Hyperkalemia in Chronic Kidney Disease: Can Virtual Patient … · 2019-10-04 · hyperkalemia...
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Hyperkalemia in Chronic Kidney Disease: Can Virtual Patient Simulation Improve Management? AMY LARKIN, PHARMD; SUSAN GITZINGER, PHARMD, MPA; DONALD M. BLATHERWICK; GEORGE BOUTSALIS, PHD; MARTIN WARTERS, MA, CHSE; GWEN LITTMAN, MD Medscape Education, New York, NY We sought to determine if an online, virtual patient simulation (VPS)- based continuing medical education (CME) intervention could improve performance of nephrologists and primary care providers (PCPs) in the evidence-based management of patients with hyperkalemia associated with chronic kidney disease (CKD) ■ The intervention comprises 1 patient at 2 different time points presenting in a VPS platform that allows learners to order laboratory tests, make diagnoses, and prescribe treatments supported by an extensive database of diagnostic and treatment possibilities matching the scope and depth of actual practice (Figure 1) ■ Learner clinical decisions, entered using open field entries, were analyzed using a sophisticated decision engine • Tailored clinical guidance (CG), based on current evidence and expert recommendation, was provided following each decision • Learners were given the opportunity to modify their decisions after receiving CG ■ Each user’s decisions were collected post-CG and compared with that user’s pre-CG data using a 2-tailed, paired t test (P <.05 considered significant) ■ Results are presented as absolute improvement (post value minus prevalue) ■ Data are reflective of learners who participated in the VPS from February 13, 2018, through May 7, 2018 BACKGROUND METHODS RESULTS CASE 1 (N = 51 NEPHROLOGISTS; N = 367 PCPS) CASE 2 (N = 34 NEPHROLOGISTS; N = 307 PCPS) MARLENE J. CASE SUMMARY Marlene is a 68-year-old woman with a long history of T2D, HTN, CHF (EF = 30%), severe osteoarthritis, and CKD (Stage 3A), who required medication adjustments to reduce hyperkalemia and address her declining eGFR. She is aware of the significance of these problems and wants to do everything possible to prevent end-stage renal disease (ESRD) and the necessity of hemodialysis. To date, the following efforts have been made to reduce her hyperkalemia and slow the decline of her eGFR: • Metformin was discontinued and an SGLT2 inhibitor was successfully introduced for her T2D • Naproxen was discontinued and tramadol extended release was successfully introduced for her arthritis-related pain • Patient and her daughter are meeting with a nutritional consultant to reduce potassium intake and maintain blood pressure and glycemic control Today, Marlene says that her new pain medicine allows her to be more active with her grandchildren and in her activities of daily living. However, she has noticed muscle cramps that interrupt her when shopping with the grandchildren and sometimes while sitting down for longer periods of time to watch television. Review of systems: Denies fatigue, numbness or tingling, nausea or vomiting, increased orthopnea, and chest pain or palpitations Surgical history: Bilateral knee replacements at age 50; bilateral cataract extraction at age 65 Current medications: empagliflozin 10 mg once daily, tramadol extended release 100 mg daily, sacubitril 24 mg/valsartan 26 mg twice daily, carvedilol 25 mg twice daily, furosemide 40 mg daily, spironolactone 25 mg daily Drug intolerances: • ACE inhibitors (cough) • Nifedipine (gingival overgrowth and GI upset) MARLENE J. CASE SUMMARY Marlene is a 68-year-old widowed, retired editor who has recently moved to the area to be near her daughter. She has severe osteoarthritis in her hands and both of her knees that limits her activities of daily living and for which she takes naproxen. She has multiple other chronic medical problems, including hypertension (HTN), congestive heart failure (CHF), type 2 diabetes (T2D), chronic kidney disease (CKD), and obesity. Marlene was first diagnosed with HTN at age 30 and has had CHF for many years. She does not have her old records but thinks she took a diuretic at first, and then a beta blocker. She had been on nifedipine until 5 months ago when it was stopped because of gingival overgrowth. About 5 years ago, Marlene was diagnosed with (what she remembers as) Stage 1 CKD, which she states her doctor attributed to the HTN and the T2D. Over the last few years and with her daughter’s prompting, Marlene has been more focused on her health and has tried to modify her diet for the better, though admits she still struggles. Two weeks ago, Marlene was seen here for her initial visit, and while her A1C was near goal, there was concern for hyperkalemia and declining eGFR consistent with Stage 3 CKD. Accordingly, metformin was discontinued and empagliflozin 10 mg daily was introduced for her T2D. Surgical history: Bilateral knee replacements at age 50; bilateral cataract removals at age 65 Current medications: naproxen 375 mg twice daily, sacubitril/valsartan 49 mg/51 mg twice daily, empagliflozin 10 mg daily, furosemide 20 mg daily, spironolactone 50 mg daily, and carvedilol 25 mg twice daily Drug intolerances: • ACE inhibitors (cough) • Nifedipine (gingival overgrowth and GI upset) • Diagnosis of hyperkalemia: 16% improvement among nephrologists (51% pre-CG vs 67% post-CG; P = .051), 51% improvement among PCPs (50% pre-CG vs 71% post-CG; P <.001) • Continue/modify spironolactone therapy in complex patients: 12% improvement among nephrologists (14% pre-CG vs 26% post-CG; P = .085), 15% improvement among PCPs (11% pre-CG vs 26% post-CG; P <.001) • Order follow-up potassium test: 12% improvement among nephrologists (59% pre-CG vs 71% post-CG; P = .105), 17% improvement among PCPs (50% pre-CG vs 67% post-CG; P <.001) • Prescribe a potassium binder: 22% improvement among nephrologists (16% pre-CG vs 18% post-CG; P = .395), no improvement among PCPs (4% pre-CG vs 4% post-CG; P = .5) • Diagnosis of CKD stage 3b: 41% improvement among nephrologists (9% pre-CG vs 50% post-CG; P <.001), 26% improvement among PCPs (17% pre-CG vs 43% post-CG; P <.001) • Initiate hyperkalemia therapy in an appropriate patient: 47% improvement among nephrologists (18% pre-CG vs 67% post-CG; P <.001), 48% improvement among PCPs (7% pre-CG vs 54% post-CG; P <.001) • Discontinue spironolactone in an appropriate patient: 29% improvement among nephrologists (9% pre-CG vs 38% post-CG; P = .001), 24% improvement among PCPs (30% pre-CG vs 54% post-CG; P <.001) CHART 1. % Correct Pre-CG Nephrologists n = 51 % Correct Post-CG % Correct Pre-CG PCPs n = 367 % Correct Post-CG C G : : G C 2 4 3 4 . + ; 4 0 4 Diagnosis of hyperkalemia Order follow-up potassium test Continue/modify spironolactone therapy Prescribe potassium binder P-Value 12% 14% 21% 50% 16% 51% 15% 59% 12% 11% 17% 50% 2% 0% 16% 4% Responses/Improvement Decision Points CHART 2. % Correct Pre-CG Nephrologists n = 34 % Correct Post-CG % Correct Pre-CG PCPs n = 307 % Correct Post-CG Patient Simulation Cases Overall, significant improvements were demonstrated by both nephrologists and PCPs related to comprehensive management of patients with hyperkalemia. PRE-CLINICAL GUIDANCE POST-CLINICAL GUIDANCE Overall Changes: Aggregate Improvement in Clinical Decision Making • Aggregate data for each physician based on responses to each clinical decision point • Concentric rings represent the overall % of decision points that were answered correctly (ie, average score) • Movement toward the “bullseye” represents a greater proportion of clinical decisions points being answered correctly by the physician .051 < .001 .499 .105 .395 < .001 .085 < .001 4 , C 6 & 6 9 1 2 7 9 > Diagnosis of CKD Stage Discontinue spironolactone Initiate hyperkalemia therapy P-Value 47% 18% 26% 17% 41% 9% 48% 9% 29% 7% 24% 30% Responses/Improvement Decision Points < .001 < .001 .001 < .001 < .001 < .001 CONCLUSIONS SOURCE OF SUPPORT This CME activity was supported by an independent educational grant from Relypsa. NOTES: For more information, contact Amy Larkin, PharmD, Director, Clinical Strategy, Medscape, LLC, at [email protected]. ■ VPS that immerses and engages physicians in an authentic and practical learning experience improved evidence-based clinical decisions of both nephrologists and PCPs related to hyperkalemia management ■ Persistent educational gaps were uncovered related to: • Appropriate CKD staging • Effective hyperkalemia management – Appropriate use of potassium binders – Continuation or discontinuation of spironolactone in various patients with hyperkalemia – Appropriate follow- up in patients with hyperkalemia Scan here to view this poster online.
Transcript of Hyperkalemia in Chronic Kidney Disease: Can Virtual Patient … · 2019-10-04 · hyperkalemia...
Hyperkalemia in Chronic Kidney Disease: Can Virtual Patient Simulation Improve Management?AMY LARKIN, PHARMD; SUSAN GITZINGER, PHARMD, MPA; DONALD M. BLATHERWICK; GEORGE BOUTSALIS, PHD; MARTIN WARTERS, MA, CHSE; GWEN LITTMAN, MD Medscape Education, New York, NY
We sought to determine if an online, virtual patient simulation (VPS)-based continuing medical education (CME) intervention could improve performance of nephrologists and primary care providers (PCPs) in the evidence-based management of patients with hyperkalemia associated with chronic kidney disease (CKD)
■ The intervention comprises 1 patient at 2 different time points presenting in a VPS platform that allows learners to order laboratory tests, make diagnoses, and prescribe treatments supported by an extensive database of diagnostic and treatment possibilities matching the scope and depth of actual practice (Figure 1)
■ Learner clinical decisions, entered using open field entries, were analyzed using a sophisticated decision engine
• Tailored clinical guidance (CG), based on current evidence and expert recommendation, was provided following each decision
• Learners were given the opportunity to modify their decisions after receiving CG
■ Each user’s decisions were collected post-CG and compared with that user’s pre-CG data using a 2-tailed, paired t test (P <.05 considered significant)
■ Results are presented as absolute improvement (post value minus prevalue)
■ Data are reflective of learners who participated in the VPS from February 13, 2018, through May 7, 2018
BACKGROUND
METHODS
RESULTS
CASE 1 (N = 51 NEPHROLOGISTS; N = 367 PCPS) CASE 2 (N = 34 NEPHROLOGISTS; N = 307 PCPS)
MARLENE J.CASE SUMMARY
Marlene is a 68-year-old woman with a long history of T2D, HTN, CHF (EF = 30%), severe osteoarthritis, and CKD (Stage 3A), who required medication adjustments to reduce hyperkalemia and address her declining eGFR. She is aware of the significance of these problems and wants to do everything possible to prevent end-stage renal disease (ESRD) and the necessity of hemodialysis. To date, the following efforts have been made to reduce her hyperkalemia and slow the decline of her eGFR:
• Metformin was discontinued and an SGLT2 inhibitor was successfully introduced for her T2D
• Naproxen was discontinued and tramadol extended release was successfully introduced for her arthritis-related pain
• Patient and her daughter are meeting with a nutritional consultant to reduce potassium intake and maintain blood pressure and glycemic control
Today, Marlene says that her new pain medicine allows her to be more active with her grandchildren and in her activities of daily living. However, she has noticed muscle cramps that interrupt her when shopping with the grandchildren and sometimes while sitting down for longer periods of time to watch television. Review of systems: Denies fatigue, numbness or tingling, nausea or vomiting, increased orthopnea, and chest pain or palpitationsSurgical history: Bilateral knee replacements at age 50; bilateral cataract extraction at age 65 Current medications: empagliflozin 10 mg once daily, tramadol extended release 100 mg daily, sacubitril 24 mg/valsartan 26 mg twice daily, carvedilol 25 mg twice daily, furosemide 40 mg daily, spironolactone 25 mg daily Drug intolerances:
• ACE inhibitors (cough) • Nifedipine (gingival overgrowth and GI upset)
MARLENE J.CASE SUMMARY
Marlene is a 68-year-old widowed, retired editor who has recently moved to the area to be near her daughter. She has severe osteoarthritis in her hands and both of her knees that limits her activities of daily living and for which she takes naproxen. She has multiple other chronic medical problems, including hypertension (HTN), congestive heart failure (CHF), type 2 diabetes (T2D), chronic kidney disease (CKD), and obesity. Marlene was first diagnosed with HTN at age 30 and has had CHF for many years. She does not have her old records but thinks she took a diuretic at first, and then a beta blocker. She had been on nifedipine until 5 months ago when it was stopped because of gingival overgrowth. About 5 years ago, Marlene was diagnosed with (what she remembers as) Stage 1 CKD, which she states her doctor attributed to the HTN and the T2D. Over the last few years and with her daughter’s prompting, Marlene has been more focused on her health and has tried to modify her diet for the better, though admits she still struggles. Two weeks ago, Marlene was seen here for her initial visit, and while her A1C was near goal, there was concern for hyperkalemia and declining eGFR consistent with Stage 3 CKD. Accordingly, metformin was discontinued and empagliflozin 10 mg daily was introduced for her T2D.
Surgical history: Bilateral knee replacements at age 50; bilateral cataract removals at age 65
Current medications: naproxen 375 mg twice daily, sacubitril/valsartan 49 mg/51 mg twice daily, empagliflozin 10 mg daily, furosemide 20 mg daily, spironolactone 50 mg daily, and carvedilol 25 mg twice daily
Drug intolerances:
• ACE inhibitors (cough) • Nifedipine (gingival overgrowth and GI upset)
• Diagnosis of hyperkalemia: 16% improvement among nephrologists (51% pre-CG vs 67% post-CG; P = .051), 51% improvement among PCPs (50% pre-CG vs 71% post-CG; P <.001)
• Continue/modify spironolactone therapy in complex patients: 12% improvement among nephrologists (14% pre-CG vs 26% post-CG; P = .085), 15% improvement among PCPs (11% pre-CG vs 26% post-CG; P <.001)
• Order follow-up potassium test: 12% improvement among nephrologists (59% pre-CG vs 71% post-CG; P = .105), 17% improvement among PCPs (50% pre-CG vs 67% post-CG; P <.001)
• Prescribe a potassium binder: 22% improvement among nephrologists (16% pre-CG vs 18% post-CG; P = .395), no improvement among PCPs (4% pre-CG vs 4% post-CG; P = .5)
• Diagnosis of CKD stage 3b: 41% improvement among nephrologists (9% pre-CG vs 50% post-CG; P <.001), 26% improvement among PCPs (17% pre-CG vs 43% post-CG; P <.001)
• Initiate hyperkalemia therapy in an appropriate patient: 47% improvement among nephrologists (18% pre-CG vs 67% post-CG; P <.001), 48% improvement among PCPs (7% pre-CG vs 54% post-CG; P <.001)
• Discontinue spironolactone in an appropriate patient: 29% improvement among nephrologists (9% pre-CG vs 38% post-CG; P = .001), 24% improvement among PCPs (30% pre-CG vs 54% post-CG; P <.001)
CHART 1.
% Correct Pre-CG
Nephrologists n = 51
% Correct Post-CG % Correct Pre-CG
PCPs n = 367
% Correct Post-CG67+71 26+26 71+67 18+4.151+50 14+11 59+50 16+4.1Diagnosis of hyperkalemia
Order follow-up potassium test
Continue/modify spironolactone therapy
Prescribe potassium binder
P-Value
12% 14%
21%50%
16%51%
15%
59% 12%
11%
17%50%
2%
0%
16%
4%
Responses/ImprovementDecision Points
CHART 2.
% Correct Pre-CG
Nephrologists n = 34
% Correct Post-CG % Correct Pre-CG
PCPs n = 307
% Correct Post-CG
Patient Simulation Cases Overall, significant improvements were demonstrated by both nephrologists and PCPs related to comprehensive management of patients with hyperkalemia.
PRE-CLINICAL GUIDANCE POST-CLINICAL GUIDANCE
Overall Changes: Aggregate Improvement in Clinical Decision Making• Aggregate data for each physician based on responses to each clinical decision point
• Concentric rings represent the overall % of decision points that were answered correctly (ie, average score)
• Movement toward the “bullseye” represents a greater proportion of clinical decisions points being answered correctly by the physician
.051
< .001
.499
.105
.395
< .001
.085
< .001
50+43 67+54 38+549+17 18+7 9+30Diagnosis of CKD Stage
Discontinue spironolactone
Initiate hyperkalemia therapy
P-Value
47% 18%
26%17%
41%9%
48%
9% 29%
7%
24%30%
Responses/ImprovementDecision Points
< .001
< .001
.001
< .001
< .001
< .001
CONCLUSIONS
SOURCE OF SUPPORT
This CME activity was supported by an independent educational grant from Relypsa.
NOTES:
For more information, contact Amy Larkin, PharmD, Director, Clinical Strategy, Medscape, LLC, at [email protected].
■ VPS that immerses and engages physicians in an authentic and practical learning experience improved evidence-based clinical decisions of both nephrologists and PCPs related to hyperkalemia management
■ Persistent educational gaps were uncovered related to:
• Appropriate CKD staging
• Effective hyperkalemia management
– Appropriate use of potassium binders
– Continuation or discontinuation of spironolactone in various patients with hyperkalemia
– Appropriate follow-up in patients with hyperkalemia
Scan here to view this poster online.
