Redefining Medication Management in Dialysis: A Kidney Pharmacy Quality Pyramid

Factors associated with patient activation among patients with diabetes on hemodialysis: a multicenter cross-sectional study from a developing country

BACKGROUND

Diabetes mellitus (DM) is a major public health concern with considerable morbidity and mortality. DM affects patients' quality of life and can lead to multiple complications, including chronic kidney disease (CKD) and the need for dialysis. Higher patient activation can improve health outcomes in hemodialysis patients with DM. This study aimed to explore the factors associated with higher patient activation and health-related quality of life (HRQoL) among hemodialysis patients with DM.

METHODS

This was a cross-sectional, questionnaire-based study conducted on hemodialysis patients with DM in Palestine. The quota sampling method was utilized to draw samples from six dialysis centers. The questionnaire consists of three sections. The first section includes demographic, socioeconomic and clinical questions. The second section utilizes the patient activation measure-13 (PAM-13) to measure patient activation, while the third section assesses HRQoL using the EQ-5D-5 L tool and the visual analog scale (VAS). Mann‒Whitney and Kruskal‒Wallis tests were employed to examine the relationships between variables at the bivariate level, and multiple regression analysis was employed at the multivariate level.

RESULTS

Of the 200 patients who were approached, 158 were included. The median PAM, EQ-5D index, and VAS score were low at 51.0, 0.58, and 60.0, respectively. A higher PAM score was independently associated with a higher household income level and taking medications independently. A higher EQ-5D index was associated with taking more than eight medications, taking medications independently, living with fewer than three comorbid conditions, and having a higher PAM. A higher VAS score was associated with being married, and receiving less than 3.5 hours of hemodialysis.

CONCLUSIONS

A higher patient activation level was associated with a higher income level and independence in taking medications. Interventions designed to improve patient activation, such as medication management programs, should address these factors among the target population. Longitudinal studies are needed to assess the time effect and direction of causation between health status and patient activation.

Prescription and Dispensation of QT-Prolonging Medications in Individuals Receiving Hemodialysis

Importance

Individuals with dialysis-dependent kidney failure have numerous risk factors for medication-related adverse events, including receipt of care by multiple clinicians and initiation of some QT-prolonging medications with known risk of torsades de pointes (TdP), which is associated with higher risk of sudden cardiac death. Little is known about the prescription and dispensation patterns of QT-prolonging medications among people receiving dialysis, hindering efforts to reduce drug-related harm from these and other medications in this high-risk population.

Objective

To examine prescription and dispensation patterns of QT-prolonging medications with known TdP risk and selected interacting medications prescribed to individuals receiving hemodialysis.

Design, Setting, and Participants

This cross-sectional study included patients 60 years or older who were enrolled in Medicare Parts A, B, and D receiving in-center hemodialysis from January 1 to December 31, 2019. Analyses were conducted from October 20, 2022, to June 16, 2023.

Exposures

New-user prescriptions for the 7 most frequently filled QT-prolonging medications characterized by the timing of the new prescription relative to acute care encounters, the type of prescribing clinician and pharmacy that dispensed the medication, and concomitant use of selected medications known to interact with the 7 most frequently filled QT-prolonging medications with known TdP risk.

Main Outcomes and Measures

The main outcomes were the frequencies of the most commonly filled and new-use episodes of QT-prolonging medications; the timing of medication fills relative to acute care events; prescribers and dispensing pharmacy characteristics for new use of medications; and the frequency and types of new-use episodes with concurrent use of potentially interacting medications.

Results

Of 20 761 individuals receiving hemodialysis in 2019 (mean [SD] age, 74 [7] years; 51.1% male), 10 992 (52.9%) filled a study drug prescription. Approximately 80% (from 78.6% for odansetron to 93.9% for escitalopram) of study drug new-use prescriptions occurred outside of an acute care event. Between 36.8% and 61.0% of individual prescriptions originated from general medicine clinicians. Between 16.4% and 26.2% of these prescriptions occurred with the use of another QT-prolonging medication. Most potentially interacting drugs were prescribed by different clinicians (46.3%-65.5%).

Conclusions and Relevance

In this cross-sectional study, QT-prolonging medications for individuals with dialysis-dependent kidney failure were commonly prescribed by nonnephrology clinicians and from nonacute settings. Prescriptions for potentially interacting medications often originated from different prescribers. Strategies aimed at minimizing high-risk medication-prescribing practices in the population undergoing dialysis are needed.

Polypharmacy in chronic kidney disease: Health outcomes & pharmacy-based strategies to mitigate inappropriate polypharmacy

The rising prevalence of comorbidities in an increasingly aging population has sparked a reciprocal rise in polypharmacy. Patients with chronic kidney disease (CKD) have a greater burden of polypharmacy due to the comorbidities and complications associated with their disease. Polypharmacy in CKD patients has been linked to myriad direct and indirect costs for patients and the society at large. Pharmacists are uniquely positioned within the healthcare team to streamline polypharmacy management in the setting of CKD. In this article, we review the landscape of polypharmacy and examine its impacts through the lens of the ECHO model of Economic, Clinical, and Humanistic Outcomes. We also present strategies for healthcare teams to improve polypharmacy care through comprehensive medication management process that includes medication reconciliation during transitions of care, medication therapy management, and deprescribing. These pharmacist-led interventions have the potential to mitigate adverse outcomes associated with polypharmacy in CKD.

Effect of medication therapy management services on medication-burden quality of life in hemodialysis patients

BACKGROUND

Hemodialysis (HD) patients commonly receive polypharmacy leading to increased likelihood of drug related problems (DRPs) and poor quality of life. Medication Therapy Management (MTM) services discover and resolve DRPs and may specifically improve Medication-burden Quality of life (MBQoL) in HD patients. We aimed to assess the effect of MTM services on DRPs and MBQoL among HD patients.

METHODS

A prospective pre-post study was conducted on 104 patients in an HD unit in Alexandria, Egypt. MBQoL was assessed at baseline and after three months of MTM sessions, using the Arabic, validated version of the Patient Reported Outcomes Measure of Pharmaceutical Therapy (PROMPT) questionnaire. Cohen's d test and multiple linear regression were used to assess the effect size of MTM and the factors affecting MBQoL, respectively. DRPs, adverse events and adherence were also monitored.

RESULTS

MBQoL improved significantly after the implementation of MTM (Cohen's d=0.88, p < 0.01) with the largest effect size in the "medicine information and relation with healthcare providers" domain. DRPs decreased significantly after MTM implementation (11.97 ± 4.65 versus 7.63 ± 3.85 per patient, p<0.001). The mean adverse events per patient were also reduced (9.69 ± 4.12 versus 6.56 ± 3.77, p < 0.001).

CONCLUSION

Applying MTM services presents an opportunity to improve care for HD patients by improving MBQoL, decreasing DRPs and adverse events.

Prescription characteristics of phosphate binders in a high pill burden for hemodialysis patients

Background

Dialysis patients have to take many oral drugs, causing a high pill burden. Phosphate binders (PBs) account for a large proportion of daily pill burden; however, the relationship between patient background and prescription status of PBs is not clear.

Methods

We clarified the characteristics of PBs in the total daily pill burden by analyzing the drugs prescribed for 533 chronic hemodialysis patients in our facility.

Results

An average of nine different types of oral drugs was prescribed for each patient. The mean and median values of total pill burden were 15.1 and 14.1 pills/day/patient, respectively. The total pill burden showed a significant negative correlation with age and a significant positive correlation with dialysis vintage. In addition, the total pill burden was significantly higher in males than in females. However, there was no difference in the pill burden between patients with and without diabetes mellitus (DM). PBs were prescribed to 409 patients (76.7%), and the mean pill burden derived from PBs was 6.44 pills/day/patient. This was by far the highest of all 35 different drug categories and accounted for 32.84% of all pills. Multiple regression analysis demonstrated that independent predictors of total pill burden were age, dialysis vintage, DM, and serum phosphorus (P) levels, and all these variables, except DM, were also independent predictors of pill burden from PBs. These variables were also selected when considering the use of calcimimetics.

Conclusions

A high pill burden is more likely to occur in younger patients with longer dialysis vintage, DM, higher serum P levels, and prescription of calcimimetics. In addition, PB was the single largest contributor to the total pill burden that positively and linearly linked to serum P levels. Therefore, P management is a high-priority issue in the mitigation of high pill burdens in dialysis patients.

Medication management in dialysis: Barriers and strategies

People with end-stage kidney disease (ESKD) who require chronic dialysis are often reliant on complicated medication regimens to manage their health conditions. Due to the complexities of the advanced kidney disease, underlying comorbidities, and special instructions, medication regimens for patients on dialysis put patients at high risk for medication therapy problems related to safety, effectiveness, appropriateness, and adherence. This article explores the factors that affect optimal medication use for people on dialysis, including the broader drug use system, and offers recommendations around medication reconciliation, medication review, deprescribing, and considering social determinants of health to improve medication management among patients with ESKD.