Jaan Sidorov
Posted 11/28/11 on The Disease Management Care Blog
100,000.
That’s how many persons aged 65 years or more are seen in U.S. emergency rooms and then hospitalized every year because of an adverse drug event.
Writing in the New England Journal, Daniel Budnitz and colleagues report data from the “National Electronic Injury Surveillance System – Cooperative Adverse Drug Event Surveillance” (NEISS-CADES) project. The Disease Management Care Blog never heard of it either, but it’s a consortium of 58 typical U.S. hospitals that are participating in an ongoing observational research project. Whenever a physician blames a drug for an emergency room (ER) visit, trained chart reviewers go through the medical record. From 2007 through 2009, there were 12,666 drug-related ER visits in the NEISS-CADES hospitals, which extrapolates to over 265,000 in the U.S. More than a third required hospitalization, which rounds to approximately 100,000.
Directors and quality assurance types may wonder how many hospitalizations were due to HEDIS high risk medications. The answer was very few: only 1.2%.
There is also a list of medications that meet the “Beers” criteria as being potentially inappropriate in the elderly. Likewise, very few could be blamed here: only 6.6%
So what caused the mayhem? Basically there were four bad actors that accounted for approximately two thirds of the hospitalizations:blood thinners (warfarin and antiplatelet agents) and diabetes drugs(insulin and hypoglycemic agents). What’s more, the rate of hospitalization was highest among persons aged 85 years or greater and if there were five or more medications being taken. Warfarin accounted for a third, the antiplatelet drugs, insulin and hypoglycemics accounted for another third and the remainder were miscellaneous.
What should the population health management community do with this information?
1. The DMCB would advise against believing that the hospitalization rate could be driven to zero. It’s well known that despite the best of care, between 1% to 2% of persons on warfarin will experience a life threatening bleed every year and, depending on how it’s defined, thatbetween 2 and 10% of persons with diabetes will experience severe low blood sugar. Until we develop better blood thinners and diabetes drugs, bleeding and low blood sugar may just be a price that has to be paid.
2. Nonetheless, there are 100,000 hospitalizations and while the authors don’t speculate on how many are avoidable, the DMCB wonders if this doesn’t represent an important opportunity for the population health service providers. Based on these data, regular outreach and monitoring of those persons on four types of drugs (warfarin, anti-platelet agents, insulin and hypoglycemic meds) who are taking multiple other medications and who are 85 years or greater may benefit from intense monitoring. If the hospitalization rate can be decreased, that’s a whole lot of savings.
Care And Cost 
I want to share a story here. My mother, who lives in India, is a diabetic (25 years now) and has recently developed renal disease. She has never overtly educated herself about the disease, and typifies a generation that inherently trusts the doctors and believes in fate. The healthcare system in India (and she has access to healthcare as she was a civil servant her entire career) and the doctors that have served her have always taken a paternalistic tone with her and told her what to do. She, in her turn, has picked and chosen which part of their prescription to follow as they have never engaged her to understand what her life is like and whether she understands why their prescription is important. The doctors have never checked to see if her dosage needed adjustment and what is happening with her glucose on a daily basis. No one has explained how she “causes” her sugar spikes and dips.
My mother visited me recently and I had her keep a journal – waking stats (BP, sugar etc.), meals, insulin and exercise. Just following this simple step got her talking about short-acting versus long-acting insulin. Within a couple days we knew that she was overdosing on the long-acting, which she took 3 times a day, and always ended up in a sugar-crash in the mid-afternoon. We also started to observe patterns in what was leading to spikes. She started discussing her health and what she was doing. She started to get more knowledgeable about the relationship between diet, exercise, insulin and blood sugar. She realized that she could cause her spikes and dips. Talk about an activated and empowered patient who went from being desultorily compliant to in-charge!
I am not saying that engaging and educating our patients will completely eliminate the hospitalizations for severe drops in blood sugar but I am sure at least some proportion of these cases are ones where the drop was probably preventable had the patient been better prepared. I know because my mother did end up getting hospitalized this visit for a diabetes complication and that is what made me purchase her a journal to keep.