TJC2024A Note for "Reason for No Mineralocorticoid Receptor Antagonist (MRA) Prescribed in the Outpatient Setting"

• Topic Version for Release TJC2024A: 17
• Topic has changed since last release: Compare versions

Rationale

The update to mineralocorticoid receptor antagonist (MRA) will provide abstractor clarification and alignment with 2022 Clinical Practice Guidelines.

Description

Name

Change from:

Reason for No Aldosterone Receptor Antagonist Prescribed in the Outpatient Setting

Change to:

Reason for No Mineralocorticoid Receptor Antagonist (MRA) Prescribed in the Outpatient Setting

Definition

Change from:

Documentation of a reason for not prescribing an aldosterone antagonist in the outpatient setting by a physician/APN/PA or pharmacist.

Change to:

Documentation of a reason for not prescribing a mineralocorticoid receptor antagonist (MRA) in the outpatient setting by a physician/APN/PA or pharmacist.

Question

Change from:

Did a physician/APN/PA or pharmacist document a contraindication to or a reason against an aldosterone antagonist prescription in the outpatient setting?

Change to:

Did a physician/APN/PA or pharmacist document a contraindication to or a reason against a mineralocorticoid receptor antagonist (MRA) prescription in the outpatient setting?

Allowable Values

Change from:

Y (Yes) There is documentation by a physician/APN/PA or pharmacist of a contraindication to or a reason for not prescribing an aldosterone receptor antagonist in the outpatient setting.

N (No) There is no documentation by a physician/APN/PA or pharmacist of a contraindication to or a reason for not prescribing an aldosterone receptor antagonist in the outpatient setting or unable to determine from medical record documentation.

Change to:

Y (Yes) There is documentation by a physician/APN/PA or pharmacist of a contraindication to or a reason for not prescribing a mineralocorticoid receptor antagonist (MRA) in the outpatient setting.

N (No) There is no documentation by a physician/APN/PA or pharmacist of a contraindication to or a reason for not prescribing a mineralocorticoid receptor antagonist (MRA) in the outpatient setting or unable to determine from medical record documentation.

Notes for Abstraction

Change from:

• All medication documentation available in the chart should be reviewed and taken into account by the abstractor.
• Reasons for not prescribing an aldosterone antagonist must be documented by a physician/APN/PA or pharmacist with one exception: Patient/family refusal of an Aldosterone Receptor Antagonist (e.g., “Patient refusing Aldosterone Receptor Antagonist”) may be documented by a nurse.
• Reasons for no aldosterone antagonist must be explicitly documented or clearly implied.
  • If reasons are not mentioned in the context of aldosterone antagonist, do not make inferences (e.g., do not assume that an aldosterone antagonist is not prescribed because of the patient's chronic renal disease alone).

    Examples

    • “Cr 2.6 mg/dL – No aldosterone antagonist” * “Severe hyperkalemia with aldosterone antagonist in past”
    • "No aldosterone – patient non-compliant with labs"
    • “Aldosterone antagonist contraindicated”
    • “Supportive care only – no medications”
    • “Aldosterone antagonist therapy not indicated”
    • “No aldosterone antagonist” (reason not given).
• Physician/APN/PA or pharmacist documentation of a hold on an aldosterone antagonist or discontinuation of an aldosterone antagonist constitutes a “clearly implied” reason for not prescribing an aldosterone antagonist.
  • A hold/discontinuation of all p.o. medications counts if an aldosterone antagonist p.o. was on order at the time of the notation.
  • If there is documentation of a plan to initiate/restart an aldosterone antagonist, and the reason/problem underlying the delay in starting/restarting the aldosterone antagonist is also noted, this constitutes a “clearly implied” reason for not prescribing an aldosterone antagonist at discharge.
  • Documentation of a conditional hold/discontinuation of a aldosterone antagonist does not count as a reason for not prescribing a aldosterone antagonist
  • Deferral of an aldosterone antagonist from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing an aldosterone antagonist, unless the problem underlying the deferral is also noted.
• An aldosterone antagonist “allergy” or “sensitivity” documented in the medical record counts as an allergy regardless of what type of reaction might be noted (e.g., “Allergies: aldosterone antagonist – select “Yes”).
  • Documentation of an allergy/sensitivity to one particular aldosterone antagonist is acceptable to take as an allergy to the entire class of aldosterone antagonist (e.g., "Allergic to Spironolactone").
• Aldosterone antagonist (along with ACEI and ARBs) are sometimes described as RAS (reninangiotensin system) or RAAS (renin-angiotensin-aldosterone system) blockers/inhibitors. Documentation of a reason for not prescribing "RAS" or "RAAS" blockers or inhibitors should be considered implicit documentation of a reason for no aldosterone antagonist (e.g., "Hold all RAS blockers").
• Documentation that refers to a more general medication class, such as "avoid all nephrotoxic medications" or "Hold BP Meds" is not acceptable as a reason for not prescribing aldosterone antagonist. Reason documentation must mention aldosterone antagonist as a class or a specific aldosterone antagonist medication.

Change to:

• All medication documentation available in the chart should be reviewed and taken into account by the abstractor.
• Reasons for not prescribing a mineralocorticoid receptor antagonist (MRA) must be documented by a physician/APN/PA or pharmacist with one exception: Patient/family refusal of a mineralocorticoid receptor antagonist (MRA) (e.g., “Patient refusing MRA”) may be documented by a nurse.
• Reasons for no mineralocorticoid receptor antagonist (MRA) must be explicitly documented or clearly implied.
  • If reasons are not mentioned in the context of mineralocorticoid receptor antagonist (MRA), do not make inferences (e.g., do not assume that an MRA is not prescribed because of the patient's chronic renal disease alone).

    Examples

    • “Cr 2.6 mg/dL – No mineralocorticoid receptor antagonist” * “Severe hyperkalemia with MRA in past”
    • "No MRA – patient non-compliant with labs"
    • “MRA contraindicated”
    • “Supportive care only – no medications”
    • “MRA therapy not indicated”
    • “No mineralocorticoid receptor antagonist (MRA)” (reason not given).
• Physician/APN/PA or pharmacist documentation of a hold on a mineralocorticoid receptor antagonist or discontinuation of an MRA constitutes a “clearly implied” reason for not prescribing an MRA.
  • A hold/discontinuation of all p.o. medications counts if an MRA p.o. was on order at the time of the notation.
  • If there is documentation of a plan to initiate/restart an MRA, and the reason/problem underlying the delay in starting/restarting the MRA is also noted, this constitutes a “clearly implied” reason for not prescribing an MRA at discharge.
  • Documentation of a conditional hold/discontinuation of an MRA does not count as a reason for not prescribing an MRA.
  • Deferral of an MRA from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing an MRA, unless the problem underlying the deferral is also noted.
• A mineralocorticoid receptor antagonist (MRA) “allergy” or “sensitivity” documented in the medical record counts as an allergy regardless of what type of reaction might be noted (e.g., “Allergies: mineralocorticoid receptor antagonist – select “Yes”).
  • Documentation of an allergy/sensitivity to one particular mineralocorticoid receptor antagonist (MRA) is acceptable to take as an allergy to the entire class of MRAs (e.g., "Allergic to Spironolactone").
• Mineralocorticoid receptor antagonist (MRA) (along with ACEI and ARBs) are sometimes described as RAS (reninangiotensin system) or RAAS (renin-angiotensin-aldosterone system) blockers/inhibitors. Documentation of a reason for not prescribing "RAS" or "RAAS" blockers or inhibitors should be considered implicit documentation of a reason for no mineralocorticoid receptor antagonist (MRA) (e.g., "Hold all RAS blockers").
• Documentation that refers to a more general medication class, such as "avoid all nephrotoxic medications" or "Hold BP Meds" is not acceptable as a reason for not prescribing mineralocorticoid receptor antagonist. Reason documentation must mention mineralocorticoid receptor antagonist (MRA) as a class or a specific MRA medication.

Guidelines for Abstraction

Exclusion Change from:

None

Change to:

All other mineralocorticoid receptor antagonist (MRA) medications other than those listed as inclusions.

Notes

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