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Reducing Emergency Department Visits due to Adverse Events from Medications

Reducing Emergency Department Visits due to Adverse Events from Medications. Daniel Budnitz MD, MPH, CDR USPHS Division of Healthcare Quality Promotion. USPHS Scientific & Training Symposium May 25, 2010. Disclaimer.

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Reducing Emergency Department Visits due to Adverse Events from Medications

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  1. Reducing Emergency Department Visits due to Adverse Events from Medications Daniel Budnitz MD, MPH, CDR USPHS Division of Healthcare Quality Promotion USPHS Scientific & Training Symposium May 25, 2010

  2. Disclaimer “The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention”

  3. An injury-based approach to medication safety Errors vs. harm Population-based harm data for priority setting Frequency, severity, preventability Patient-centered interventions Opportunities, collaboration & injury prevention Overview

  4. 1. An Injury-based Approach

  5. Bank Robber 1901 - 1980 http://www.fbi.gov/libref/historic/famcases/sutton/sutton.htm

  6. William SuttonGentleman, Innovator, &… Bank Robber 1901 - 1980 http://www.fbi.gov/libref/historic/famcases/sutton/sutton.htm

  7. “Slick Willie” SuttonGentleman, Innovator, &… Bank Robber “Why do you rob banks?” “Because, that’s where the money is.” 1901 - 1980 http://www.fbi.gov/libref/historic/famcases/sutton/sutton.htm

  8. Sutton’s Law & Drug Safety “Where the highest costs are incurred, therein lies the highest potential for over-all cost reduction” -- Sutton’s Law applied to management accounting

  9. Sutton’s Law & Drug Safety “Where the highest costs are incurred, therein lies the highest potential for over-all cost reduction” -- Sutton’s Law applied to management accounting “Where the highest number of adverse drug events (ADEs) occur, therein lies the highest potential for over-all harm reduction” -- Sutton’s Law applied to drug safety

  10. Mediation Safety in 2000s: Decade of Errors 2000 2006

  11. A Focus on Error Reduction… Errors Errors = Preventable events that may lead toinappropriate medication use or patient harm

  12. ... Rather Than Harm Reduction ADEs ADE = Injury (harm) caused by a drug

  13. Some Errors ∩ Harm Errors ADEs Injured Patient Stable Patient

  14. Why Not Start with Harms? Errors ADEs (Harms) Injured Patient

  15. Focus on Harms that are… Errors Serious, Common, Preventable Injured Patient

  16. Design Intervention Identify Risk & Protective Factors Identify the Harm Public Health Approach Evaluate Impact Population Surveillance Data Drive the Public Health Approach

  17. Design Intervention Identify Risk & Protective Factors Identify the Harm Public Health Approach Little national data on harms Evaluate Impact Population Surveillance Data Drive the Public Health Approach

  18. Identify the Harm January, 2000 Evaluate Impact “…the data on emergency department visits and hospital admissions are insufficient for estimating overall ADE frequency”

  19. 2. Population-based Harm Data for Priority Setting Frequency, severity, preventability

  20. Why Emergency Visits & Hospitalizations? Medication use 1 82% adults take at least 1 medicine 18% adults >64 take 10 or more 1. Slone Epidemiology Center at Boston University, 2008

  21. Why Emergency Visits & Hospitalizations? Medication use 1 82% adults take at least 1 medicine 18% adults >64 take 10 or more Medication costs 2 1. Slone Epidemiology Center at Boston University, 2008 2. Hoffman et al. Am J Health Syst Pharm2009;66:237-57

  22. Serious, Acute Harms: Emergency Departments (EDs) ED visit

  23. NEISS-CADES:Population Representative Surveillance • Stratified probability sample of 24-hour EDs • 63 hospitals • 4 strata by hospital size / 1 stratum for pediatric • Cases weighted by inverse probability of selection

  24. Case Definition (ADEs) Injury from the use of a drug: • Emergency department (ED) visit • Treating physician explicitly attributed • To a drug* • Intended for therapeutic use *Drugs include: Rx, OTC, Supplements, Vaccines Budnitz DS et al. JAMA 2006;296:1858-1866

  25. Estimated Annual Impact ofAmbulatory Adverse Drug Events2004-2005 Deaths ? 0.4 per 1,000 Hospitalizations >117,000 Emergency visits >700,000 2.4 per 1,000 > 3.6 million Office visits 14.3 per 1,000 Budnitz DS et al. JAMA 2006;296:1858-66 Zhan C et al. JtComm J Qual Patient Saf2005;7:372-8

  26. ED Visits for ADEs by Event Type, United States, 2004-2005 • Similar numbers of ED visit for allergic reactions, non-allergic adverse effects, and unintentional overdoses Budnitz DS et al. JAMA 2006;296:1858-1866 Budnitz, D. S. et al. JAMA 2006;296:1858-1866.

  27. Hospitalizations for ADEs by Event Type, United States, 2004-2005 • Most hospitalizations due to unintended overdoses • 66% due to warfarin, antidiabetic agents, or other narrow-therapeutic index drugs ► Budnitz DS et al. JAMA 2006;296:1858-1866 Budnitz, D. S. et al. JAMA 2006;296:1858-1866.

  28. Drugs Implicated in ED Visits for ADEs United States, 2004-2005 ► ► Budnitz DS et al. JAMA 2006;296:1858-1866

  29. ADEs Treated in EDs by Patient Age, United States, 2004-2005 Budnitz DS et al. JAMA 2006;296:1858-1866

  30. Design Intervention Identify Risk & Protective Factors Identify the Harm Public Health Approach for Medication Safety, 2008 • Older Adults • ~ 1 out of 150 per year • ~ 7x hospitalization rate ~ 927,000 ED visits, 2008

  31. Design Intervention Identify Risk & Protective Factors Identify the Harm Public Health Approach for Medication Safety “Potentially Inappropriate” Medications ?? • Older Adults • ~ 1 out of 150 per year • ~ 7x hospitalization rate ~ 927,000 ED visits, 2008

  32. “Potentially Inappropriate” Medicines Adapted from Fick DM et al. Arch Intern Med 2003;163:2716-25 Budnitz, DS et al. Ann Intern Med 2007;147:755-765

  33. “Potentially Inappropriate” Prescribing Impacts Interventions • National Quality Measures • HEDIS / National Quality Forum measure • AHRQ annual Healthcare Quality Report • CMS • Monitoring of nursing home prescribing • Part D payment for Medication Therapy Management • 9th Scope of Work for quality improvement • Computerized clinical decision support • “Meaningful Use”

  34. Frequency of ED Visits for ADEs, Persons ≥65 Years ► Budnitz DS et al. Ann Intern Med 2007;147:755-765

  35. Frequency of ED Visits for ADEs, Persons ≥65 Years ► ► ► ► Budnitz DS et al. Ann Intern Med 2007;147:755-765

  36. Frequency of ED Visits for ADEs, Persons ≥65 Years Budnitz DS et al. Ann Intern Med 2007;147:755-765

  37. Risk of ED Visits for ADEs, Persons ≥65 Years Budnitz DS et al. Ann Intern Med 2007;147:755-765

  38. Based on Harm: Focus on Older Adults & Certain Medicines • Frequency: • 1 in 150 older adults / year • Severity: 7x more likely to be hospitalized • Preventability:Dosing and monitoring • 3 drugs (insulin, warfarin, and digoxin) • 33% of estimated ADEs treated in EDs

  39. Design Intervention Identify Risk & Protective Factors Identify the Harm Public Health Approach for Medication Safety “Potentially Inappropriate” Medications • Older Adults • ~ 1 out of 150 per year • ~ 7x hospitalization rate ~ 927,000 ED visits, 2008

  40. Design Intervention Identify Risk & Protective Factors Identify the Harm Public Health Approach for Medication Safety AnticoagulantsInsulins NTI Medicines • Older Adults • ~ 1 out of 150 per year • ~ 7x hospitalization rate ~ 927,000 ED visits, 2008

  41. Design Intervention Identify Risk & Protective Factors Identify the Harm Public Health Approach Evaluate Impact AnticoagulantsInsulins NTI Medicines

  42. 4 proposed Sub-objectives http://www.healthypeople.gov/HP2020/Objectives/

  43. 3. Patient-centered Prevention Partnerships

  44. ADEs Treated in EDs by Patient Age, United States, 2004-2005 Budnitz DS et al. JAMA 2006;296:1858-1866

  45. Unintentional Overdoses Cause Most Emergency Visits in Children <5 Years Old Cohen AL, et al. J Pediatr 2008;152: 416-421

  46. Rates of Emergency Department Visits for Unintentional Overdoses, 2004-2005 Schillie SF et al. Am J Prev Med 2009;37:181-7

  47. Rates of Emergency Department Visits for Unintentional Overdoses, 2004-2005 1 out of every 180 two-year-olds each year Schillie SF et al. Am J Prev Med 2009;37:181-7

  48. Underlying Causes of Emergency Department Visits for Child Overdoses, 2004-2005 Schillie SF, et al. Am J Prev Med 2009;37:181-7

  49. Underlying Causes of Emergency Department Visits for Child Overdoses, 2004-2005 Schillie SF, et al. Am J Prev Med 2009;37:181-7

  50. Underlying Causes of Emergency Department Visits for Child Overdoses, 2004-2005 Schillie SF, et al. Am J Prev Med 2009;37:181-7

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