Patients with chronic kidney disease (CKD) and end stage kidney disease have complex medication regimens and multiple comorbidities and can take in excess of 12 medications daily (1). High pill burden and multiple care providers place CKD and dialysis patients at risk for medication-related problems (MRPs). It has been shown that for every $1 spent on detecting and addressing MRPs in the dialysis population, $4 may be saved by the health care system (2). The Centers for Medicare & Medicaid Services (CMS) now requires monthly medication reconciliation in the End-Stage Renal Disease Quality Incentive Program (ESRD QIP).
As medication experts, pharmacists are trained to perform medication reconciliation, detect dosing errors, and identify drug interactions. Pharmacists can improve medication access for patients by identifying gaps in insurance coverage, submitting prior authorization requests, enrolling patients in patient-assistance programs, and providing medication education.
[Including] clinical pharmacists on dialysis and CKD care teams can address gaps in services.
A recent study found that incorporating a pharmacist into the dialysis care team reduced the number of MRPs by 50% (3). The most common problems were found to be related to nonadherence (27%), prescription renewals (21%), and excessive drug doses (14%) (Figure 1). Medication reconciliation and review are time-intensive processes that when done comprehensively, can take approximately 40 minutes (3). However, the CMS Conditions for Coverage for ESRD Facilities does not mandate the inclusion of pharmacists in the dialysis care team.
Types of medication-related problems in dialysis patients
Citation: Kidney News 14, 9
Clinical pharmacist interventions have demonstrated improvements in the management of anemia, hypertension, and hyperlipidemia, as well as mineral metabolism and bone disease for individuals with CKD (4). Clinical pharmacist interventions reduced hospital admissions, length of hospital stay, and incidence of ESRD or death (4). Clinical pharmacists contribute to the development of quality performance indicators—Joint Commission quality certification programs in CKD—leading to high-quality CKD care (5).
However, CMS does not recognize pharmacists as providers in important services, such as kidney disease education, and limits reimbursement for kidney disease education to physicians, physician assistants, clinical nurse specialists, and nurse practitioners. These reimbursement issues create barriers to adding the pharmacist to CKD care teams. The inclusion of clinical pharmacists on dialysis and CKD care teams can address gaps in services and provide a unique opportunity to improve the care of patients with kidney diseases through the optimization of medications.
References
- 1.↑
Manley HJ, et al. Medication prescribing patterns in ambulatory haemodialysis patients: Comparisons of USRDS to a large not-for-profit dialysis provider. Nephrol Dial Transplant 2004; 19: 1842–1848. doi: 10.1093/ndt/gfh280
- 2.↑
Manley HJ, Carroll CA. The clinical and economic impact of pharmaceutical care in end-stage renal disease patients. Semin Dial 2002; 15:45–49. doi: 10.1046/j.1525-139x.2002.00014.x
- 3.↑
Dyer SA, et al. Impact of medication reconciliation by a dialysis pharmacist. Kidney360, May 2022; 3:922–925. https://doi.org/10.34067/KID.0007182021
- 4.↑
Al Raiisi F, et al. Clinical pharmacy practice in the care of chronic kidney disease patients: A systematic review. Int J Clin Pharm 2019; 41:630–666. doi: 10.1007/s11096-019-00816-4
- 5.↑
Awdishu L, et al. A primer on quality assurance and performance improvement for interprofessional chronic kidney disease care: A path to Joint Commission certification. Pharmacy (Basel) 2019; 7:E83. doi: 10.3390/pharmacy7030083
