Impact of pharmacist-managed erythropoiesis-stimulating agents clinics for patients with non-dialysis-dependent CKD.
BACKGROUND
Erythropoiesis-stimulating agents (ESAs) are associated with serious adverse events, and maintaining hemoglobin levels within a narrow range can be difficult. We examined the quality of ESA prescribing and monitoring in pharmacist-managed ESA clinics versus usual care in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD).


METHODS
Historical cohort.


METHODS
Outpatients receiving ESAs for NDD-CKD at 10 Veterans Affairs Medical Centers with both pharmacist-managed ESA clinics (n = 314) and physician-based care (ie, usual care; n = 91) and 6 sites with usual care only (n = 167) on January 1, 2009, were followed up for 6 months.


METHODS
Type/site of care (ie, pharmacist-managed ESA clinic, usual care at ESA clinic site, usual-care site).


RESULTS
Primary outcomes were proportion of hemoglobin values in the target range of 10-12 g/dL, ESA dose, and frequency of hemoglobin monitoring. Factors associated with hemoglobin values out of target range were identified using multinomial logistic regression.


RESULTS
More hemoglobin values were in the target range in pharmacist-managed ESA clinics (71.1% vs 56.9% for usual-care sites; P < 0.001). The average 30-day dose of darbepoetin was 163 μg in pharmacist-managed ESA clinic patients versus 240 μg in usual-care site patients and 258 μg in usual-care patients at ESA clinic sites. For epoetin, corresponding average 30-day doses were 44,890 versus 47,141 and 57,436 IU. Veterans in pharmacist-managed ESA clinics had more hemoglobin measurements on average (5.8 vs 3.6 in usual-care sites and 3.8 in usual care at ESA clinic sites; P = 0.007). In the multinomial model, usual care was associated with hemoglobin levels out of target range, whereas heart failure and diabetes were associated with values in range.


CONCLUSIONS
We could not assess whether different hemoglobin targets were used by usual-care providers.


CONCLUSIONS
Relative to usual care, pharmacist-managed clinics provided improved quality of ESA dosing and monitoring for patients with NDD-CKD.
Veterans Affairs Center for Medication Safety, Hines, IL, USA. sherrie.aspinall@va.gov
Sherrie L
SL
Aspinall
Francesca E
FE
Cunningham
Xinhua
X
Zhao
Joy S
JS
Boresi
Ivy Q
IQ
Tonnu-Mihara
Kenneth J
KJ
Smith
Roslyn A
RA
Stone
Chester B
CB
Good
D000368:Aged; D000553:Ambulatory Care / Q000379:methods* / Q000458:organization & administration*; D000554:Ambulatory Care Facilities / Q000458:organization & administration; D000740:Anemia / Q000188:drug therapy* / Q000209:etiology; D015331:Cohort Studies; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D000068256:Darbepoetin alfa; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D004921:Erythropoietin / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives; D005260:Female; D006397:Hematinics / Q000009:adverse effects / Q000627:therapeutic use*; D006787:Hospitals, Veterans; D006801:Humans; D007677:Kidney Function Tests; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D016017:Odds Ratio; D010595:Pharmacists / Q000458:organization & administration*; D011361:Professional Competence; D011379:Prognosis; D011786:Quality Control; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000175:diagnosis; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome
D006397:Hematinics; D004921:Erythropoietin; D000068256:Darbepoetin alfa