PRACTICE INSIGHTS Pharmacist-Driven Renal Medication Dosing Intervention in a Primary Care Patient-Centered Medical Home Kelli D. Barnes,1 Neeraj H. Tayal,2 Amy M. Lehman,3 and Stuart J. Beatty1,* 1
Division of Pharmacy Practice and Administration, The Ohio State University College of Pharmacy, Columbus, Ohio; 2Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio; 3 The Ohio State University Center for Biostatistics, Columbus, Ohio
PURPOSE The purposes of this population management intervention were to identify patients with stage 3, 4, or 5 chronic kidney disease (CKD) and to improve care in a patient-centered medical home (PCMH). Objectives of the intervention were to (i) increase the identification of CKD, (ii) increase the use of aspirin and angiotensin-converting enzyme inhibitors (ACE-Is) or angiotensin II receptor blockers (ARBs) in patients with CKD, and (iii) ensure that all medications prescribed to patients with CKD were dosed appropriately based on renal function. SETTING This intervention was completed at a National Committee for Quality Assurance tier 3 PCMH associated with a major, academic health system. PATIENTS A list of 328 patients with an estimated glomerular filtration rate of < 60 mL/min per 1.73 m2 was generated using the electronic medical record; 146 patients underwent the intervention. MEASUREMENTS AND OBSERVATIONS A pharmacist review of the electronic medical record was completed to confirm stage 3, 4, or 5 CKD based on estimated glomerular filtration rate, to ensure that ACEIs/ARBs and aspirin were prescribed, and to ensure that all medications were dosed appropriately based on renal dosing adjustment recommendations. Recommendations were made to improve medication use and safety in patients with CKD. Before intervention, 73% of patients were prescribed an ACE-I/ARB and 72% of patients were prescribed aspirin. After the intervention, use of these medications increased to 77% and 82% of patients, respectively. Pharmacist recommendations to adjust medication dosing based on Cockcroft-Gault calculated creatinine clearance were made for 138 medications (0.95 medication per patient); 90 (65.2%) recommendations were accepted by the patients’ physicians. CONCLUSION These results demonstrate the impact of a pharmacist-driven renal medication dosing intervention within a PCMH on medication use and safety for patients with CKD. KEY WORDS electronic medical record, population management, patient-centered medical home, pharmacist, chronic kidney disease, primary care. (Pharmacotherapy 2014;**(**):**–**) doi: 10.1002/phar.1508
Patients with chronic kidney disease (CKD) take multiple medications for the management of CKD, CKD-related comorbidities, and other *Address for correspondence: Stuart J. Beatty, Division of Pharmacy Practice and Administration, The Ohio State University College of Pharmacy, 500 W. 12th Ave., Columbus, OH 43210; e-mail: [email protected]. Ó 2014 Pharmacotherapy Publications, Inc.
chronic disease states. Many of these medications require dosage adjustment to achieve patient outcomes while preventing adverse drug events or progression of renal disease.1 Additionally, the Kidney Disease Outcome Quality Initiative guidelines highlight the importance of using preventive medication such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) to slow
2
PHARMACOTHERAPY Volume **, Number **, 2014
the progression of renal dysfunction, as well as aspirin to prevent cardiovascular events.2, 3 Primary care physicians (PCPs) are commonly the first health care providers to identify and manage CKD.4, 5 Shortages in physician time, lack of consistent care, and inadequate application of clinical practice guidelines lead to missed opportunities and suboptimal CKD care.5 Previous studies have determined that up to 87% of patients lacked appropriate documentation of CKD as a medical problem, and these patients were less likely to receive recommended care.6–9 Additionally, noncompliance with renal dosing guidelines occurred for up to 67% of the medications prescribed for patients with CKD, leaving patients at high risk for the morbidity and mortality associated with inappropriate drug use.6, 7, 10, 11 Providing optimal medication therapy to patients is imperative to improve the quality of care provided and to minimize increasing health care costs. As reimbursement for patient care shifts toward a model that incentivizes quality care, the incorporation of collaborative patient care teams will be necessary to meet patient care demands.12, 13 Pharmacists are perfectly positioned to improve medication use and safety, given their specialized training in medication management. Pharmacist involvement in medication dosing for hospitalized patients has improved compliance with renal dosing recommendations, lowered drug costs, and decreased risk for adverse drug events.11, 14 Similarly, pharmacist-driven interventions in outpatient settings have decreased drug-related problems and reduced hospitalizations in patients receiving dialysis.15–17 One study also focused on pharmacist intervention to improve medication use in patients with CKD before dialysis; however, only patients with hypertension and diabetes were included and physicians accepted only 40.9% of the recommendations made.7 This low acceptance rate was likely attributable to the indirect communication methods between pharmacists and physicians.7 Based on these results, one could hypothesize that a pharmacist-driven population management intervention would improve recommended medication use and medication safety in all patients with CKD in a patient-centered medical home (PCMH). The objectives of this intervention were to (i) increase the identification of CKD as a medical problem, (ii) increase the use of aspirin and ACEIs/ARBs in patients with CKD, and (iii) ensure that all medications prescribed to patients with CKD were dosed
appropriately based on Cockcroft-Gault calculated creatinine clearance. Setting This intervention was conducted at a National Committee for Quality Assurance tier 3 PCMH associated with a major, academic health system from December 2011 to December 2012.12 Health care professionals at the site include 10 attending physicians, 75 medical residents, 1 pharmacist, 2 pharmacy practice residents, 1 nurse practitioner, 3 registered nurses, 1 social worker, and several medical assistants. The clinic cares for more than 20,000 patients annually. Payer breakdown for patients in the clinic included 39% third-party insurance, 35% Medicaid, 18% Medicare, and 8% uninsured. The clinic’s electronic medical record (EMR) is integrated with the entire health system and contains clinical documentation, laboratory values, current and previously prescribed medications, specialty referrals, diagnosis codes, and medical problem lists that are updated by providers throughout the system. At the time of this intervention, the EMR did not provide any decisionsupport technology for medication prescribing in patients with decreased renal function. Patients A list of all patients and corresponding serum creatinine for five attending PCPs was generated using EMR reporting software. For the purpose of CKD staging, eGFR was calculated using the modification of diet in renal disease calculation.18 For patients with eGFR less than 60 ml/min per 1.73 m2, the pharmacist completed a chart review to identify a second eGFR value of less than 60 ml/min per 1.73 m2at least 3 months before the date listed on the report to confirm the presence of stage 3, 4, or 5 CKD.19 Patients were categorized as having stage 3, 4, or 5 CKD if their most recent eGFR was 30–59 ml/min per 1.73 m2, 15–29 ml/min per 1.73 m2, or less than 15 ml/min per 1.73 m2, respectively. Patients were included in the intervention if they had stage 3, 4, or 5 CKD and were at least 18 years of age. Patients were excluded if they were no longer a patient at our office, were deceased, did not have an office visit at our clinic in the last 24 months, were receiving dialysis, had a previous renal transplant, or did not have all necessary information available in the EMR. This intervention was approved by The
RENAL MEDICATION DOSING IN PCMH Barnes et al Ohio State Board.
University
Institutional
Review
Intervention The EMRs of included patients were reviewed by a pharmacist to ensure that CKD was listed as a problem on the patient’s medical problem list. If CKD was not listed as a medical problem in the patient’s EMR, it was discussed with the patient’s PCP; CKD was added to the problem list if the PCP determined the addition was appropriate. Each patient’s medication list was also reviewed by a pharmacist to ensure that patients had received prescriptions for an ACEI/ARB and aspirin or had a contraindication for the use of these medications. Additionally, each patient’s creatinine clearance was calculated using the Cockroft-Gault equation, and all medications were reviewed to ensure they were dosed appropriately based on renal dosing adjustment recommendations outlined by the Micromedex online database.20, 21 Any recommended medications that were not currently prescribed and any inappropriate medication doses identified during the intervention were communicated to the patient’s PCP, who could accept or decline the pharmacist’s recommendation. Orders for accepted recommendations were signed by the PCP, and patients were contacted to implement any medication changes. Measurements The percentage of patients with CKD identified as a medical problem before and after pharmacist intervention was reported. The percentage of patients not taking an ACEI/ARB and the percentage of patients not taking aspirin who did not have any contraindication for use of these medications before the intervention were also tracked. To assess potential improvements in recommended medication use, the proportions of patients who were not taking an ACE I/ARB or aspirin preintervention but were prescribed the medication following the pharmacist intervention were calculated with 95% confidence intervals (CIs). Comparisons in medication use and likelihood of having CKD listed as a medical problem in the EMR were made using v2 tests. Similarly, comparisons in medication use and likelihood of having diabetes, hypertension, coronary artery disease, and hyperlipidemia were also made using v2 tests.
3
Holm’s procedure was again used to control the overall error rate at 0.05. Finally, the percentages of medications dosed inappropriately or contraindicated before and after pharmacist intervention were calculated to assess suboptimal medication use. All analyses were performed using SAS/STAT software, version 9.2 (SAS Institute, Inc., Cary, NC). Observations The EMR generated a list of 3214 patients for five physicians; 328 (10.2%) patients were identified with an eGFR less than 60 ml/min per 1.73 m2. Of these, 146 patients had the full intervention completed by a pharmacist and 182 patients were excluded from the intervention (Figure 1). Baseline characteristics of the 146 patients included in the intervention are summarized in Table 1. Of the 146 patients included, 51 (34.9%) patients had CKD listed as a medical problem in the EMR before pharmacist intervention. This improved to 145 (99.3%) patients after intervention. Medication Use Aspirin was prescribed or contraindicated in 71.9% of patients at baseline, while ACEIs/ARBs were prescribed or contraindicated in 73.3% of patients (Table 2). Following pharmacist intervention, this increased to 82% of patients taking aspirin and 77% of patients taking an ACEI/ ARB. Patients with hypertension listed as a medical problem were more likely to be taking an ACEI/ARB than were patients without hypertension listed as a medical problem, (81% vs 30%, p
Division of Pharmacy Practice and Administration, The Ohio State University College of Pharmacy, Columbus, Ohio; 2Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio; 3 The Ohio State University Center for Biostatistics, Columbus, Ohio
PURPOSE The purposes of this population management intervention were to identify patients with stage 3, 4, or 5 chronic kidney disease (CKD) and to improve care in a patient-centered medical home (PCMH). Objectives of the intervention were to (i) increase the identification of CKD, (ii) increase the use of aspirin and angiotensin-converting enzyme inhibitors (ACE-Is) or angiotensin II receptor blockers (ARBs) in patients with CKD, and (iii) ensure that all medications prescribed to patients with CKD were dosed appropriately based on renal function. SETTING This intervention was completed at a National Committee for Quality Assurance tier 3 PCMH associated with a major, academic health system. PATIENTS A list of 328 patients with an estimated glomerular filtration rate of < 60 mL/min per 1.73 m2 was generated using the electronic medical record; 146 patients underwent the intervention. MEASUREMENTS AND OBSERVATIONS A pharmacist review of the electronic medical record was completed to confirm stage 3, 4, or 5 CKD based on estimated glomerular filtration rate, to ensure that ACEIs/ARBs and aspirin were prescribed, and to ensure that all medications were dosed appropriately based on renal dosing adjustment recommendations. Recommendations were made to improve medication use and safety in patients with CKD. Before intervention, 73% of patients were prescribed an ACE-I/ARB and 72% of patients were prescribed aspirin. After the intervention, use of these medications increased to 77% and 82% of patients, respectively. Pharmacist recommendations to adjust medication dosing based on Cockcroft-Gault calculated creatinine clearance were made for 138 medications (0.95 medication per patient); 90 (65.2%) recommendations were accepted by the patients’ physicians. CONCLUSION These results demonstrate the impact of a pharmacist-driven renal medication dosing intervention within a PCMH on medication use and safety for patients with CKD. KEY WORDS electronic medical record, population management, patient-centered medical home, pharmacist, chronic kidney disease, primary care. (Pharmacotherapy 2014;**(**):**–**) doi: 10.1002/phar.1508
Patients with chronic kidney disease (CKD) take multiple medications for the management of CKD, CKD-related comorbidities, and other *Address for correspondence: Stuart J. Beatty, Division of Pharmacy Practice and Administration, The Ohio State University College of Pharmacy, 500 W. 12th Ave., Columbus, OH 43210; e-mail: [email protected]. Ó 2014 Pharmacotherapy Publications, Inc.
chronic disease states. Many of these medications require dosage adjustment to achieve patient outcomes while preventing adverse drug events or progression of renal disease.1 Additionally, the Kidney Disease Outcome Quality Initiative guidelines highlight the importance of using preventive medication such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) to slow
2
PHARMACOTHERAPY Volume **, Number **, 2014
the progression of renal dysfunction, as well as aspirin to prevent cardiovascular events.2, 3 Primary care physicians (PCPs) are commonly the first health care providers to identify and manage CKD.4, 5 Shortages in physician time, lack of consistent care, and inadequate application of clinical practice guidelines lead to missed opportunities and suboptimal CKD care.5 Previous studies have determined that up to 87% of patients lacked appropriate documentation of CKD as a medical problem, and these patients were less likely to receive recommended care.6–9 Additionally, noncompliance with renal dosing guidelines occurred for up to 67% of the medications prescribed for patients with CKD, leaving patients at high risk for the morbidity and mortality associated with inappropriate drug use.6, 7, 10, 11 Providing optimal medication therapy to patients is imperative to improve the quality of care provided and to minimize increasing health care costs. As reimbursement for patient care shifts toward a model that incentivizes quality care, the incorporation of collaborative patient care teams will be necessary to meet patient care demands.12, 13 Pharmacists are perfectly positioned to improve medication use and safety, given their specialized training in medication management. Pharmacist involvement in medication dosing for hospitalized patients has improved compliance with renal dosing recommendations, lowered drug costs, and decreased risk for adverse drug events.11, 14 Similarly, pharmacist-driven interventions in outpatient settings have decreased drug-related problems and reduced hospitalizations in patients receiving dialysis.15–17 One study also focused on pharmacist intervention to improve medication use in patients with CKD before dialysis; however, only patients with hypertension and diabetes were included and physicians accepted only 40.9% of the recommendations made.7 This low acceptance rate was likely attributable to the indirect communication methods between pharmacists and physicians.7 Based on these results, one could hypothesize that a pharmacist-driven population management intervention would improve recommended medication use and medication safety in all patients with CKD in a patient-centered medical home (PCMH). The objectives of this intervention were to (i) increase the identification of CKD as a medical problem, (ii) increase the use of aspirin and ACEIs/ARBs in patients with CKD, and (iii) ensure that all medications prescribed to patients with CKD were dosed
appropriately based on Cockcroft-Gault calculated creatinine clearance. Setting This intervention was conducted at a National Committee for Quality Assurance tier 3 PCMH associated with a major, academic health system from December 2011 to December 2012.12 Health care professionals at the site include 10 attending physicians, 75 medical residents, 1 pharmacist, 2 pharmacy practice residents, 1 nurse practitioner, 3 registered nurses, 1 social worker, and several medical assistants. The clinic cares for more than 20,000 patients annually. Payer breakdown for patients in the clinic included 39% third-party insurance, 35% Medicaid, 18% Medicare, and 8% uninsured. The clinic’s electronic medical record (EMR) is integrated with the entire health system and contains clinical documentation, laboratory values, current and previously prescribed medications, specialty referrals, diagnosis codes, and medical problem lists that are updated by providers throughout the system. At the time of this intervention, the EMR did not provide any decisionsupport technology for medication prescribing in patients with decreased renal function. Patients A list of all patients and corresponding serum creatinine for five attending PCPs was generated using EMR reporting software. For the purpose of CKD staging, eGFR was calculated using the modification of diet in renal disease calculation.18 For patients with eGFR less than 60 ml/min per 1.73 m2, the pharmacist completed a chart review to identify a second eGFR value of less than 60 ml/min per 1.73 m2at least 3 months before the date listed on the report to confirm the presence of stage 3, 4, or 5 CKD.19 Patients were categorized as having stage 3, 4, or 5 CKD if their most recent eGFR was 30–59 ml/min per 1.73 m2, 15–29 ml/min per 1.73 m2, or less than 15 ml/min per 1.73 m2, respectively. Patients were included in the intervention if they had stage 3, 4, or 5 CKD and were at least 18 years of age. Patients were excluded if they were no longer a patient at our office, were deceased, did not have an office visit at our clinic in the last 24 months, were receiving dialysis, had a previous renal transplant, or did not have all necessary information available in the EMR. This intervention was approved by The
RENAL MEDICATION DOSING IN PCMH Barnes et al Ohio State Board.
University
Institutional
Review
Intervention The EMRs of included patients were reviewed by a pharmacist to ensure that CKD was listed as a problem on the patient’s medical problem list. If CKD was not listed as a medical problem in the patient’s EMR, it was discussed with the patient’s PCP; CKD was added to the problem list if the PCP determined the addition was appropriate. Each patient’s medication list was also reviewed by a pharmacist to ensure that patients had received prescriptions for an ACEI/ARB and aspirin or had a contraindication for the use of these medications. Additionally, each patient’s creatinine clearance was calculated using the Cockroft-Gault equation, and all medications were reviewed to ensure they were dosed appropriately based on renal dosing adjustment recommendations outlined by the Micromedex online database.20, 21 Any recommended medications that were not currently prescribed and any inappropriate medication doses identified during the intervention were communicated to the patient’s PCP, who could accept or decline the pharmacist’s recommendation. Orders for accepted recommendations were signed by the PCP, and patients were contacted to implement any medication changes. Measurements The percentage of patients with CKD identified as a medical problem before and after pharmacist intervention was reported. The percentage of patients not taking an ACEI/ARB and the percentage of patients not taking aspirin who did not have any contraindication for use of these medications before the intervention were also tracked. To assess potential improvements in recommended medication use, the proportions of patients who were not taking an ACE I/ARB or aspirin preintervention but were prescribed the medication following the pharmacist intervention were calculated with 95% confidence intervals (CIs). Comparisons in medication use and likelihood of having CKD listed as a medical problem in the EMR were made using v2 tests. Similarly, comparisons in medication use and likelihood of having diabetes, hypertension, coronary artery disease, and hyperlipidemia were also made using v2 tests.
3
Holm’s procedure was again used to control the overall error rate at 0.05. Finally, the percentages of medications dosed inappropriately or contraindicated before and after pharmacist intervention were calculated to assess suboptimal medication use. All analyses were performed using SAS/STAT software, version 9.2 (SAS Institute, Inc., Cary, NC). Observations The EMR generated a list of 3214 patients for five physicians; 328 (10.2%) patients were identified with an eGFR less than 60 ml/min per 1.73 m2. Of these, 146 patients had the full intervention completed by a pharmacist and 182 patients were excluded from the intervention (Figure 1). Baseline characteristics of the 146 patients included in the intervention are summarized in Table 1. Of the 146 patients included, 51 (34.9%) patients had CKD listed as a medical problem in the EMR before pharmacist intervention. This improved to 145 (99.3%) patients after intervention. Medication Use Aspirin was prescribed or contraindicated in 71.9% of patients at baseline, while ACEIs/ARBs were prescribed or contraindicated in 73.3% of patients (Table 2). Following pharmacist intervention, this increased to 82% of patients taking aspirin and 77% of patients taking an ACEI/ ARB. Patients with hypertension listed as a medical problem were more likely to be taking an ACEI/ARB than were patients without hypertension listed as a medical problem, (81% vs 30%, p
