Implementation of a Clinical Pharmacist in a Hemodialysis Facility: A Quality Improvement Report

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Abstract

Rationale & Objective

Hemodialysis (HD) patients have complicated disease states, placing them at higher risk for medication-related problems, medication discrepancies, and nonadherence. The objective of this study is to evaluate the impact of a clinical pharmacist in a single HD facility by assessing the efficacy of medication reconciliation in HD patients and evaluating the potential impact on a single health care system.

Study Design

Retrospective study.

Setting & Participants

Greenfield Health Systems, a wholly owned subsidiary of Henry Ford Health System, operates 14 HD facilities throughout Southeast Michigan. The West Pavilion facility is located in Detroit, MI. Patients with end-stage kidney disease included in the study had a minimum of 4 encounters with the clinical pharmacist or pharmacy interns between August 2017 and October 2018.

Exposure

A clinical pharmacist performed medication reconciliation and medication reviews with HD patients to assess medication-related problems and identify gaps in care. Interventions made by the pharmacist were prespecified through a collaborative practice agreement.

Outcomes

To evaluate the impact of a clinical pharmacist in an HD facility by assessing the efficacy of medication reconciliation in HD patients and evaluating the potential impact on this health system through an estimated cost avoidance.

Analytical Approach

Descriptive statistics were used to collect medication-related problems and classified based on a modified Hepler-Strand approach.

Results

There were 1,403 medication-related problems, with an average of 8.96 medication-related problems per patient. Adherence was the most common medication-related problem (31%). Antihypertensive medication was the most common drug class in which the pharmacist intervened (37%), followed by vitamin D analogues and calcimimetics (29%). A projected total of US $447,355 was saved.

Limitations

Retrospective analysis of observational data and descriptive statistics with the potential for residual bias and confounding.

Conclusions

Pharmacists in HD facilities have a positive influence on HD patients through medication management that results in cost savings.

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Most cited references 13

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Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients.

Yi-Wen Chiu, Isaac Teitelbaum, Madhukar Misra … (2009)

Dialysis patients have a high burden of co-existing diseases, poor health-related quality of life (HR-QOL), and are prescribed many medications. There are no data on daily pill burden and its relationship to HR-QOL and adherence to therapy. Two hundred and thirty-three prevalent, chronic dialysis patients from three units in different geographic areas in the United States underwent a single, cross-sectional assessment of total daily pill burden and that from phosphate binders. HR-QOL, adherence to phosphate binders, and serum phosphorus levels were the three main outcome measures studied. The median daily pill burden was 19; in one-quarter of subjects, it exceeded 25 pills/d. Higher pill burden was independently associated with lower physical component summary scale scores on HR-QOL on both univariate and multivariate analyses. Phosphate binders accounted for about one-half of the daily pill burden; 62% of the participants were nonadherent. There was a modest relationship between pill burden from phosphate binders and adherence and serum phosphorus levels; these associations persisted on multivariate analyses. There was no relationship between adherence and serum phosphorus levels. The daily pill burden in dialysis patients is one of the highest reported to date in any chronic disease state. Higher pill burden is associated with lower HR-QOL. There are many reasons for uncontrolled serum phosphorus levels; increasing the number of prescribed pills does not seem to improve control and may come at the cost of poorer HR-QOL.

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Opportunities and responsibilities in pharmaceutical care.

C D Hepler, L Strand (1990)

Pharmacy's opportunity to mature as a profession by accepting its social responsibility to reduce preventable drug-related morbidity and mortality is explored. Pharmacy has shed the apothecary role but has not yet been restored to its erst-while importance in medical care. It is not enough to dispense the correct drug or to provide sophisticated pharmaceutical services; nor will it be sufficient to devise new technical functions. Pharmacists and their institutions must stop looking inward and start redirecting their energies to the greater social good. Some 12,000 deaths and 15,000 hospitalizations due to adverse drug reactions (ADRs) were reported to the FDA in 1987, and many went unreported. Drug-related morbidity and mortality are often preventable, and pharmaceutical services can reduce the number of ADRs, the length of hospital stays, and the cost of care. Pharmacists must abandon factionalism and adopt patient-centered pharmaceutical care as their philosophy of practice. Changing the focus of practice from products and biological systems to ensuring the best drug therapy and patient safety will raise pharmacy's level of responsibility and require philosophical, organizational, and functional changes. It will be necessary to set new practice standards, establish cooperative relationships with other health-care professions, and determine strategies for marketing pharmaceutical care. Pharmacy's reprofessionalization will be completed only when all pharmacists accept their social mandate to ensure the safe and effective drug therapy of the individual patient.

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Drug-related morbidity and mortality: updating the cost-of-illness model.

F Ernst, A Grizzle (2016)

To update the 1995 estimate of $76.6 billion for the annual cost of drug-related morbidity and mortality resulting from drug-related problems (DRPs) in the ambulatory setting in the United States to reflect current treatment patterns and costs. For this study, we employed the decision-analytic model developed by Johnson and Bootman. We used the model's original design and probability data, but used updated cost estimates derived from the current medical and pharmaceutical literature. Sensitivity analyses were performed on cost data and on probability estimates. Ambulatory care environment in the United States in the year 2000. A hypothetical cohort of ambulatory patients. Average cost of health care resources needed to manage DRPs. As estimated using the decision-tree model, the mean cost for a treatment failure was $977. For a new medical problem, the mean cost was $1,105, and the cost of a combined treatment failure and resulting new medical problem was $1,488. Overall, the cost of drug-related morbidity and mortality exceeded $177.4 billion in 2000. Hospital admissions accounted for nearly 70% ($121.5 billion) of total costs, followed by long-term-care admissions, which accounted for 18% ($32.8 billion). Since 1995, the costs associated with DRPs have more than doubled. Given the economic and medical burdens associated with DRPs, strategies for preventing drug-related morbidity and mortality are urgently needed.

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Author and article information

Contributors

Chantale Daifi

Journal

Journal ID (nlm-ta): Kidney Med

Journal ID (iso-abbrev): Kidney Med

Title: Kidney Medicine

Publisher: Elsevier

ISSN (Electronic): 2590-0595

Publication date PMC-release: 10 February 2021

Publication date Collection: Mar-Apr 2021

Publication date (Electronic): 10 February 2021

Volume: 3

Issue: 2

Pages: 241-247.e1

Affiliations

[1 ]Division of Community Care Services, Department of Pharmacy, Henry Ford Health System, Detroit, MI

[2 ]Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI

Author notes

[∗ ] Address for Correspondence: Chantale Daifi, PharmD, Henry Ford Hospital, 2799 West Grand Blvd, CFP-510, Detroit, MI 48202. cdaifi1@ 123456hfhs.org

Article

Publisher Item ID: S2590-0595(21)00017-0

DOI: 10.1016/j.xkme.2020.11.015

PMC ID: 8039404

PubMed ID: 33851119

SO-VID: 90119ba2-c533-4abe-9e2c-23e5a69a1f20

License:

This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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Implementation of a Clinical Pharmacist in a Hemodialysis Facility: A Quality Improvement Report

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Abstract

Rationale & Objective

Study Design

Setting & Participants

Exposure

Outcomes

Analytical Approach

Results

Limitations

Conclusions

Graphical abstract

Related collections

Wits Journal of Clinical Medicine

Most cited references 13

Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients.

Opportunities and responsibilities in pharmaceutical care.

Drug-related morbidity and mortality: updating the cost-of-illness model.

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Contributors

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Cited by 7

Most referenced authors 128