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



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 m2and 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.



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 m2in 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.



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.



ClinicalTrials.gov, NCT02208674 Registered August 1, 2014, first patient enrolled September 30, 2014.
Division of Nephrology, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA. achang@geisinger.edu.|Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA. achang@geisinger.edu.
Alex R
AR
Chang
Geisinger Health System, Enterprise Pharmacy, Danville, PA, USA.
Michael
M
Evans
Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA.
Christina
C
Yule
Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA.
Larissa
L
Bohn
Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA.
Amanda
A
Young
Geisinger Health System, Health Economics Research and Evaluation, Danville, PA, USA.
Meredith
M
Lewis
Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA.
Elisabeth
E
Graboski
Geisinger Health System, Enterprise Pharmacy, Danville, PA, USA.
Bethany
B
Gerdy
Geisinger Health System, Enterprise Pharmacy, Danville, PA, USA.
William
W
Ehmann
Geisinger Health System, Enterprise Pharmacy, Danville, PA, USA.
Jonathan
J
Brady
Geisinger Health System, Enterprise Pharmacy, Danville, PA, USA.
Leah
L
Lawrence
Geisinger Health System, Center for Health Research, Danville, PA, USA.
Natacha
N
Antunes
Division of Nephrology, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA.|Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA.
Jamie
J
Green
Geisinger Health System, Health Economics Research and Evaluation, Danville, PA, USA.
Susan
S
Snyder
Geisinger Health System, Biomedical and Translational Informatics, Danville, PA, USA.
H Lester
HL
Kirchner
Johns Hopkins University, Welch Center for Prevention, Epidemiology and Clinical, Baltimore, MD, USA.
Morgan
M
Grams
Bayer HealthCare, Whippany, NJ, USA.
Robert
R
Perkins
D000368:Aged; D000959:Antihypertensive Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D001794:Blood Pressure; D002985:Clinical Protocols; D050171:Dyslipidemias / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy*; D005240:Feasibility Studies; D005260:Female; D005919:Glomerular Filtration Rate; D019983:Guideline Adherence; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D006973:Hypertension / Q000188:drug therapy*; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D017060:Patient Satisfaction; D010595:Pharmacists; D010865:Pilot Projects; D017410:Practice Guidelines as Topic; D024382:Professional Role; D011507:Proteinuria / Q000175:diagnosis*; D051436:Renal Insufficiency, Chronic / Q000503:physiopathology / Q000628:therapy*; D018570:Risk Assessment / Q000379:methods; D012720:Severity of Illness Index
D000959:Antihypertensive Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors
Albuminuria; Chronic kidney disease; KDIGO guidelines; Pharmacist medication therapy management; Proteinuria; Screening