Utility of an adverse drug event trigger tool in Veterans Affairs nursing facilities.

OBJECTIVE: To determine the utility (i.e., positive predictive value [PPV] and time requirement) of an adverse drug event (ADE) trigger tool in Veterans Affairs (VA) nursing facilities and to describe the most common types of potential ADEs detected with the trigger tool. DESIGN: Retrospective chart review. SETTING/PATIENTS: Veterans residing in three VA nursing facilities between September 29, 2010, and October 29, 2010. MEASUREMENT: We used the Institute for Healthcare Improvement-endorsed nursing facility ADE trigger tool, modified to enhance its clinical relevance to detect potential ADEs. Electronic medical records were screened to identify residents with one or more abnormal laboratory values specified in the trigger tool. MAIN OUTCOME MEASURES: A potential ADE was defined as the concurrent administration of medication that could cause the abnormal laboratory value. An overall PPV, or proportion of residents with an abnormal laboratory value who had a potential ADE, and average time required to complete each trigger tool assessment, were calculated. RESULTS: Among 321 veterans, 50.5% (n = 162) had at least one abnormal laboratory value contained in the trigger tool. Ninety-nine potential ADEs involving 146 medications were detected in 65 veterans. The overall PPV of the ADE trigger tool was 40.1% (65/162), and the average time to complete resident assessments was 8.8 (standard deviation ± 5.7) minutes. The most common potential ADEs were acute kidney injury (n = 30 residents), hypokalemia (n = 18), hypoglycemia (n = 13), and hyperkalemia (n = 10). CONCLUSIONS: The modified nursing facility trigger tool was shown to be an effective and efficient method for detecting potential ADEs.

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.

Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly.

PURPOSE: To determine if inpatient or outpatient geriatric evaluation and management, as compared with usual care, reduces adverse drug reactions and suboptimal prescribing in frail elderly patients. METHODS: The study employed a randomized 2 x 2 factorial controlled design. Subjects were patients in 11 Veterans Affairs (VA) hospitals who were > or =65 years old and met criteria for frailty (n = 834). Inpatient geriatric unit and outpatient geriatric clinic teams evaluated and managed patients according to published guidelines and VA standards. Patients were followed for 12 months. Blinded physician-pharmacist pairs rated adverse drug reactions for causality (using Naranjo's algorithm) and seriousness. Suboptimal prescribing measures included unnecessary and inappropriate drug use (Medication Appropriateness Index), inappropriate drug use (Beers criteria), and underuse. RESULTS: For serious adverse drug reactions, there were no inpatient geriatric unit effects during the inpatient or outpatient follow-up periods. Outpatient geriatric clinic care resulted in a 35% reduction in the risk of a serious adverse drug reaction compared with usual care (adjusted relative risk = 0.65; 95% confidence interval: 0.45 to 0.93). Inpatient geriatric unit care reduced unnecessary and inappropriate drug use and underuse significantly during the inpatient period (P <0.05). Outpatient geriatric clinic care reduced the number of conditions with omitted drugs significantly during the outpatient period (P <0.05). CONCLUSION: Compared with usual care, outpatient geriatric evaluation and management reduces serious adverse drug reactions, and inpatient and outpatient geriatric evaluation and management reduces suboptimal prescribing, in frail elderly patients.