D/C mortality
Epo (Hb= hemoglobin, mg/dl; sCr=serum creatinine, mg/dl) Anemia was more severe in bloodless (*p<0.05). No significant difference in mortality (5/14 vs 13/56, p= 0.265), length of stay (los) or ICU days when matched for AKI disease severity was seen. Epo use (units/los) was greater in these bloodless patients (*p<0.05). In summary, despite more severe anemia, AKI has similar outcomes in patients managed exclusively without transfusion compared with similar severity of AKI in those who are transfusion eligible but utilizes more erythropoietin (Epo).
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