NN&I - May 2010
Facility Management 40 Nephrology News & Issues May 2010www.nephronline.comIntroduction The prevalence of estimated chronic kidney disease has increased 20% to 30% in the past decade.1 Patients with CKD and those receiving dialysis face an extremely high risk for drug therapy problems, including adverse drug events and drug-drug interactions due to the complex nature of their medication regimens.2 Due to reduced renal function, many medications have altered pharmacokinetics in patients with CKD and end-stage renal disease, further predisposing patients to adverse drug events. Additionally, the removal of medications by hemodi -alysis (HD) or peritoneal dialysis (PD) makes drug dosing complex, as many drug factors (such as molecular weight) influence removal.3 In a pooled analysis of studies, ambula-tory hemodialysis patients took an average of 12 different medications and experienced multiple medication-related problems (1,593 problems were identified in 395 patients).2The United States Joint Commission on Accreditation of Healthcare Organizations recommends that a pharmacist review all medication orders before medications are dis -pensed,4 and Accreditation Canada recommends that phar -macists work closely with prescribers 5 to improve medica -tion safety. These recommendations provide impetus for increased clinical roles for pharmacists in many patient care areas, including for patients with CKD and ESRD. The increase in the prevalence of CKD and the complexity of medication regimens suggests an expanding role for renal pharmacists to care for this population. Renal pharmacists have established a well defined role in the care of CKD and ESRD patients; they fulfill this role by identifying, preventing, and resolving drug therapy prob-lems.2,6-12 Studies have demonstrated that renal clinical phar -macists improve quality of life,10 reduce hospitalizations,12 improve outcomes for anemia, hypertension, hyperparathy- roidism, diabetes mellitus, and hyperlipidemia,8 and reduce health care costs for patients with CKD and ESRD.11,12 Little is known about the proportion of CKD and ESRD patients who receive clinical pharmacy services.13 A recent survey about CKD patients demonstrated that 65% of Canadian nephrologists had access to a pharmacist in a mul-Establishing and funding renal clinical pharmacy services By Colette B. Raymond BScPharm, PharmD, MSc, Lori D. Wazny BSc(Pharm), PharmD, Amy R. Sood BScPharm, PharmD, and Lavern M. Vercaigne BScPharm, PharmD tidisciplinary care team environment.14 A U.S. survey found that ambulatory-care pharmacists were not consistently involved in the routine monitoring of common complica -tions of CKD; only a small proportion of survey respondents monitored anemia and mineral metabolism targets amongst patients with CKD in their practices.15 The recent decision by the Centers for Medicare & Medicaid Services to not fund pharmacist services in dialysis units will serve to further limit the exposure of patients with CKD in the United States to the benefits of a clinical pharmacist.18 To date, there is no published literature that describes a funding model for dedi- cated clinical pharmacy services for patients with CKD. The purpose of this article is to describe a unique, population-based funding structure for renal clinical pharmacists and propose pharmacist-to-patient ratios for patients with CKD and those receiving dialysis. BackgroundThe Manitoba Renal Program (MRP), in the province of Manitoba, Canada (population 1.1 million) was cre -ated by the provincial government (Manitoba Health) in 1998. Under the Canada Health Act, clinical care (phy-sician visits, hospitalization, and all aspects of dialysis care) is provided at no cost to all Canadians. However, outpatient prescription drugs are excluded (erythropoietic- stimulating agents and select over-the-counter medications for CKD patients and those receiving dialysis are covered by MRP).19 Manitobans also have access to income-based insurance coverage for prescription medicines through pub -lic (Manitoba Pharmacare) or private insurance plans. The mandate of the MRP includes providing clinical care and education regarding all aspects of care for adults patients with CKD and those receiving dialysis within the province of Manitoba. The MRP provides clinical care at four urban hospitals and 12 satellite dialysis units in rural and north-ern Manitoba. Health services offered include in-center HD, PD, home HD, nocturnal HD, multidisciplinary renal health clinics for individuals with Stages 1-5 CKD, as well as renal health outreach education for patients, caregivers, and health professionals. Currently, the MRP has approximately Dr. Raymond is a clinical pharmacist at the Winnipeg Regional Health Authority and the Manitoba Renal Program, as well as clinical assistant professor at the University of Manitoba in Winnipeg, Manitoba. Dr. Wazny and Dr. Sood are pharmaceutical care coordinators with the Manitoba Renal Program and clinical assis-tant professors at the University of Manitoba. Dr. Vercaigne is a professor at the University of Manitoba's Apotex Centre. Pharmaco Facility_6.indd 40 4/19/10 3:26:33 PM
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