Own your own prescriptions (part 2)

[ventana]

Interesting article  https://www.medscape.com/viewarticle/923383

 

Kidney Disease Up as Prescribing Errors Exacerbate the Problem

Nancy A. Melville

 

January 06, 2020

The prevalence of chronic kidney disease (CKD), as well as its major risk factors, has steadily increased in recent years, yet measures to identify, treat, and avoid medications that can exacerbate the disease remain low, new research indicates.

 

These latest findings reveal "a burgeoning number of patients with CKD and its major risk factors. Rates of identification and use of kidney protective agents were low, while potential nephrotoxin use was widespread, underscoring the pressing need for practice-based improvements in CKD prevention, recognition, and treatment" conclude the authors of the study published December 20 in JAMA Network Open.

 

"These real-world data lay the groundwork for the development of more effective strategies to deliver care that enhances wellness and survival for patients with, and at risk for, CKD," they add.

For the cohort study, first author Katherine R. Tuttle, MD, and colleagues analyzed data from the Center for Kidney Disease Research, Education, and Hope (CURE-CKD) registry of electronic health records, sponsored by Providence St Joseph Health and the University of California, Los Angeles.

The CURE-CKD registry is considered to be among the world's most comprehensive CKD registries, featuring extensive patient-level data on laboratory measures, prescriptions, and vital signs, combined with administrative codes, they note.

 

 

Albuminuria and Proteinuria Testing for CKD Rarely Reported

The registry sample of 2,625,963 patients included adults and children with CKD, although it excluded those with end-stage kidney disease and adults considered at risk of CKD because of conditions including prediabetes, diabetes, or hypertension.

Among those in the registry sample, 606,064 (23.1%) of the adult patients met the registry's criteria for CKD, assessed by a combination of estimated glomerular filtration rate (eGFR), albuminuria, and proteinuria measures, and administrative code criteria.

Overall, the prevalence of CKD represented 4.8% of the total of 12.6 million patients who received care at the two centers between 2006 and 2017.

 

A breakdown of time periods showed the prevalence of CKD increased over time, from just 1.6% of people from 2006 to 2009; to 5.7% from 2010 to 2013; and up to 8.4% from 2014 to 2017 (P < .001).

 

Those with CKD were a median age of 70 (range 59-81) years; 55.9% were female and 71.7% were non-Latino white individuals.

 

The authors note, however, that after adjusting for age, sex, and race/ethnicity, the CKD prevalence was 22.6% when assessed according to persistently low eGFR alone.

 

Of the 12,591 children with CKD in the group (0.4%), the median age was 6 (1-13) years; 56.2% were girls and 52.8% were non-Latino white children.

 

In terms of eGFR, 22.7% of patients had category 1-2 CKD, more than half had category 3 CKD — including 37.4% with category 3a and 16.5% with category 3b — 6.5% had category 4, 3.4% had category 5, and 13.5% were uncategorized.

 

Among the adults with CKD, albuminuria assessments were available for just 52,551 (8.7%) patients, and proteinuria measures were available for fewer — only 25,035 (4.1%) patients.

 

"Albuminuria and proteinuria testing for CKD assessment were rarely reported," the authors note. 

 

Renoprotective Drugs Not Prescribed Enough

Meanwhile, renin-angiotensin system (RAS) inhibitor drugs, which are renoprotective, were only prescribed to about one fifth (20.6%) of adult patients with CKD.

 

And potentially harmful nephrotoxins, such as nonsteroidal anti-inflammatory agents (NSAIDs) or proton pump inhibitors (PPIs), were prescribed to a third, or 33.7%, of the patients with CKD.

 

Although a greater increase was observed in uptake of RAS inhibitors among adults with CKD categories 3a to 5 over time, NSAID and PPI prescribing also rose.

 

For the 75.1% of patients in the cohort who did not have CKD but were considered at risk, 26% had diabetes, considered the leading cause of CKD, or prediabetes, and 48.4% had hypertension, the second most frequent cause of CKD.

 

About a quarter (25.6%) had hypertension in addition to diabetes or prediabetes.

 

"The present findings from CURE-CKD point to the critical need for quality improvement and research at the point of care," Tuttle, of Providence St Joseph Health, Providence Medical Research Center, Spokane, Washington, and coauthors, stress.

 

"Although nearly two thirds of the adults with CKD had diabetes, hypertension, or prediabetes, rates of laboratory testing for albuminuria or proteinuria and of prescribing ACE inhibitors or ARBs were low," they stress.

 

Meanwhile, "Potentially nephrotoxic agents (ie, NSAIDs and PPIs) were used more commonly than RAS inhibitors," they note.

 

And "Given the most common cause of death in CKD is cardiovascular disease, the low use of preventive agents, such as statins and aspirin, is also concerning," they conclude.

 

JAMA Netw Open. 2019;2:e1918169. Full text

 

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Cite this: Kidney Disease Up as Prescribing Errors Exacerbate the Problem - Medscape - Jan 06, 2020.

 

[dfw6er]

Yeah I totally believe this.  I can't tell you how many times I've run across diabetics, hypertensives, etc who's PCP have never screened them for microalbuminuria.  But honestly lots of PCPs aren't doing a good job with preventive medicine in general.  Too many don't screen baby boomers for Hep C or vaccinate those with risk factors against pneumococcal disease.  IIRC there've been numerous studies showing how bad PCPs are at even getting 50 year olds to get CRC screening.  

As for NSAIDs....I've even caught my coworkers prescribing them to patients with impaired GFRs.   The response when challenged has been...."well, their GFR isn't that bad....and I don't want to give them a Norco prescription."

 

[Mayamom]

When I was in practice I tried to get people off PPI.  Was near impossible.  And with the opioid hysteria providers are going to push the limit with CKD and NSAID,.    GI bleeds are also going to be increasing again.  

[thinkertdm]

I guess I'm missing the anger directed at providers in general.  I would say the fault (mostly) is on administration and the push to move medicine, of all things, into a retail, commercial enterprise.  In two of the three civilian jobs I've been at, I saw four patients an hour.  Given the ma/lpn time, I have what, seven? minutes to talk with the patient about his midsternal burning pain, ask enough questions to make sure it's not cardiac, make sure it's  not a GI bleed, make sure I'm not going to get sued...then talk with them about lifestyle interventions and risks vs benefits of medications.  Then face administrations wrath when press Haney scores are in the soup because I didn't write him for...anything.

ok, one down...twenty more to go, and the next guy has chronic knee pain that Tylenol "doesn't work".  I could sell him on weight loss, any number of better, long term pain management options, but damn, I'm already burnt out, and it's the second patient of the day.

Not an excuse to practice bad medicine, I know.  But medicine in general is a high stress occupation, even for us assistants.  Things in high stress situations are prone to breakage.  That's the elevator has a weight limit.  We have no warning signs, no schedule for maintenance.  Vacations are not an answer, they come once a year, temporarily take our mind off of work (if we take one), then it's back into the breach.  

Psychology trainees and probably psychologists have a "debriefing", where the stress can be safely offloaded.  We have no such outlet.

Another problem is the growing lack of responsibility on the part of the patient.  Little education in news and Social media.. .patients pick and choose what they want to do based upon the latest meme on Facebook.  I can't tell you how many people say they have a fever, yet dont have a thermometer.  How many people are not taking a cholesterol medication because it'll give them muscle pain.  

So yeah, lets blame docs, pas, and nps, and ignore the ceos and upper management staff who's "bonus" relies on productivity.

oh, lastly- we could stand up for ourselves and refuse to do it, refuse to go at that pace.  The problem is that everyone else in the practice thinks it's ok to provide mediocre care; they leave on time, and sleep well.  The rebel will always leave late, run behind, and burn out far faster than his substandard but administration ass kissing colleagues.

My two cents.

[Marinejiujitsu]

Totally agree. Besides people not really maintaining their proper preventative healthcare, and providers having to go faster and faster to keep their jobs. It's a recipe for disaster. Healthcare is going down the toilet.

Sent from my SM-N975U using Tapatalk

[Cideous]

On 1/8/2020 at 7:22 AM, thinkertdm said:

I guess I'm missing the anger directed at providers in general.  I would say the fault (mostly) is on administration and the push to move medicine, of all things, into a retail, commercial enterprise.  In two of the three civilian jobs I've been at, I saw four patients an hour.  Given the ma/lpn time, I have what, seven? minutes to talk with the patient about his midsternal burning pain, ask enough questions to make sure it's not cardiac, make sure it's  not a GI bleed, make sure I'm not going to get sued...then talk with them about lifestyle interventions and risks vs benefits of medications.  Then face administrations wrath when press Haney scores are in the soup because I didn't write him for...anything.

ok, one down...twenty more to go, and the next guy has chronic knee pain that Tylenol "doesn't work".  I could sell him on weight loss, any number of better, long term pain management options, but damn, I'm already burnt out, and it's the second patient of the day.

Not an excuse to practice bad medicine, I know.  But medicine in general is a high stress occupation, even for us assistants.  Things in high stress situations are prone to breakage.  That's the elevator has a weight limit.  We have no warning signs, no schedule for maintenance.  Vacations are not an answer, they come once a year, temporarily take our mind off of work (if we take one), then it's back into the breach.  

Psychology trainees and probably psychologists have a "debriefing", where the stress can be safely offloaded.  We have no such outlet.

Another problem is the growing lack of responsibility on the part of the patient.  Little education in news and Social media.. .patients pick and choose what they want to do based upon the latest meme on Facebook.  I can't tell you how many people say they have a fever, yet dont have a thermometer.  How many people are not taking a cholesterol medication because it'll give them muscle pain.  

So yeah, lets blame docs, pas, and nps, and ignore the ceos and upper management staff who's "bonus" relies on productivity.

oh, lastly- we could stand up for ourselves and refuse to do it, refuse to go at that pace.  The problem is that everyone else in the practice thinks it's ok to provide mediocre care; they leave on time, and sleep well.  The rebel will always leave late, run behind, and burn out far faster than his substandard but administration ass kissing colleagues.

My two cents

What an absolutely fantastic post.  Sitting at home eating lunch I actually stopped and read it word for word out load to my wife in the kitchen.  She is amazing and has always been the only other person in this world to understand the stress we are under.  She loved your post.  Thanks for writing it.

[surgblumm]

I am a believer. Why? Because my IM MD never mentioned CKD and as I looked at my lab work and past labs, I discovered that my eGFR was declining every year and my creatine and BUN had been elevated for the pst three years. I then went o my VA Medical Center where I have always had excellent help and was sent to their Renal Clinic and I have Grade lllA CKD. I am on top of this now but the article is a great warning and superb guidance for FP and IM.