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Manis MM, Skelley JW, Read JB, Maxson R, O'Hagan E, Wallace JL, Siew ED, Barreto EF, Silver SA, Kane-Gill SL, Neyra JA. Role of a Pharmacist in Postdischarge Care for Patients With Kidney Disease: A Scoping Review. Ann Pharmacother 2024:10600280241240409. [PMID: 38563565 DOI: 10.1177/10600280241240409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE The objective was to explore and describe the role of pharmacists in providing postdischarge care to patients with kidney disease. DATA SOURCES PubMed, Embase (Elsevier), CINAHL (Ebscohost), Web of Science Core Collection, and Scopus were searched on January 30, 2023. Publication date limits were not included. Search terms were identified based on 3 concepts: kidney disease, pharmacy services, and patient discharge. Experimental, quasi-experimental, observational, and qualitative studies, or study protocols, describing the pharmacist's role in providing postdischarge care for patients with kidney disease, excluding kidney transplant recipients, were eligible. STUDY SELECTION AND DATA EXTRACTION Six unique interventions were described in 10 studies meeting inclusion criteria. DATA SYNTHESIS Four interventions targeted patients with acute kidney injury (AKI) during hospitalization and 2 evaluated patients with pre-existing chronic kidney disease. Pharmacists were a multidisciplinary care team (MDCT) member in 5 interventions and were the sole provider in 1. Roles commonly identified include medication review, medication reconciliation, medication action plan formation, kidney function assessment, drug dose adjustments, and disease education. Some studies showed improvements in diagnostic coding, laboratory monitoring, medication therapy problem (MTP) resolution, and patient education; prevention of hospital readmission was inconsistent. Limitations include lack of standardized reporting of kidney disease, transitions of care processes, and differences in outcomes evaluated. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review identifies potential roles of a pharmacist as part of a postdischarge MDCT for patients with varying degrees of kidney disease. CONCLUSIONS The pharmacist's role in providing postdischarge care to patients with kidney disease is inconsistent. Multidisciplinary care teams including a pharmacist provided consistent identification and resolution of MTPs, improved patient education, and increased self-awareness of diagnosis.
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Affiliation(s)
- Melanie M Manis
- Department of Pharmacy Practice, McWhorter School of Pharmacy, Samford University, Birmingham, AL, USA
- Division of Nephrology, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jessica W Skelley
- Department of Pharmacy Practice, McWhorter School of Pharmacy, Samford University, Birmingham, AL, USA
| | - J Braden Read
- Department of Pharmacy Practice, McWhorter School of Pharmacy, Samford University, Birmingham, AL, USA
| | - Rebecca Maxson
- Department of Pharmacy Practice, Harrison College of Pharmacy, Auburn University, Auburn, AL, USA
| | - Emma O'Hagan
- Department of Libraries, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jessica L Wallace
- Department of Pharmacy Practice, College of Pharmacy, Lipscomb University, Nashville, TN, USA
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
- Tennessee Valley Health Systems (TVHS), Nashville Veterans Affairs Medical Center, Nashville, TN, USA
| | | | - Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
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May HP, Herges JR, Anderson BK, Hanson GJ, Kashani KB, Kattah AG, Cole KC, McCoy RG, Meade LA, Rule AD, Schreier DJ, Tinaglia AG, Barreto EF. Posthospital Multidisciplinary Care for AKI Survivors: A Feasibility Pilot. Kidney Med 2023; 5:100734. [PMID: 37964784 PMCID: PMC10641567 DOI: 10.1016/j.xkme.2023.100734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
Rationale & Objective Innovative models are needed to address significant gaps in kidney care follow-up for acute kidney injury (AKI) survivors. Study Design This quasi-experimental pilot study reports the feasibility of the AKI in Care Transitions (ACT) program, a multidisciplinary approach to AKI survivor care based in the primary care setting. Setting & Participants The study included consenting adults with stage 3 AKI discharged home without dialysis. Interventions The ACT intervention included predischarge education from nurses and coordinated postdischarge follow-up with a primary care provider and pharmacist within 14 days. ACT was implemented in phases (Usual Care, Education, ACT). Outcomes The primary outcome was feasibility. Secondary outcomes included process and clinical outcomes. Results In total, 46 of 110 eligible adults were enrolled. Education occurred in 18/18 and 14/15 participants in the Education and ACT groups, respectively. 30-day urine protein evaluation occurred in 15%, 28%, and 87% of the Usual Care, Education, and ACT groups, respectively (P < 0.001). Cumulative incidence of provider (primary care or nephrologist) and laboratory follow-up at 14 and 30 days was different across groups (14 days: Usual care 0%, Education 11%, ACT 73% [P < 0.01]; 30 days: 0%, 22%, and 73% [P < 0.01]). 30-day readmission rates were 23%, 44%, and 13% in the Usual Care, Education, and ACT groups, respectively (P = 0.13). Limitations Patients were not randomly assigned to treatment groups. The sample size limited the ability to detect some differences or perform multivariable analysis. Conclusions This study demonstrated the feasibility of multidisciplinary AKI survivor follow-up beginning in primary care. We observed a higher cumulative incidence of laboratory and provider follow-up in ACT participants. Trial Registration ClinicalTrials.gov (NCT04505891). Plain-Language Summary Abrupt loss of kidney function in hospitalized patients, acute kidney injury (AKI), increases the chances of long-term kidney disease and a worse health care experience for patients. One out of 3 people who experience AKI do not get the follow-up kidney care they need. We performed a pilot study to test whether a program that facilitates structured AKI follow-up in primary care called the AKI in Care Transitions (ACT) program was possible. ACT brings together the unique expertise of nurses, doctors, and pharmacists to look at the patient's kidney health plan from all angles. The study found that the ACT program was possible and led to more complete kidney care follow-up after discharge than the normal approach to care.
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Affiliation(s)
| | | | | | - Gregory J. Hanson
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kianoush B. Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Andrea G. Kattah
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kristin C. Cole
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Rozalina G. McCoy
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Laurie A. Meade
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | | | | | - ACT Study Group
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
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Kashani KB, Koyner JL. Digital health utilities in acute kidney injury management. Curr Opin Crit Care 2023; 29:542-550. [PMID: 37861196 PMCID: PMC11285742 DOI: 10.1097/mcc.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) is a highly prevalent clinical syndrome that substantially impacts patient outcomes. It is accepted by the clinical communities that the management of AKI is time-sensitive. Unfortunately, despite growing proof of its preventability, AKI management remains suboptimal in community, acute care, and postacute care settings. Digital health solutions comprise various tools and models to improve care processes and patient outcomes in multiple medical fields. AKI development, progression, recovery, or lack thereof, offers tremendous opportunities for developing, validating, and implementing digital health solutions in multiple settings. This article will review the definitions and components of digital health, the characteristics of AKI that allow digital health solutions to be considered, and the opportunities and threats in implementing these solutions. RECENT FINDINGS Over the past two decades, the academic output related to the use of digital health solutions in AKI has exponentially grown. While this indicates the growing interest in the topic, most topics are primarily related to clinical decision support by detecting AKI within hospitals or using artificial intelligence or machine learning technologies to predict AKI within acute care settings. However, recently, projects to assess the impact of digital health solutions in more complex scenarios, for example, managing nephrotoxins among adults of pediatric patients who already have AKI, is increasing. Depending on the type of patients, chosen digital health solution intervention, comparator groups, and selected outcomes, some of these studies showed benefits, while some did not indicate additional gain in care processes or clinical outcomes. SUMMARY Careful needs assessment, selection of the correct digital health solution, and appropriate clinical validation of the benefits while avoiding additional health disparities are moral, professional, and ethical obligations for all individuals using these healthcare tools, including clinicians, data scientists, and administrators.
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Affiliation(s)
- Kianoush B. Kashani
- Division of Nephrology and Hypertension, University of Chicago, Chicago, Illinois, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, University of Chicago, Chicago, Illinois, USA
| | - Jay L. Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
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May HP, Griffin JM, Herges JR, Kashani KB, Kattah AG, Mara KC, McCoy RG, Rule AD, Tinaglia AG, Barreto EF. Comprehensive Acute Kidney Injury Survivor Care: Protocol for the Randomized Acute Kidney Injury in Care Transitions Pilot Trial. JMIR Res Protoc 2023; 12:e48109. [PMID: 37213187 PMCID: PMC10242466 DOI: 10.2196/48109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/24/2023] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND Innovative care models are needed to address gaps in kidney care follow-up among acute kidney injury (AKI) survivors. We developed the multidisciplinary AKI in Care Transitions (ACT) program, which embeds post-AKI care in patients' primary care clinic. OBJECTIVE The objective of this randomized pilot trial is to test the feasibility and acceptability of the ACT program and study protocol, including recruitment and retention, procedures, and outcome measures. METHODS The study will be conducted at Mayo Clinic in Rochester, Minnesota, a tertiary care center with a local primary care practice. Individuals who are included have stage 3 AKI during their hospitalization, do not require dialysis at discharge, have a local primary care provider, and are discharged to their home. Patients unable or unwilling to provide informed consent and recipients of any transplant within 100 days of enrollment are excluded. Consented patients are randomized to receive the intervention (ie, ACT program) or usual care. The ACT program intervention includes predischarge kidney health education from nurses and coordinated postdischarge laboratory monitoring (serum creatinine and urine protein assessment) and follow-up with a primary care provider and pharmacist within 14 days. The usual care group receives no specific study-related intervention, and any aspects of AKI care are at the direction of the treating team. This study will examine the feasibility of the ACT program, including recruitment, randomization and retention in a trial setting, and intervention fidelity. The feasibility and acceptability of participating in the ACT program will also be examined in qualitative interviews with patients and staff and through surveys. Qualitative interviews will be deductively and inductively coded and themes compared across data types. Observations of clinical encounters will be examined for discussion and care plans related to kidney health. Descriptive analyses will summarize quantitative measures of the feasibility and acceptability of ACT. Participants' knowledge about kidney health, quality of life, and process outcomes (eg, type and timing of laboratory assessments) will be described for both groups. Clinical outcomes (eg, unplanned rehospitalization) up to 12 months will be compared with Cox proportional hazards models. RESULTS This study received funding from the Agency for Health Care Research and Quality on April 21, 2021, and was approved by the Institutional Review Board on December 14, 2021. As of March 14, 2023, seventeen participants each have been enrolled in the intervention and usual care groups. CONCLUSIONS Feasible and generalizable AKI survivor care delivery models are needed to improve care processes and health outcomes. This pilot trial will test the ACT program, which uses a multidisciplinary model focused on primary care to address this gap. TRIAL REGISTRATION ClinicalTrials.gov NCT05184894; https://www.clinicaltrials.gov/ct2/show/NCT05184894. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/48109.
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Herges JR, May HP, Meade L, Anderson B, Tinaglia AG, Schreier DJ, Kashani KB, Kattah A, McCoy RG, Rule AD, Mara KC, Barreto EF. Pharmacist-provider collaborative visits after hospital discharge in a comprehensive acute kidney injury survivor model. J Am Pharm Assoc (2003) 2023; 63:909-914. [PMID: 36702735 PMCID: PMC10198834 DOI: 10.1016/j.japh.2022.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/19/2022] [Accepted: 12/28/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Postdischarge follow-up in primary care is an opportunity for pharmacists to re-evaluate medication use in acute kidney injury (AKI) survivors. Of the emerging AKI survivor care models described in literature, only one involved a pharmacist with limited detail about the direct impact. OBJECTIVE This study aimed to describe pharmacist contributions to a comprehensive postdischarge AKI survivorship program in primary care (the AKI in Care Transitions [ACT] program). METHODS The ACT program was piloted from May to December of 2021 at Mayo Clinic as a bundled care strategy for patients who survived an episode of AKI and were discharged home without the need for hemodialysis. Patients received education and care coordination from nurses before discharge and later completed postdischarge laboratory assessment and clinician follow-up in primary care. During the follow-up encounter, patients completed a 30-minute comprehensive medication management visit with a pharmacist focusing on AKI survivorship considerations. Medication therapy recommendations were communicated to a collaborating primary care provider (PCP) before a separate 30-minute visit with the patient. PCPs had access to clinical decision support with evidence-based post-AKI care recommendations. Medication-related issues were summarized descriptively. RESULTS Pharmacists made 28 medication therapy recommendations (median 3 per patient, interquartile range 2-3) and identified 14 medication discrepancies for the 11 patients who completed the pilot program, and 86% of the medication therapy recommendations were acted on by the PCP within 7 days. Six recommendations were made to initiate renoprotective medications, and 5 were acted on (83%). CONCLUSION During the pilot phase of a multifaceted transitional care program for AKI survivors, pharmacists' successfully identified and addressed multiple medication therapy problems, including for renally active drugs. These results demonstrate the potential for pharmacist-provider collaborative visits in primary care to improve safe and effective medication use in AKI survivors.
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Quality, safety, and implementation science in acute kidney care. Curr Opin Crit Care 2022; 28:613-621. [PMID: 36226720 DOI: 10.1097/mcc.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Quality and safety are important themes in acute kidney care (AKC). There have been many recent initiatives highlighting these aspects. However, for these to become part of clinical practice, a rigorous implementation science methodology must be followed. This review will present these practices and will highlight recent initiatives in acute kidney injury (AKI), kidney replacement therapy (KRT) and recovery from AKI. RECENT FINDINGS The 22nd Acute Disease Quality Initiative (ADQI) focused on achieving a framework for improving AKI care. This has led to various quality improvement (QI) initiatives that have been implemented following a robust implementation science methodology. In AKI, QI initiatives have been focused on implementing care bundles and early detection systems for patients at risk or with AKI. KRT initiatives have focused on measuring and reporting key performance indicators (KPIs), and providing targeted feedback and education to improve delivery of KRT. Finally, it has been recognized that post-AKI care is vitally important, and ongoing work has been focused on implementing pathways to ensure continuing kidney-focused care. SUMMARY Quality and safety continue to be important focuses in AKC. Although recent work have focused on initiatives to improve these themes, additional work is necessary to further develop these items as we strive to improve the care to patients with AKI.
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May HP, Krauter AK, Finnie DM, McCoy RG, Kashani KB, Griffin JM, Barreto EF. Optimising transitions of care for acute kidney injury survivors: protocol for a mixed-methods study of nephrologist and primary care provider recommendations. BMJ Open 2022; 12:e058613. [PMID: 35732395 PMCID: PMC9226954 DOI: 10.1136/bmjopen-2021-058613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) affects nearly 20% of all hospitalised patients and is associated with poor outcomes. Long-term complications can be partially attributed to gaps in kidney-focused care and education during transitions. Building capacity across the healthcare spectrum by engaging a broad network of multidisciplinary providers to facilitate optimal follow-up care represents an important mechanism to address this existing care gap. Key participants include nephrologists and primary care providers and in-depth study of each specialty's approach to post-AKI care is essential to optimise care processes and healthcare delivery for AKI survivors. METHODS AND ANALYSIS This explanatory sequential mixed-methods study uses survey and interview methodology to assess nephrologist and primary care provider recommendations for post-AKI care, including KAMPS (kidney function assessment, awareness and education, medication review, blood pressure monitoring and sick day education) elements of follow-up, the role of multispecialty collaboration, and views on care process-specific and patient-specific factors influencing healthcare delivery. Nephrologists and primary care providers will be surveyed to assess recommendations and clinical decision-making in the context of post-AKI care. Descriptive statistics and the Pearson's χ2 or Fisher's exact test will be used to compare results between groups. This will be followed by semistructured interviews to gather rich, qualitative data that explains and/or connects results from the quantitative survey. Both deductive analysis and inductive analysis will occur to identify and compare themes. ETHICS AND DISSEMINATION This study has been reviewed and deemed exempt by the Institutional Review Board at Mayo Clinic (IRB 20-0 08 793). The study was deemed exempt due to the sole use of survey and interview methodology. Results will be disseminated in presentations and manuscript form through peer-reviewed publication.
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Affiliation(s)
| | | | - Dawn M Finnie
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | | | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Joan M Griffin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
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