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      Quality of Care for Acute Kidney Disease: Current Knowledge Gaps and Future Directions

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          Abstract

          Acute kidney injury (AKI) and acute kidney disease (AKD) are common complications in hospitalized patients and are associated with adverse outcomes. Although consensus guidelines have improved the care of patients with AKI and AKD, guidance regarding quality metrics in the care of patients after an episode of AKI or AKD is limited. For example, few patients receive follow-up laboratory testing of kidney function or post-AKI or AKD care through nephrology or other providers. Recently, the Acute Disease Quality Initiative developed a consensus statement regarding quality improvement goals for patients with AKI or AKD specifically highlighting efforts regarding quality and safety of care after hospital discharge after an episode of AKI or AKD. The goal is to use these measures to identify opportunities for improvement that will positively affect outcomes. We recommend that health care systems quantitate the proportion of patients who need and actually receive follow-up care after the index AKI or AKD hospitalization. The intensity and appropriateness of follow-up care should depend on patient characteristics, severity, duration, and course of AKI of AKD, and should evolve as evidence-based guidelines emerge. Quality indicators for discharged patients with dialysis requiring AKI or AKD should be distinct from end-stage renal disease measures. Besides, there should be specific quality indicators for those still requiring dialysis in the outpatient setting after AKI or AKD. Given the limited preexisting data guiding the care of patients after an episode of AKI or AKD, there is ample opportunity to establish quality measures and potentially improve patient care and outcomes. This review will provide specific evidence-based and expert opinion–based guidance for the care of patients with AKI or AKD after hospital discharge.

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          Most cited references 53

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          Acute kidney injury, mortality, length of stay, and costs in hospitalized patients.

          The marginal effects of acute kidney injury on in-hospital mortality, length of stay (LOS), and costs have not been well described. A consecutive sample of 19,982 adults who were admitted to an urban academic medical center, including 9210 who had two or more serum creatinine (SCr) determinations, was evaluated. The presence and degree of acute kidney injury were assessed using absolute and relative increases from baseline to peak SCr concentration during hospitalization. Large increases in SCr concentration were relatively rare (e.g., >or=2.0 mg/dl in 105 [1%] patients), whereas more modest increases in SCr were common (e.g., >or=0.5 mg/dl in 1237 [13%] patients). Modest changes in SCr were significantly associated with mortality, LOS, and costs, even after adjustment for age, gender, admission International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis, severity of illness (diagnosis-related group weight), and chronic kidney disease. For example, an increase in SCr >or=0.5 mg/dl was associated with a 6.5-fold (95% confidence interval 5.0 to 8.5) increase in the odds of death, a 3.5-d increase in LOS, and nearly 7500 dollars in excess hospital costs. Acute kidney injury is associated with significantly increased mortality, LOS, and costs across a broad spectrum of conditions. Moreover, outcomes are related directly to the severity of acute kidney injury, whether characterized by nominal or percentage changes in serum creatinine.
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            KDIGO Clinical Practice Guidelines for Acute Kidney Injury

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              Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review.

              Over a quarter of hospital prescribing errors are attributable to incomplete medication histories being obtained at the time of admission. We undertook a systematic review of studies describing the frequency, type and clinical importance of medication history errors at hospital admission. We searched MEDLINE, EMBASE and CINAHL for articles published from 1966 through April 2005 and bibliographies of papers subsequently retrieved from the search. We reviewed all published studies with quantitative results that compared prescription medication histories obtained by physicians at the time of hospital admission with comprehensive medication histories. Three reviewers independently abstracted data on methodologic features and results. We identified 22 studies involving a total of 3755 patients (range 33-1053, median 104). Errors in prescription medication histories occurred in up to 67% of cases: 10%- 61% had at least 1 omission error (deletion of a drug used before admission), and 13%- 22% had at least 1 commission error (addition of a drug not used before admission); 60%- 67% had at least 1 omission or commission error. Only 5 studies (n = 545 patients) explicitly distinguished between unintentional discrepancies and intentional therapeutic changes through discussions with ordering physicians. These studies found that 27%- 54% of patients had at least 1 medication history error and that 19%- 75% of the discrepancies were unintentional. In 6 of the studies (n = 588 patients), the investigators estimated that 11%-59% of the medication history errors were clinically important. Medication history errors at the time of hospital admission are common and potentially clinically important. Improved physician training, accessible community pharmacy databases and closer teamwork between patients, physicians and pharmacists could reduce the frequency of these errors.
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                Author and article information

                Contributors
                Journal
                Kidney Int Rep
                Kidney Int Rep
                Kidney International Reports
                Elsevier
                2468-0249
                06 August 2020
                October 2020
                06 August 2020
                : 5
                : 10
                : 1634-1642
                Affiliations
                [1 ]Division of Nephrology, Departments of Medicine and Anesthesia, University of California, San Francisco, California, USA
                [2 ]Division of Critical Care Medicine, Departments of Medicine and Anesthesia, University of California, San Francisco, California, USA
                [3 ]Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
                [4 ]Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
                [5 ]Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
                [6 ]Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
                [7 ]Division of Nephrology, Department of Medicine, University of California, San Diego Medical Center, San Diego, San Diego, California, USA
                [8 ]Department of Medicine (DIMED), University of Padova, Padova, Italy
                [9 ]Department of Nephrology, Dialysis and Transplantation, and International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
                [10 ]Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
                [11 ]Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
                [12 ]Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
                [13 ]Medical Faculty, Otto-von-Guericke University Magdeburg and Diaverum MVZ, Potsdam, Germany
                [14 ]Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
                Author notes
                [] Correspondence: Jay L. Koyner, Section of Nephrology, University of Chicago, Suite S-507, MC5100, Chicago, Illinois 60637, USA. jkoyner@ 123456uchicago.edu
                Article
                S2468-0249(20)31430-3
                10.1016/j.ekir.2020.07.031
                7569680
                © 2020 International Society of Nephrology. Published by Elsevier Inc.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                Categories
                Review

                recovery, acute kidney injury, outcomes, quality

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