Medication Prescribing Quality in Australian Primary Care Patients with Chronic Kidney Disease

The prevalence and contributing factors of NSAIDs prescription among chronic kidney disease patients in primary care: a mixed methods study from Kingdom of Bahrain

BACKGROUND

The prevalence of Non-steroidal Anti-Inflammatory Drugs (NSAIDs) prescription and its contributory factors among chronic kidney disease (CKD) patients are unknown in the Kingdom of Bahrain - though NSAIDs are known to cause significant renal impairment. This study will determine the prevalence of NSAIDs prescription among CKD patients and the contributory factors to this behavior from the perspective of primary care physicians in Bahrain.

METHODOLOGY

A sequential mixed-method design study comprising of a retrospective cross-sectional survey drawn from patients' electronic medical records (EMR) and qualitative in-depth interviews with primary care physicians (PCPs) was conducted between December 2022 and January 2023 - with an EMR data lookback from 1 st June 2021 to 1 st June 2022 Quantitative descriptive analysis was conducted to estimate the prevalence of NSAIDs and their associations with sociodemographic and service delivery indicators. An Ishikawa diagram was used to describe contributory factors to NSAID prescription among CKD patients drawing from the literature and was used to guide a deductive thematic analysis of the qualitative data.

RESULT

Of the enrolled CKD patient population (4,380 patients), 17.4% had at least one inappropriate NSAID prescription. 80% of these patients had moderate renal impairment, while 19.3% had severe impairment. Most of the prescriptions were in 24-h health centers (48.5%). A Bivariate relationship between the prescription and the sociodemographic factors showed a significant P value regarding age (P-value 0.008*) and the severity of the renal impairment (P-value < 0.001*). The contributory factors were divided into five themes: patient factors, physician factors, health team factors, I SEHA factors and system factors. Of these themes, patients and PCPs were identified by the primary care physicians as some of the most important reasons for NSAIDs prescription among CKD patients.

CONCLUSION

The prevalence of NSAIDs prescription among CKD patients is relatively high in the kingdom of Bahrain - largely due to patient and physician factors as identified by primary care physicians. Possible solutions for addressing these factors include raising awareness among patients, PCPs, and other healthcare workers and activating the Swiss Cheese Model that involves patients, PCPs, and other health team members to ensure appropriate medication practice and patients' safety.

Trends in renal function testing in patients with dementia: a repeated cross-sectional analysis in Australian general practice

BACKGROUND

There is little published evidence regarding the extent to which renal function testing is performed in older Australians, particularly those with dementia.

OBJECTIVES

To examine the prevalence and temporal trends in renal function testing and the factors associated with renal function testing in patients with dementia using Australian general practice data.

METHODS

Ten consecutive cross-sectional analyses were performed to evaluate the proportion of patients aged ≥ 65 years with a recorded diagnosis of dementia, along with matched controls, who had renal function tests using estimated glomerular filtration rate (eGFR) within the twelve months of each year from 2011 to 2020.

RESULTS

Before matching, 24,701 patients (59.2% females) with, and 72,105 patients (59.2% females) without, a recorded diagnosis of dementia were included. Over the study period, renal function testing increased in both groups, although less for the patients with dementia; from 38.6% (95% CI 37.1-40.0%) in 2011 to 41.9% (95% CI 41-42.9%; p for trend < 0.001) in 2020 in the dementia group, and 49% (95% CI 47.6-50.5%) to 60.4% (95% CI 59.5-61.4%; p for trend < 0.001) in the matched controls. Younger patients with dementia (< 85 years of age), males, and those with more general practitioner visits in the preceding 12 months, hypertension, diabetes, chronic kidney disease, osteoporosis, or pain were most likely to have renal function testing.

CONCLUSION

Rates of renal function testing in primary care patients with dementia in Australia were significantly lower than for matched controls, and improved only marginally between 2011 and 2020.

Assessing the quality of CKD care using process quality indicators: A scoping review

INTRODUCTION

Assessing the quality of chronic kidney disease (CKD) management is crucial for optimal care and identifying care gaps. It is largely unknown which quality indicators have been widely used and the potential variations in the quality of CKD care. We sought to summarize process quality indicators for CKD and assess the quality of CKD care.

METHODS

We searched databases including Medline (Ovid), PubMed, Cochrane Library, Web of Science, CINAHL, and Scopus from inception to June 20, 2024. Two reviewers screened the identified records, extracted relevant data, and classified categories and themes of quality indicators.

RESULTS

We included 24 studies, extracted 30 quality indicators, and classified them into three categories with nine themes. The three categories included laboratory measures and monitoring of CKD progression and/or complications (monitoring of kidney markers, CKD mineral and bone disorder, anemia and malnutrition, electrolytes, and volume), use of guideline-recommended therapeutic agents (use of medications), and attainment of therapeutic targets (blood pressure, glycemia, and lipids). Among the frequently reported quality indicators (in five or more studies), the following have a median proportion of study participants achieving that quality indicator exceeding 50%: monitoring of kidney markers (Scr/eGFR), use of medications (ACEIs/ARBs, avoiding non-steroidal anti-inflammatory drugs (NSAIDs)), management of blood pressure (with a target of ≤140/90, or without specific targets), and monitoring for glycated hemoglobin A1c (HbA1c)). The presence of diabetes, hypertension, cardiovascular disease, or proteinuria was associated with higher achievement in indicators of monitoring of kidney markers, use of recommended medications, and management of blood pressure and glycemia.

CONCLUSION

The quality of CKD management varies with quality indicators. A more consistent and complete reporting of key quality indicators is needed for future studies assessing CKD care quality.

The Prevalence of Potentially Inappropriate Medications Among Patients With Diabetic Nephropathy: A Cross-Sectional Study Conducted at a Tertiary Care Hospital

Background Diabetic nephropathy is a serious complication of diabetes that significantly increases the risk of chronic kidney disease (CKD) and end-stage renal disease (ESRD). A critical concern in managing patients with diabetic nephropathy is the prevalence of potentially inappropriate medications (PIMs), which can exacerbate kidney dysfunction and lead to adverse health outcomes. PIMs are defined as medications whose risks outweigh their benefits, particularly when safer alternatives are available. The exact prevalence of the potentially inappropriate fraction of this as well as factors associated with the prescription of these medications remains variable. This study seeks to investigate the prevalence of PIMs in a diabetic population with CKD, aiming to identify the factors that contribute to this issue.  Methods We conducted a cross-sectional study analyzing clinical and electronic data from patients with diabetic nephropathy who were receiving care in the wards and outpatient clinics of Hamad Medical Corporation. Data were extracted from medical records, encompassing demographic information, comorbidities, prescribed medications, and kidney function, measured as estimated glomerular filtration rate (eGFR). The American Geriatrics Society Beers Criteria was employed to identify PIMs in older adults. Statistical analyses included chi-square tests for categorical variables and logistic regression to identify factors associated with PIM prescriptions. Results Of the 860 patients analyzed, 248 (28.8%) were prescribed at least one PIM. The most commonly prescribed classes of PIMs were sulfonylureas and nonsteroidal anti-inflammatory drugs (NSAIDs). Significant factors associated with PIM prescriptions included older age (OR 1.52, 95% CI 1.21-1.92), lower eGFR (OR 1.67, 95% CI 1.28-2.19), and polypharmacy (OR 1.83, 95% CI 1.42-2.36). Conclusion In this examination of the combined inpatient and outpatient database of patients with diabetic nephropathy, we identified a high prevalence of PIMs, particularly in individuals of older age, those with lower eGFR, and those experiencing polypharmacy. The findings underscore the importance of addressing polypharmacy through targeted therapeutic interventions aimed at reducing the use of PIMs in this population. By implementing such strategies, we can enhance medication safety and improve overall health outcomes for patients with diabetic nephropathy.

Prevalence and Risk Factors of Inappropriate Drug Dosing among Older Adults with Dementia or Cognitive Impairment and Renal Impairment: A Systematic Review

Background: Potentially inappropriate medication prescribing is prevalent and well studied in older adults. However, limited data are available on inappropriate drug dosing in those with dementia or cognitive impairment and renal impairment. Objectives: We aimed to examine the prevalence of, and factors associated with, inappropriate drug dosing in older patients with dementia or cognitive impairment and renal impairment. Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline and the Cochrane Handbook for Systematic Reviews of Interventions. We searched Medline, Embase, CINAHL, and PubMed for studies on inappropriate drug dosing in older patients with dementia or cognitive impairment and renal impairment, published from 1 January 2000 to 31 August 2024, with English language restriction following the PICOS search strategy. Two reviewers independently screened all titles and abstracts, extracted data from included studies, and undertook quality assessment using the Joanna Briggs Institute (JBI) tool. Descriptive statistics were used to summarise and present findings. Results: In total, eight retrospective cohort studies were included. Of the total number of patients with dementia who had renal impairment (n = 5250), there were 2695 patients (51.3%; range: 0-60%) who had inappropriate drug dosing. Drugs commonly prescribed in inappropriate doses in patients with dementia who had renal impairment included memantine, baclofen, nonsteroidal anti-inflammatory drugs (NSAIDs), metformin, digoxin, morphine, and allopurinol. The studies did not identify statistically significant risk factors for inappropriate drug dosing. Conclusions: Inappropriate drug dosing among older adults with dementia or cognitive impairment and renal impairment appears to occur frequently. While our findings should be interpreted with caution owing to the small number of studies and substantial heterogeneity, proactive prevention, recognition, and management of inappropriate drug dosing in this population is warranted.

Renal drug dosage adjustments and adverse drug events in patients with chronic kidney disease admitted to the hospital: a cross-sectional study

BACKGROUND

The study aimed to evaluate the agreement of prescribed drug dosages with renal dosing recommendations and describe adverse drug events (ADEs) contributing to hospital admissions of patients with chronic kidney disease (CKD).

METHODS

This cross-sectional study focused on CKD patients admitted to University Hospital Hradec Králové, with an estimated glomerular filtration rate below 60 ml/min. The necessity for renal dosage adjustments was determined using the Summary of Product Characteristics (SmPC). For medications requiring renal dosage adjustment according to SmPC, agreement between the prescribed and recommended renal dosage was assessed. ADEs were adjudicated using the OPERAM drug-related hospital admissions adjudication guide.

RESULTS

Of 375 CKD patients, 112 (30%, 95% CI 25-34) were prescribed drug dosages in disagreement with SmPC renal dosage recommendations. Perindopril, metformin, and ramipril were most frequently dosed in disagreement with SmPC. ADE-related hospital admissions occurred in 20% (95% CI 16-24) of CKD patients.

CONCLUSION

CKD patients are often prescribed medication dosages in disagreement with SmPC renal dosing recommendations. Besides explicit factors, treatment goals, feasibility of monitoring and alternative treatment must be weighed when assessing drug and dosage appropriateness. Gastrointestinal bleeding was the most frequent ADE that contributed to hospital admissions of CKD patients.

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.

Quality and variation of care for chronic kidney disease in Swiss general practice: A retrospective database study

Background

Chronic kidney disease (CKD) is a common condition in general practice. Data about quality and physician-level variation of CKD care provided by general practitioners is scarce. In this study, we evaluated determinants and variation of achievement of 14 quality indicators for CKD care using electronic medical records data from Swiss general practice during 2013–2019.

Methods

We defined two patient cohorts from 483 general practitioners, one to address renal function assessment in patients with predisposing conditions (n = 47,201, median age 68 years, 48.7% female) and one to address care of patients with laboratory-confirmed CKD (n = 14,654, median age 80 years, 57.5% female). We investigated quality indicator achievement with mixed-effect logistic regression and expressed physician-level variation as intraclass correlation coefficients (ICCs) and range odds ratios (rORs).

Results

We observed the highest quality indicator achievement rate for withholding non-steroidal anti-inflammatory drug prescription in patients with CKD staged G2–3b within 12 months of follow-up (82.6%), the lowest for albuminuria assessment within 18 months of follow-up (18.1%). Highest physician-level variation was found for renal function assessment during 18 months of follow-up in patients with predisposing conditions (diabetes: ICC 0.31, rOR 26.5; cardiovascular disease: ICC 0.28, rOR 17.4; hypertension: ICC 0.24, rOR 17.2).

Conclusion

This study suggests potentially unwarranted variation in general practice concerning RF assessment in patients affected by conditions predisposing for CKD. We further identified potential gaps in quality of CKD monitoring as well as lower quality of CKD care for female patients and patients not affected by comorbidities.

Comparing the renal outcomes in patients with atrial fibrillation receiving different oral anticoagulants

BACKGROUND

We aimed to compare renal function changes in patients with atrial fibrillation (AF) prescribed different oral anticoagulants (OACs).

RESEARCH DESIGN AND METHODS

We performed a retrospective analysis of Australian national primary care data. A total of 12,562 patients with AF and initiated OAC between 1 Jan 2013 and 31 Dec 2017 were included. Inverse probability of treatment weighting was used for balancing baseline characteristics and the risks of decline in estimated glomerular filtration rate (eGFR) in patients prescribed each OAC were compared using Cox proportional hazards regression model.

RESULTS

Compared with warfarin, prescribing of direct-acting oral anticoagulants (DOACs) was associated with a lower risk of renal function decline per 1000 person-years: hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.68-0.81, p<0.001 for ≥30% decline in eGFR; HR 0.28, 95% CI 0.20-0.41, p<0.001 for eGFR decline to ≤30 mL/min/1.73m²; and HR 0.45, 95% CI 0.35-0.58, p<0.001 for serum creatinine doubling. Compared with dabigatran, rivaroxaban use had a significantly lowered risk of decline in eGFR to ≤30 mL/min/1.73m² (HR 0.29, 95% CI 0.13-0.66, p=0.003) and risk of doubling of serum creatinine (HR 0.62, 95% CI 0.40-0.95, p=0.030).

CONCLUSIONS

The risk of renal function decline appeared to be lower in patients prescribed DOACs versus warfarin.

Oral Anticoagulant Treatment and the Risk of Dementia in Patients With Atrial Fibrillation: A Population-Based Cohort Study

Background

We compared the dementia incidence rate between users and nonusers of oral anticoagulants (OACs) in a large cohort of primary care patients with atrial fibrillation.

Methods and Results

We performed a retrospective study using an Australia‐wide primary care data set, MedicineInsight. Patients aged ≥18 years and newly diagnosed with atrial fibrillation between January 1, 2010, and December 31, 2017, and with no recorded history of dementia or stroke were included and followed until December 31, 2018. We applied a propensity score for 1:1 pair matching of baseline covariates and Cox regression for comparing the dementia incidence rates for OAC users and nonusers. Data were analyzed for 18 813 patients with atrial fibrillation (aged 71.9±12.6 years, 47.1% women); 11 419 had a recorded OAC prescription for at least 80% of their follow‐up time. During the mean follow‐up time of 3.7±2.0 years, 425 patients (2.3%; 95% CI, 2.1%–2.5%) had a documented diagnosis of dementia. After propensity matching, the incidence of dementia was significantly lower in OAC users (hazard ratio [HR], 0.59; 95% CI, 0.44–0.80; P<0.001) compared with nonusers. Direct‐acting oral anticoagulant users had a lower incidence of dementia than non‐OAC users (HR, 0.49; 95% CI, 0.33–0.73; P<0.001) or warfarin users (HR, 0.46; 95% CI, 0.28–0.74; P=0.002). No significant difference was seen between warfarin users and non‐OAC users (HR, 1.08; 95% CI, 0.70–1.70; P=0.723).

Conclusions

In patients with atrial fibrillation, direct‐acting oral anticoagulant use may result in a lower incidence of dementia compared with treatment with either warfarin or no anticoagulant.

Ten-year trends in prescribing of antiarrhythmic drugs in Australian primary care patients with atrial fibrillation

Despite changes in antiarrhythmic drug (AAD) choice in patients with atrial fibrillation (AF), trends in AAD prescribing remain not investigated. We aimed to examine these changes using a nationwide Australian general practice data from 2009 to 2018. Over the 10 years, AAD prescribing in patients with AF decreased, which was mainly due to a reduction in the use of amiodarone, sotalol and digoxin. In contrast, the use of beta-blockers and flecainide increased.

Stroke risk reassessment and oral anticoagulant initiation in primary care patients with atrial fibrillation: A ten-year follow-up

AIM

To examine the change in stroke risk over time and determine the proportion of patients with atrial fibrillation (AF) who were initiated on an oral anticoagulant (OAC) as their stroke risk increased from low/moderate to high, using the Australian general practice data set, MedicineInsight.

METHODS

A total of 2296 patients diagnosed with AF between 1 January 2007 and 31 December 2008, aged 18 years or older and not initiated on an OAC before 2009, were included. We assessed the change in stroke risk and the proportion of patients who had a recorded prescription of an OAC, each year from 1 January 2009 to 31 December 2018.

RESULTS

At baseline, 23.9%, 22.9% and 53.2% were categorised as being at low (score = 0), moderate (score = 1) and high stroke risk (score ≥ 2), respectively, using the sexless CHA₂ DS₂ -VASc (CHA₂ DS₂ -VA) score. Overall, the CHA₂ DS₂ -VA score increased by a mean of 1.34 (95% confidence interval, 1.29-1.39) points over the study period. Nearly two-thirds of patients (65%, 412/632) whose stroke risk changed from baseline low/moderate to high were subsequently prescribed an OAC. The median (interquartile range) lag time from becoming high stroke risk to having OAC initiation was 2 (5) years.

CONCLUSIONS

Nearly one-third of patients reclassified as being at high risk of stroke during the study period were not prescribed OAC therapy. Furthermore, the delay in OAC initiation following classification as being at high risk was a median of 2 years, suggesting that more frequent stroke reassessment is needed.

Factors influencing oral anticoagulant use in patients newly diagnosed with atrial fibrillation

BACKGROUND

We investigated factors that influenced oral anticoagulant (OAC) initiation and choice in Australian general practice patients newly diagnosed with AF.

METHODS

Using an Australian nationally representative general practice dataset, MedicineInsight, we identified patients newly diagnosed with AF between January 2009 and April 2019. Logistic regression analyses were used to examine factors associated with OAC initiation and choice.

RESULTS

A total of 63 212 patients with AF (53.7% males, mean age 72.4 years) were identified. Nearly two-thirds of these patients (40 854 [64.6%]) were initiated on an OAC, at a median time of 6 days after the documented diagnosis date. The proportion of patients who were initiated an OAC increased from 44.8% in 2009 to 72.2% in 2019 (P < .001). High risk of stroke (CHA₂ DS₂ -VASc, adjusted odds ratio (AOR), 4.39 [95% CI, 3.99-4.83]), low risk of bleeding (ORBIT, AOR, 1.87 [95% CI, 1.72-2.03]), not having a recorded history of dementia (AOR, 1.81 [95% CI, 1.65-1.98]) and male sex (AOR, 1.29 [95% CI, 1.22-1.35]) were independently associated with OAC initiation. Direct-acting oral anticoagulant (DOAC) use increased from 11.9% in 2011 to 94.0% of all OAC initiations in April 2019 (P < .001).

CONCLUSIONS

The proportion of newly diagnosed patients with AF initiated on OAC increased markedly following the introduction of the DOACs. Of those initiated, 9 in 10 were receiving a DOAC at the end of the study period. There is potential underuse in women and individuals with dementia.

Five-Year Trends in Potential Drug Interactions with Direct-Acting Oral Anticoagulants in Patients with Atrial Fibrillation: An Australian-Wide Study

Background: Co-prescribing medications that can interact with direct-acting oral anticoagulants (DOACs) may decrease their safety and efficacy. The aim of this study was to examine the co-prescribing of such medications with DOACs using the Australian national general practice dataset, MedicineInsight, over a five-year period. Methods: We performed five sequential cross-sectional analyses in patients with atrial fibrillation (AF) and a recorded DOAC prescription. Patients were defined as having a drug interaction if they had a recorded prescription of an interacting medication while they had had a recorded prescription of DOAC in the previous six months. The sample size for the cross-sectional analyses ranged from 5333 in 2014 to 19,196 in 2018. Results: The proportion of patients who had potential drug interactions with a DOAC decreased from 45.9% (95% confidence interval (CI) 44.6%–47.4%) in 2014 to 39.9% (95% CI 39.2%–40.6%) in 2018, p for trend < 0.001. During this period, the most frequent interacting class of medication recorded as having been prescribed with DOACs was selective serotonin/serotonin and norepinephrine reuptake inhibitor (SSRI/SNRI) antidepressants, followed by non-steroidal anti-inflammatory drugs (NSAIDs), calcium channel blockers (CCBs) and amiodarone. Conclusions: Overall, potential drug interactions with DOACs have decreased slightly over the last five years; however, the rate of possible interaction with SSRIs/SNRIs has remained relatively unchanged and warrants awareness-raising amongst prescribers.