The missing piece: Clinical pharmacists enhancing the interprofessional nephrology clinic model

Connecting the disconnected: Leveraging an in-home team member for video visits for older adults

BACKGROUND

Older adults are interested and able to complete video visits, but often require coaching and practice to succeed. Data show a widening digital divide between older and younger adults using video visits. We conducted a qualitative feasibility study to investigate these gaps via ethnographic methods, including a team member in older participants' homes.

METHODS

This ethnographic feasibility study included a virtual medication reconciliation visit with a clinical pharmacist for Veterans aged 65 and older taking 5 or more medications. An in-home study team member joined the participant and recorded observations in structured fieldnotes derived from the Updated Consolidated Framework for Implementation Research and Age-Friendly Health Systems. Fieldnotes included behind-the-scenes facilitators, barriers, and solutions to challenges before and during the visits. We conducted a thematic analysis of these observations and matched themes to implementation solutions from the Expert Recommendations for Implementing Change.

RESULTS

Twenty participants completed a video visit. Participants were 74 years old (range 68-80) taking 12 daily medications (range 7-24). Challenges occurred in half of the visits and took the in-home team member and/or pharmacist an average of 10 minutes to troubleshoot. Challenges included notable new findings, such as that half of the participants required technology assistance for challenges that would not have been able to be solved by the pharmacist virtually. Furthermore, although many participants had a device or had used video visits before, some did not have a single device with video, audio, Internet, and access to their email username and password.

CONCLUSIONS

Clinicians may apply these evidence-based implementation solutions to their approach to video visits with older adults, including having a team member join the visit before the clinician, involving tech-savvy family members, ensuring the device works with the visit platform ahead of time, and creating a troubleshooting guide from our common challenges.

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.

Prevalence and global trends of polypharmacy in patients with chronic kidney disease: A systematic review and meta-analysis

Background and objectives: Polypharmacy and chronic kidney disease (CKD) are becoming increasingly common due to an ageing population and the rise of multimorbidity. In line with the therapeutic guidelines, managing CKD and its complications necessitates prescribing multiple medications, which predisposes patients to polypharmacy. The aim of this systematic review and meta-analysis is to describe the prevalence of polypharmacy in patients with CKD and to explore the global trends of factors driving any apparent variability in prevalence estimates. Methods: PubMed, Scopus, the Cochrane Database of Systematic Reviews (CDSR), and Google Scholar were searched from 1999 to November 2021. Study selection, data extraction, and critical appraisal were conducted by two independent reviewers. The pooled prevalence of polypharmacy was estimated utilizing the random effects model using the default double arcsine transformation. Results: This review involved 14 studies comprising of 17 201 participants, a significant proportion of which were males (56.12%). The mean age of the review population was 61.96 (SD ± 11.51) years. The overall pooled prevalence of polypharmacy amongst patients with CKD was 69% (95% CI: 49%-86%) (I² = 100%, p < 0.0001), with a proportionately higher prevalence in North America and Europe as compared to Asia. Conclusion: The results from this meta-analysis showed a high pooled prevalence estimates of polypharmacy amongst patient cohorts with CKD. The exact interventions that are likely to significantly mitigate its effect remain uncertain and will need exploration by future prospective and systematic studies. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022306572].

The role of the clinical pharmacist in the prevention of drug-induced acute kidney injury in the intensive care unit

WHAT IS KNOWN AND OBJECTIVE

Acute kidney injury (AKI) is a disorder that is commonly seen in patients in the intensive care unit (ICU) and has a detrimental impact on the patients' clinical prognosis. Although a variety of factors contribute to the development of AKI in patients, drug-induced AKI is a common occurrence in the ICU. With the widespread availability of clinical pharmacy services, the clinical pharmacist's consultation service to the healthcare team aids in the resolution of drug-related issues and the enhancement of therapeutic outcomes. The involvement of a clinical pharmacist in the ICU team is expected to minimize the incidence of drug-induced AKI and enhance therapeutic results. Therefore, the goal of our study was to demonstrate the impact of having a clinical pharmacist on the occurrence, stages, and treatment of AKI.

METHODS

The study included two patient groups: intervention (n = 75) (IG) and control (n = 75) (CG) groups. The clinical pharmacist has made recommendations to the ICU team regarding the treatment of IG patients on drug selection, drug administration routes, drug dose adjustment, drug-drug interactions, drug-food or nutritional solution interactions, drug side effect management, and drug incompatibility. No interventions were provided by the clinical pharmacist in the CG patients. The clinical pharmacist visited patients regularly and noted the laboratory findings and pharmacological treatments of patients in the study groups on the patient follow-up forms. The obtained data of IG and CG were compared and statistical methods were used to assess them.

RESULTS AND DISCUSSION

According to our findings, AKI was found to be more common in CG than in IG (p < 0.05). Stage 1 was shown to be the most common AKI stage in the patients (p > 0.05). The gap between the patients' highest Cr and basal sCr values was less in IG (p < 0.05). When the association between reasons for ICU admission and AKI was investigated, pulmonary edema and acute respiratory failure were found to have a significant and positive relationship with AKI (p < 0.05). Furthermore, it was shown that patients with diabetes and cancer comorbidities were the most vulnerable to developing AKI (p < 0.05). Antibiotics, anaesthetics, and cardiovascular system medication categories were found to have a significant and positive correlation with AKI in patients (p < 0.05). Also, it was revealed that the usage of vancomycin, colistin, ampicillin-sulbactam, clarithromycin, ceftriaxone, midazolam, and dexketoprofen caused AKI (p < 0.05).

WHAT IS NEW AND CONCLUSION

Our findings demonstrate that if a clinical pharmacist is included in the ICU team and provides consultation services to the ICU team regarding patient treatment by performing regular patient follow-up, the incidence of AKI in patients can be minimized and therapeutic outcomes can be improved.

Drug-drug interactions in polypharmacy patients: The impact of renal impairment

Chronic kidney disease (CKD) is a long-term condition characterized by a gradual loss of kidney functions, usually accompanied by other comorbidities including cardiovascular diseases (hypertension, heart failure and stroke) and diabetes mellitus. Therefore, multiple pharmacological prescriptions are very common in these patients. Epidemiological and clinical observations have shown that polypharmacy may increase the probability of adverse drug reactions (ADRs), possibly through a higher risk of drug-drug interactions (DDIs). Renal impairment may further worsen this scenario by affecting the physiological and biochemical pathways underlying pharmacokinetics and ultimately modifying the pharmacodynamic responses. It has been estimated that the prevalence of DDIs in CKD patients ranged between 56.9% and 89.1%, accounting for a significant increase in healthcare costs, length and frequency of hospitalization, with a detrimental impact on health and quality of life of these patients. Despite these recognized high-risk conditions, scientific literature released on this topic is still limited. Basing on the most commonly prescribed therapies in patients with CKD, the present short review summarizes the current state of knowledge of the putative DDIs occurring in CKD patients undergoing polytherapy. The most relevant underlying mechanisms and their clinical significance are also debated.

Perceived Versus Demonstrated Understanding of the Complex Medications of Medically Complex Children

OBJECTIVES

Parents and caregivers of children with medical complexity (CMC) manage complex medication regimens (CMRs) at home. Parental understanding of CMRs is critical to safe medication administration. Regarding CMR administration, we 1) described the population of CMC receiving CMRs; 2) assessed parental perceived confidence and understanding; and 3) evaluated parental demonstrated understanding.

METHODS

Cross-sectional clinic-based assessment of knowledge and understanding of CMC using CMRs who received primary care in a large pediatric complex care clinic. CMRs were identified by the receipt of ≥1 of the following: 1) ≥10 concurrent medications; 2) ≥1 high-risk medication; or 3) ≥1 extemporaneously compounded medication. Parents reported their perceived confidence and understanding of CMRs, and then demonstrated understanding through 3 medication-related tasks.

RESULTS

Of 156 CMCs, most were <10 years of age (63.5%), white (75%), had neurologic impairment (76.9%), and used a median of 8 medications (IQR, 5-10). Parents were female (76.9%) with a mean age of 38.8 ± 11.5 years, white (69.9%), spoke English (94.2%), and had some college education (82.1%). On 11 confidence and understanding statements, most parents reported a high perceived level of understanding and confidence, with combined agreement or strong agreement ranging between 81.2% and 98.7%. Only 73.1% correctly identified medications taken for specified conditions, 40.4% reported complete dosing parameters, and 54.8% correctly measured 2 different medication doses. Significant differences existed between parental perceived understanding versus the 3 demonstrated tasks (all p < 0.05).

CONCLUSIONS

Substantial opportunities exist to improve medication safety and efficacy in the outpatient, in-home setting including improved medication-specific education and medication-related supports.

Pharmacist impact on medication dosing and billable coding accuracy in outpatients with chronic kidney disease

BACKGROUND

Ambulatory care pharmacists can enhance economic and clinical outcomes as part of interdisciplinary health care teams. Patients with chronic kidney disease (CKD) often have complex medication regimens, potentially resulting in dosing errors and drug interactions.

OBJECTIVE

To demonstrate the impact that clinic-based pharmacists may have in populations comprising ambulatory patients with CKD.

PRACTICE DESCRIPTION

Community-owned, not-for-profit health system with outpatient, primary, and specialty care clinics.

PRACTICE INNOVATION

This quality-assurance, cohort, interventional study included patients aged at least 18 years with a CKD- or end-stage renal disease-associated diagnosis code seen by a clinic primary care provider at least once between January and June 2019. Primary outcomes included the number of medications requiring pharmacist intervention, pharmacist-initiated recommendations, and associated outcomes.

EVALUATION METHODS

Patients were randomly assigned to 2 cohorts. Providers of patients in the proactive pharmacist intervention group were notified of pharmacist recommendations immediately after initial data collection. Providers of patients in the group undergoing usual care (control group) were notified of identified medication recommendations after a 3-month period of usual care. Demographics were assessed using descriptive statistics. Differences in CKD staging, number of recommendations made, and provider responses were assessed using the chi-square, Fisher exact, and Mann-Whitney U tests.

RESULTS

A total of 182 patients were eligible for inclusion. In the intervention group, 22.1% of patients were identified as having inappropriately dosed medications versus 19.5% in the control group. In the intervention group, 46 of the 95 patients (48.4%) had an inaccurate CKD stage documented compared with 48 of the 87 patients (55.2%) in the control group (P = 0.772). The rate of pharmacist recommendation rejection substantially decreased between the intervention and control groups' provider responses (24% to 11.8%).

CONCLUSION

Pharmacist-initiated recommendations resulted in the identification and resolution of medication-dosing errors and improved collaboration between providers and pharmacists.

Differential Diagnoses and Clinical Implications of Medication Nonadherence in Older Patients with Chronic Kidney Disease: A Review

Older adults with chronic kidney disease (CKD) often have many comorbidities, which requires them to take multiple medications. As the number of daily medications prescribed increases, the risk for polypharmacy increases. Understanding and improving medication adherence in this patient population is vital to avoiding the drug-related adverse events of polypharmacy. The primary objective of this review is to summarize the existing literature and to understand the factors leading to medication nonadherence in older patients with CKD. In this review, we discuss the prevalence of polypharmacy, the current lack of consensus on the incidence of medication nonadherence, the heterogeneity of assessing medication adherence, and the most common differential diagnoses for medication nonadherence in this population. Specifically, the most common differential diagnoses for medication nonadherence in older adults with CKD are (1) medication complexity; (2) cognitive impairment; (3) low health literacy; and (4) systems-based barriers. We provide tailored strategies to address these differential diagnoses and subsequently improve medication adherence. The clinical implications include deprescribing to decrease medication complexity and polypharmacy, utilizing a team-based approach to identify and support patients with cognitive impairment, enriching communication between health providers and patients with low health literacy, and improving health care access to address systems-based barriers. Further research is needed to determine the effects of addressing these differential diagnoses and medication adherence in older adults with CKD.

Rapid Integration of Home Telehealth Visits Amidst COVID-19: What Do Older Adults Need to Succeed?

OBJECTIVE

Our objective was to identify and address patient-perceived barriers to integrating home telehealth visits.

DESIGN

We used an exploratory sequential mixed-methods design to conduct patient needs assessments, a home telehealth pilot, and formative evaluation of the pilot.

SETTING

Veterans Affairs geriatrics-renal clinic.

PARTICIPANTS

Patients with scheduled clinic visits from October 2019 to April 2020.

MEASUREMENTS

We conducted an in-person needs assessment and telephone postvisit interviews.

RESULTS

Through 50 needs assessments, we identified patient-perceived barriers in interest, access to care, access to technology, and confidence. A total of 34 (68%) patients were interested in completing a home telehealth visit, but fewer (32 (64%)) had access to the necessary technology or were confident (21 (42%)) that they could participate. We categorized patients into four phenotypes based on their interest and capability to complete a home telehealth visit: interested and capable, interested and incapable, uninterested and capable, and uninterested and incapable. These phenotypes allowed us to create trainings to overcome patient-perceived barriers. We completed 32 home telehealth visits and 12 postvisit interviews. Our formative evaluation showed that our pilot was successful in addressing many patient-perceived barriers. All interviewees reported that the home telehealth visits improved their well-being. Home telehealth visits saved participants an average of 166 minutes of commute time. Five participants borrowed a device from a family member, and five visits were finished via telephone. All participants successfully completed a home telehealth visit.

CONCLUSIONS

We identified patient-perceived barriers to home telehealth visits and classified patients into four phenotypes based on these barriers. Using principles of implementation science, our home telehealth pilot addressed these barriers, and all patients successfully completed a visit. Future study is needed to understand methods to deploy larger-scale efforts to integrate home telehealth visits into the care of older adults.

Accuracy of Prescription Claims Data in Identifying Truly Nonadherent Patients

BACKGROUND

Administrative claims data are increasingly used to identify nonadherent patients. This necessitates a comprehensive review and assessment of their accuracy in identifying nonadherent patients.

OBJECTIVES

To (a) compare administrative claims-based measures of adherence with nonadherence verified by patient interview; (b) determine if and to what extent patients classified as nonadherent based on prescription claims differ from patients classified as nonadherent based on interventions designed to gather multiple types of medication lists to compare against the prescription fill history; and (c) assess the various patient-reported reasons for nonadherence.

METHODS

A cross-sectional study was used to identify patients from the Southern Piedmont Community Care Network of North Carolina who were enrolled with Medicaid between January 1, 2012, and May 31, 2013, and were using prescription medications for 1 or more chronic conditions. Patients with more than a 30-day gap in refill history were identified using prescription claims and were interviewed by pharmacists to assess the reasons for nonadherence. Based on the patient-reported reasons for a gap in refill, patients were classified as interview-verified nonadherent patients or interview-verified adherent patients. The positive predictive value of prescription claims in identifying nonadherent patients was calculated, and descriptive statistics were reported. Characteristics of interview-verified nonadherent patients were compared with adherent patients using t-tests and chi-square statistics.

RESULTS

1,425 patients representing 2,936 patient-class of medication combinations were included in the final analysis. 824 (28.07%) of the 2,936 records that were flagged as nonadherent using claims analysis were confirmed as adherent during patient interviews. The positive predictive value of claims records in identifying nonadherent patients was 0.72. The 2 most common reasons for patients to be misclassified as nonadherent in claims data following self-report were discontinuation of medication on prescribers' directions (21.93%) and having an alternate channel for receiving the medication (6.13%). Among interview-verified nonadherent patients, side effects, patient beliefs, education, and socioeconomic barriers were the most common patient-reported reasons for gaps in refill.

CONCLUSIONS

Prescription claims may underestimate adherence in patients. When interviewed directly by a pharmacist, most patients reported discontinuation of medication as per prescribers' directions. To determine the overall validity of prescription claims data, further analysis is required to assess its accuracy in identifying truly nonadherent patients among those who are identified as nonadherent by claims data.

DISCLOSURES

No outside funding supported this study. Glassberg and Wei were employees at Community Care of North Carolina when this research was conducted. Trygstad is an employee of Community Care of North Carolina; Robinson is an employee of Community Care of Southern Piedmont, a subsidiary of Community Care of North Carolina. The geographies, health care professionals, and subjects involved in the study were related to the care coordination work that Community Care of North Carolina was charged with implementing through its informatics and subject matter expertise assistance provided to these local entities to augment primary care activities. Farley has received funding from the Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, American College of Clinical Pharmacy, the National Institutes of Health, and Community Care of North Carolina and has also received consulting funds from UCB. The other authors have nothing additional to report.