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

Chang et al. BMC Nephrology (2016) 17:168 DOI 10.1186/s12882-016-0383-7 RESEARCH ARTICLE Open Access Using pharmacists to improve risk stratification and management of stage 3A chronic kidney disease: a feasibility study Alex R. Chang1,2*, Michael Evans3, Christina Yule2, Larissa Bohn2, Amanda Young2, Meredith Lewis5, Elisabeth Graboski2, Bethany Gerdy3, William Ehmann3, Jonathan Brady3, Leah Lawrence3, Natacha Antunes4, Jamie Green1,2, Susan Snyder5, H. Lester Kirchner6, Morgan Grams7 and Robert Perkins8 Abstract Background: Measurement of albuminuria to stratify risk in chronic kidney disease (CKD) is not done universally in the primary care setting despite recommendation in KDIGO (Kidney Disease Improving Global Outcomes) guidelines. Pharmacist medication therapy management (MTM) may be helpful in improving CKD risk stratification and management. Methods: We conducted a pragmatic, cluster-randomized trial using seven primary care clinic sites in the Geisinger Health System to evaluate the feasibility of pharmacist MTM in patients with estimated glomerular filtration rate (eGFR) 45–59 ml/min/1.73 m2 and uncontrolled blood pressure (≥150/85 mmHg). In the three pharmacist MTM sites, pharmacists were instructed to follow a protocol aimed to improve adherence to KDIGO guidelines on testing for proteinuria and lipids, and statin and blood pressure medical therapy. In the four control clinics, patients received usual care. The primary outcome was proteinuria screening over a follow-up of 1 year. A telephone survey was administered to physicians, pharmacists, and patients in the pharmacist MTM arm at the end of the trial. Results: Baseline characteristics were similar between pharmacist MTM (n = 24) and control (n = 23) patients, although pharmacist MTM patients tended to be younger (64 vs. 71 y; p = 0.06) and less likely to have diabetes (17 % vs. 35 %; p = 0.2) or baseline proteinuria screening (41.7 % vs. 60.9 %, p = 0.2). Mean eGFR was 54 ml/min/1. 73 m2 in both groups. The pharmacist MTM intervention did not significantly improve total proteinuria screening at the population level (OR 2.6, 95 % CI: 0.5–14.0; p = 0.3). However, it tended to increase screening of previously unscreened patients (78.6 % in the pharmacist MTM group compared to 33.3 % in the control group; OR 7.3, 95 % CI: 0.96–56.3; p = 0.05). In general, the intervention was well-received by patients, pharmacists, and providers, who agreed that pharmacists could play an important role in CKD management. A few patients contacted the research team to express anxiety about having a CKD diagnosis without prior knowledge. Conclusions: Pharmacist MTM may be useful in improving risk stratification and management of CKD in the primary care setting, although implementation requires ongoing education and multidisciplinary collaboration and careful communication regarding CKD diagnosis. Future studies are needed to establish the effectiveness of pharmacist MTM on slowing CKD progression and improvement in cardiovascular outcomes. (Continued on next page) * Correspondence: 1 Division of Nephrology, Geisinger Health System, 100 N Academy Ave, Danville, PA 17821, USA 2 Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA 17821, USA Full list of author information is available at the end of the article © The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Chang et al. BMC Nephrology (2016) 17:168 Page 2 of 9 (Continued from previous page) Trial registration: ClinicalTrials.gov, NCT02208674 Registered August 1, 2014, first patient enrolled September 30, 2014 Keywords: Pharmacist medication therapy management, Chronic kidney disease, Albuminuria, Proteinuria, Screening, KDIGO guidelines Background Chronic kidney disease (CKD) affects one in seven adults in the U.S. and is estimated to account for more than 20 % of annual Medicare expenditures [1, 2]. Optimal screening and treatment strategies for CKD have been recommended by KDIGO (Kidney Disease: Improving Global Outcomes). For example, guidelines recommend using both estimated glomerular filtration rate (eGFR) and quantification of albuminuria (or proteinuria) to stratify renal and cardiovascular risk in CKD patients [3–5]. For patients with non-proteinuric CKD, KDIGO guidelines recommend treatment to a blood pressure goal of ≤140/90. For patients with proteinuric CKD, KDIGO guidelines recommend a lower blood pressure goal of ≤130/80,and the use of angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) [3]. KDIGO guidelines also recommend treatment with statins for all adults ≥ 50 years with CKD, regardless of proteinuria status [3, 6]. Despite these recommendations, adherence to CKD guidelines is low; for instance, proteinuria screening rates in CKD patients range from 10 to 45 % across different health systems. [7–10] Similar deficiencies in CKD guideline adherence have been reported for achievement of optimal blood pressure goals [7–9], prescription of indicated ACEIs and ARBs [11–13], and prescription of statin therapy [14, 15]. Primary care providers manage the majority of CKD patients and often do not list CKD as a problem list diagnosis [8]. Thus, effective interventions, delivered in the primary care setting, are needed to improve screening and treatment for CKD. Pharmacist medication therapy management (MTM) has been shown to be effective in treating hypertension [16, 17], diabetes [18], and CKD-related anemia [19]. We performed a pilot, cluster-randomized trial of outpatient primary care clinics to examine the feasibility of using pharmacist MTM to improve proteinuria screening and CKD management in a large, integrated health system. Methods The pilot study was a prospective 2-arm, clusterrandomized pragmatic trial, funded by Geisinger Clinic. We recruited participants from seven primary care clinic sites at Geisinger, a large integrated health system that includes 43 community practice clinic sites across central and northeastern Pennsylvania and an extensive pharmacist-led MTM program. The Geisinger Clinic institutional review board (IRB Number 2014-0251) approved the protocol. A modified informed consent process was utilized, which entailed full disclosure and explanation to eligible patients (delivered by mail) and to participating providers (by email) at the primary care sites. Eligible patients were asked to respond within 7 d (...truncated)