Outcomes of pharmacist-provided medication review in collaborative care for adult Singaporeans receiving hemodialysis

Peter WL, Shubrook JH. Type 2 Diabetes and Chronic Kidney Disease: An Opportunity for Pharmacists to Improve Outcomes

Chronic kidney disease (CKD) is an important contributor to end-stage kidney disease, cardiovascular disease, and death in people with type 2 diabetes (T2D), but current evidence suggests that diagnosis and treatment are often not optimized. This review examines gaps in care for patients with CKD and how pharmacist interventions can mitigate these gaps. We conducted a PubMed search for published articles reporting on real-world CKD management practice and compared the findings with current recommendations. We find that adherence to guidelines on screening for CKD in patients with T2D is poor with particularly low rates of testing for albuminuria. When CKD is diagnosed, the prescription of recommended heart-kidney protective therapies is underutilized, possibly due to issues around treatment complexity and safety concerns. Cost and access are barriers to the prescription of newer therapies and treatment is dependent on racial, ethnic, and socioeconomic factors. Rates of nephrologist referrals for difficult cases are low in part due to limitations of information and communication between specialties. We believe that pharmacists can play a vital role in improving outcomes for patients with CKD and T2D and support the cost-effective use of healthcare resources through the provision of comprehensive medication management as part of a multidisciplinary team. The Advancing Kidney Health through Optimal Medication Management initiative supports the involvement of pharmacists across healthcare systems to ensure that comprehensive medication management can be optimally implemented.

Pharmacists’ strategies to detect, resolve, and prevent DRPs in CKD patients

Pharmacists have undergone obstacles in the process of detecting, resolving, and preventing CKD patients’ DRPs. Thus, optimal strategies were needed. A total of 19 articles were included based on the article searching process. Based on the articles, it can be concluded: The strategies of detecting DRPs in CKD patients were carried out through medication reconciliation and medication review. The outcomes of these strategies were the number of DRPs/patients and types of DRPs detected. Strategies to resolve and prevent DRPs in CKD patients were conducted through interprofessional collaboration, education, and counselling. The outcome of these strategies was a change in the patients’ DRPs status. Optimization of detection, resolution, and prevention strategies were performed by improving pharmacists’ professional hard and soft-skills as well as modifying the pharmaceutical care delivery model. A decrease in the number of DRPs/patients and a change in DRPs status were reported as the outcomes of optimizing this process.

Integrating pharmacists into a kidney transplant clinic: Developing and implementing a collaborative pharmacy practice agreement

BACKGROUND

Collaborative pharmacy practice agreements (CPPAs) grant patient care authorities to pharmacists (PharmDs) under a scope of practice without direct physician supervision.

OBJECTIVES

The aim of this study was to discuss steps for developing and implementing a CPPA in an outpatient renal transplant clinic and assess changes in physician and nurse burden, integrated pharmacy growth, and patient safety.

PRACTICE DESCRIPTION

A CPPA was developed between physicians and pharmacists and implemented into a renal transplant clinic and the integrated pharmacy over the course of several years.

PRACTICE INNOVATION

CPPA execution in a post-transplant clinic has not been previously described and is needed to help advance patient care delivery models.

EVALUATION METHODS

This single center, retrospective study compared immunosuppressant prescriptions generated by each authorizer type (nurse, physician, pharmacist) across 3 time periods: before pharmacist integration, during CPPA development, and after CPPA implementation. Pharmacy manpower and patient safety concerns post-CPPA implementation were also reviewed.

RESULTS

Results show that prescription authorization migrated from either a nurse or physician (57% and 43% respectively) in pre-PharmD period, to mostly by physicians (72%) in PharmD pre-CPPA period, and largely by pharmacists (85%) in PharmD post-CPPA period. Quarterly prescription volume increased (6019 in quarter 3 of 2015 vs. 14,806 in quarter 4 of 2018) and integrated pharmacy staff grew from 8 employees (Pre-PharmD period) to 20 in PharmD post-CPPA period. No safety concerns were reported in any time period.

CONCLUSION

CPPAs have the advantage of reducing physician and nurse workload related to prescribing and advancing the role of the pharmacist by utilizing their expertise to take over certain tasks. Lessons learned during the CPPA implementation process include identifying needs, promoting maximal utility of pharmacists, and maintaining optimal communication between the healthcare team.

Treatment related problems in Jordanian hemodialysis patients

Background Treatment related problems are any event or circumstance involving patient treatment that actually or potentially interferes with an optimum outcome for a patient. Hemodialysis patients have on average 5-6 comorbid conditions and require 8-12 medications each day making them vulnerable to treatment related problems. Objective This study aimed to investigate treatment related problems affecting Jordanian hemodialysis patients, as well as assessing the factors associated with them. Setting Three hemodialysis centers in Jordan. Method A cross sectional multi-centered study was conducted. Direct interviews and patient files were used to collect patient information. A validated data collection form was used. Main outcome measure The average number of treatment related problems per patient. Results 160 patients from three different Jordanian dialysis centers were included. The cohort was 53 ± 15.2 years old, been on dialysis for 5.9 ± 5.3 years, had 3.9 ± 1.8 comorbid conditions and took 10.2 ± 2.8 different medications. There were a total of 1018 treatment related problems, a treatment related problem occurred once every 1.47 drug exposures. Adverse events were the most commonly occurring treatment related problems (27%), followed by indication related errors and dosing errors (24% and 21%, respectively). The number of treatment related problems is positively associated with age, the number of comorbid conditions, the number of hospital admissions in the previous year and the number of medications taken by the patient. Conclusion In the Jordanian hemodialysis population, treatment related problems affect virtually all patients. Most patients suffered adverse drug events and/or had drug indication problems. The number of treatment related problems correlated positively with age and the number of medications taken by the patient. Those with more treatment related problems also had higher hospital admissions and longer admission periods. Serious measures should be made in order to reduce the number of treatment related problems affecting this vulnerable population.

Pharmacist-led medication reviews in pre-dialysis and dialysis patients

BACKGROUND

Pre-dialysis and dialysis patients are at risk for drug related problems (DRPs) due to a high incidence of comorbidities. Pharmacist-led medication reviews might reduce the number of DRPs.

OBJECTIVES

The aim of this study was to evaluate pharmacist-led medication reviews in pre-dialysis and dialysis patients by determining the number and type of DRPs, nephrologist acceptance of pharmacist interventions and time investment.

METHODS

From September 2017 until December 2018, pharmacist-led medication reviews were performed on pre-dialysis and dialysis patients. DRPs (medication discrepancies, prescribing issues related to drug and dose selection, drug use problems) were identified using the pharmacists' expert opinion and the STOPP/START criteria. Number and type of accepted pharmacist interventions, sustainability of interventions after at least 1 month and time investment were determined. Practical barriers in the process were appraised.

RESULTS

One-hundred twenty five patients were reviewed: 37 pre-dialysis and 88 dialysis patients. In 100 (80%) patients 277 medication discrepancies were identified of which 224 (81%) were accepted by the nephrologist. Pharmacists suggested 422 interventions concerning drug or dose selection for 115 patients; 106 interventions were accepted by the nephrologist, which resulted in 60 patients having medication changed. Ninety percent of those changes remained implemented on follow-up after at least 1 month. In 46 (37%) patients, the clinical pharmacist detected DRPs concerning the drug use process and performed patient counseling. The average time investment was 85 min per patient for the clinical pharmacist and 15 min for the nephrologist. Besides time investment, unclear responsibility for medication management due to multiple prescribers was an important barrier in the process and the main reason for nephrologists to reject pharmacist interventions.

CONCLUSION

Pharmacist-led medication reviews in pre-dialysis and dialysis patients led to medication changes in half of the patients. However, efficiency should be improved before adopting pharmacist-led medication reviews into clinical practice.

Clinical pharmacy practice in the care of Chronic Kidney Disease patients: a systematic review

Background Clinical pharmacy services have potential to contribute significantly to the multidisciplinary team providing safe, effective and economic care for patients. Given recent practice developments (e.g. polypharmacy reviews and pharmacist prescribing) there is a need to provide a current synthesis of the evidence base for characteristics and outcomes of clinical pharmacy practice in chronic kidney disease patients. Aim of the review To critically appraise, synthesise and present the available evidence of the characteristics (structures and processes) and outcomes of clinical pharmacy practice as part of the multidisciplinary care of patients with chronic kidney disease. Method PubMed, International Pharmaceutical Abstracts (IPA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline and Scopus were searched for peer reviewed papers using improved search strategy. Included studies were quality assessed using Downs and Black tool for controlled studies and the mixed methods appraisal tool for all controlled and non-controlled studies. Data were extracted and synthesised using a narrative approach. Screening, quality assessment and data extraction were performed by two independent researchers. Ethics approval was not required. Results Forty-seven studies were identified from a variety of countries, with 31 based in a hospital setting. Controlled study designs were employed in 20, with only ten of these using randomisation. Resources available for service provision were poorly reported in all papers. Positive impact on clinical outcomes included significant improvement in parathyroid hormone, blood pressure, haemoglobin and creatinine clearance. Pharmacists identified 5302 drug related problems in 2933 patients and made 3160 recommendations with acceptance rates up to 95%. Impact on humanistic outcomes was shown through improvement in health related quality of life and patient satisfaction. Economic benefits arose from significant cost savings through pharmaceutical care provision. Conclusion While there is some evidence of positive impact on clinical, humanistic and economic outcomes, this evidence is generally of low quality and insufficient volume. While the existing evidence is in favour of pharmacists' involvement in the multidisciplinary team providing care to patients with chronic kidney disease, more high-quality research is warranted.

Effectiveness and safety of physician–pharmacist collaborative care for rheumatoid arthritis patients: The Changi General Hospital’s experience

Background:

Increasing demand for follow-up of rheumatoid arthritis has encouraged pharmacists to collaborate with physicians to assist with patient care.

Objective:

The aim of this study was to assess the effectiveness and safety of the collaborative care model in a rheumatoid arthritis clinic.

Methods:

We performed a retrospective review of patient case notes and medication records from March 2013 to February 2016. The effectiveness and safety of collaborative care was examined in pre-implementation (standard care) versus post-implementation (collaborative care) cohorts. All patients were assessed for 12 months. Effectiveness of clinic was measured using the percentage of patients that achieved optimal doses of non-biologic disease-modifying anti-rheumatic drugs (nb-DMARDs). Clinic safety performance was evaluated based on the percentage of patients in each cohort that achieved compliance to in-house hospital guidelines on nb-DMARD monitoring. Other clinic safety factors monitored included the incidence and characteristics of nb-DMARD-associated adverse drug events.

Results:

Thirty-eight patients who had received standard care and collaborative care were reviewed. More patients receiving collaborative care achieved nb-DMARD dose optimization within a year of initiation of therapy (68.4% vs 39.5%; p-value < 0.05). Compliance to safety recommendations from hospital guidelines on nb-DMARD monitoring was significantly higher in the collaborative care group (70.6% vs 44.1%; p-value < 0.05). Collaborative care resulted in a higher incidence of nb-DMARD-associated adverse drug events being detected (26.3% vs 18.4%; p-value < 0.05). The most common adverse drug events were gastrointestinal (29.4%), dermatological (17.6%), and hematologic (17.6%), the majority being mild in severity.

Conclusion:

Collaborative rheumatoid arthritis care contributed to improvements in nb-DMARD dose optimization, compliance to hospital guidelines on monitoring, and the detection of nb-DMARD-related adverse drug events.