A pharmacist based intervention to improve the care of patients with CKD: a pragmatic, randomized, controlled trial

Abstract

BackgroundPrimary care providers do not routinely follow guidelines for the care of patients with chronic kidney disease (CKD). Multidisciplinary efforts may improve care for patients with chronic disease. Pharmacist based interventions have effectively improved management of hypertension. We performed a pragmatic, randomized, controlled trial to evaluate the effect of a pharmacist based quality improvement program on 1) outcomes for patients with CKD and 2) adherence to CKD guidelines in the primary care setting.MethodsPatients with moderate to severe CKD receiving primary care services at one of thirteen community-based Veterans Affairs outpatient clinics were randomized to a multifactorial intervention that included a phone-based pharmacist intervention, pharmacist-physician collaboration, patient education, and a CKD registry (n = 1070) or usual care (n = 1129). The primary process outcome was measurement of parathyroid hormone (PTH) during the one year study period. The primary clinical outcome was blood pressure (BP) control in subjects with poorly controlled hypertension at baseline.ResultsAmong those with poorly controlled baseline BP, there was no difference in the last recorded BP or the percent at goal BP during the study period (42.0% vs. 41.2% in the control arm). Subjects in the intervention arm were more likely to have a PTH measured during the study period (46.9% vs. 16.1% in the control arm, P <0.001) and were on more classes of antihypertensive medications at the end of the study (P = 0.02).ConclusionsA one-time pharmacist based intervention proved feasible in patients with CKD. While the intervention did not improve BP control, it did improve guideline adherence and increased the number of antihypertensive medications prescribed to subjects with poorly controlled BP. These findings can inform the design of quality improvement programs and future studies which are needed to improve care of patients with CKD.Trial registrationClinicalTrials.gov: NCT01290614.Electronic supplementary materialThe online version of this article (doi:10.1186/s12882-015-0052-2) contains supplementary material, which is available to authorized users.

Pharmacist-based antihypertensive medication review and assignment of morning versus evening dosing of once-daily antihypertensive medications: A pilot study to assess feasibility and efficacy in chronic kidney disease patients

“…Although adherence to dosing did not differ between the morning and evening groups in the current study, a previous study assessed electronically compiled dosing histories to investigate adherence to prescribed antihypertensive medications in 4783 patients and found that patients were more likely to take their medications as prescribed in the morning than in the evening (26). Previous studies have demonstrated that pharmacist-based interventions can improve adherence in both the CKD patient population and in primary care (14–21,27). The results of the current study further support the notion that pharmacist-based interventions can improve adherence in chronic patient disease populations, but as identified in previous clinical studies, further research must be conducted to evaluate the impact of adherence on long-term clinical outcomes (21,27).…”

“…Previous studies have demonstrated that pharmacist-based interventions can improve adherence in both the CKD patient population and in primary care (14–21,27). The results of the current study further support the notion that pharmacist-based interventions can improve adherence in chronic patient disease populations, but as identified in previous clinical studies, further research must be conducted to evaluate the impact of adherence on long-term clinical outcomes (21,27). …”

“…Studies have demonstrated pharmacist-physician collaborative interventions have successfully reduced nighttime blood pressure (12,13). Research has also examined the value of pharmacist-based interventions to improve medication adherence, and has illustrated that pharmacists play a unique role in improving blood pressure control in patients with and without CKD (14–21). These studies suggest that a pharmacist-physician collaborative may be a feasible strategy to implement evening dosing of antihypertensive medications, although there is little data regarding how these interventions affect patient adherence to their once daily medication.…”

Pragmatic Clinical Trials in CKD: Opportunities and Challenges

“…Examples of studies bridging nephrology and primary care include trials of CKD care coordination with patient navigators 30 and strategies to implement guidelineconcordant CKD care with electronic checklists, 31 primary care practice facilitation, 32 and pharmacist-led interventions. 33 Third, pragmatic trials offer an opportunity to examine clinical questions that have been identified by diverse stakeholders, including patients, caregivers, and providers, as high-priority CKD research areas (Box 1). 34,35 Outcomes of interest to these stakeholders include traditional clinical events such as hospitalizations, emergency room visits, and mortality as well as patientcentered outcomes of growing interest, such as symptoms, treatment preferences, quality of life, and satisfaction with care.…”

Using pharmacists to improve risk stratification and management of stage 3A chronic kidney disease: a feasibility study

“…However, extended follow-up analysis of this trial found that nurse practitioner support decreased risk of a combined renal outcome (doubling of creatinine, ESRD or death) by 20 % [24]. Recently, a randomized pragmatic trial of 2199 veterans found that a telephone-based pharmacist intervention improved CKD-related lab testing and increased the number of antihypertensive medications prescribed, but had no significant effect on blood pressure [25]. However, pharmacists in this study were limited to one-time telephone contacts with patients and could only recommend medication changes to primary care providers.…”