Corresponding author: Eli Halimah ( eli.halimah@unpad.ac.id ) Academic editor: Valentina Petkova
© 2021 Ni Made Susilawati, Eli Halimah, Siti Saidah.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Susilawati NM, Halimah E, Saidah S (2021) Pharmacists’ strategies to detect, resolve, and prevent DRPs in CKD patients. Pharmacia 68(3): 619-626. https://doi.org/10.3897/pharmacia.68.e65136
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Pharmacists have undergone obstacles in the process of detecting, resolving, and preventing CKD patients’ DRPs. Thus, optimal strategies were needed. A total of 19 articles were included based on the article searching process. Based on the articles, it can be concluded: The strategies of detecting DRPs in CKD patients were carried out through medication reconciliation and medication review. The outcomes of these strategies were the number of DRPs/patients and types of DRPs detected. Strategies to resolve and prevent DRPs in CKD patients were conducted through interprofessional collaboration, education, and counselling. The outcome of these strategies was a change in the patients’ DRPs status. Optimization of detection, resolution, and prevention strategies were performed by improving pharmacists’ professional hard and soft-skills as well as modifying the pharmaceutical care delivery model. A decrease in the number of DRPs/patients and a change in DRPs status were reported as the outcomes of optimizing this process.
Chronic Kidney Disease, Drug-Related Problems, Pharmaceutical Care, Pharmacist
Chronic Kidney Disease (CKD) is one of the deadliest diseases globally, ranked 17th in 1990 and 12th in 2017. Its global prevalence has increased by 29.3% from 1990 to 2017 (
Based on these problems, DRPs management in CKD patients carried out by pharmacists is crucial. It has been proven to give some advantages, namely a better quality of life for patients, a shorter average Length of Stay (LOS), mortality prevention, and health cost reduction (
The method used in this literature review article was through articles search on three databases with specific keywords for each database. It is shown as follows:
The article selection process used inclusion and exclusion criteria. The inclusion criteria included research articles that discussed about pharmaceutical care activities in CKD patients with DRPs as one of the study outcomes. The process of article selection is shown in Figure
The term pharmaceutical care according to the Pharmaceutical Care Network Europe (PCNE) in 2013, is “The pharmacist’s contribution to the care of individuals in order to optimize medicines use and improve health outcomes” (
Summary of Four Studies on Pharmaceutical Care for CKD Patients (Experimental Study).
References | Participants (Mean Age (year)) | Pharmaceutical care activities* | Study outcomes | |||||||
---|---|---|---|---|---|---|---|---|---|---|
1 | 2 | 3 | 4 | 5 | Prevalence of DRPs | Mean of DRPs | Acceptance recommendation | DRPs status | ||
( |
130 CKD patients (56.3±17.8) | √ | √ | √ | √ | (Not Reported) | 5,31±2,61 DRPs/patient | A total of 690 recommendations were given, 86.6% were accepted, 69.2% were accepted and implemented, 2.3% were corrected by physicians | 17% DRPs resolved and 37.4% DRPs prevented | |
( |
Haemodialysis patients | √ | √ | √ | √ | (Not Reported) | IG: 0,329 DRPs/patient | Three types of interventions were accepted by patients 100%, 98%, and 96%, respectively. Physicians accepted three types of recommendations 100%, 95%, and 100%, respectively | (Not Reported) | |
CG: 25 patients (11.5±0.6) | ||||||||||
IG: 25 patients (10.8±0.64) | ||||||||||
( |
CKD without dialysis patients. | √ | √ | √ | (Not Reported) | (Not Reported) | (Not Reported) | The decreased DRPs/patient in both groups: 2.16±2.10 to 1.60±1.79 for IG and 1.70±2.02 to 1.62±1.79 for CG. The difference in the decline between the two groups was -0.32 (95% CI, -0.63 to -0.01). | ||
IG: 304 patients (71.9±12.0) | ||||||||||
CG: 138 patients (71.2±12.5) | ||||||||||
( |
47 CKD patients (Not Reported) | √ | √ | √ | √ | (Not Reported) | (Not Reported) | There were 35 recommendation accepted from a total of 41 recommendation | (Not Reported) |
Summary of 15 Studies on Pharmaceutical Care for CKD Patients (Observational Study).
References | Participants (Mean Age (year)) | Pharmaceutical care activities* | Study outcomes | |||||||
---|---|---|---|---|---|---|---|---|---|---|
1 | 2 | 3 | 4 | 5 | Prevalence of DRPs | Mean of DRPs | Acceptance recommendation | DRPs status | ||
( |
67 CKD patients (70) | √ | √ | √ | √ | 93% | 2 DRPs/patient | Nephrologist accepted 82.6% of total 142 recommendations | (Not Reported) | |
( |
37 Haemodialysis Patients (Not Reported) | √ | √ | √ | 51,35% | 2,05 DRPs/patient | A total of 39 recommendations, 23.07% were accepted and the therapy was changed, 48.72% was accepted but the therapy was not changed, and 28.05%, neither the recommendation was accepted nor prescriber changed the therapy | (Not Reported) | ||
( |
79 CKD without dialysis patients (78.7±10.2) | √ | √ | √ | 62% | 1,8 DRPs/patient | Recommendations accepted by physicians were 95.7% of 69 recommendations | (Not Reported) | ||
( |
177 CKD without dialysis patients (78.1) | √ | √ | √ | (Not Reported) | (Not Reported) | Recommendations accepted by general practitioners were 33.3% of 18 recommendations | 33,3% DRPs resolved | ||
( |
90 Haemodialysis Patients (Not Reported) | √ | √ | √ | (Not Reported) | 0,5±0,8 DRPs/patient | Recommendations accepted by the prescriber and nurse were 27% of 64 recommendations | (Not Reported) | ||
( |
105 CKD patients (Not Reported) | √ | √ | √ | (Not Reported) | 10 DRPs/patient | (Not Reported) | (Not Reported) | ||
( |
Haemodialysis Patients. | √ | √ | √ | √ | (Not Reported) | CC: 3,8 DRPs/patient | Physicians accepted 67.6% of 343 recommendations | 83,3% DRPs resolved | |
UC: 190 patients (60.4±10.8) | ||||||||||
CC:134 patients (62.0±11.4) | ||||||||||
( |
60 CKD without dialysis patients (54.2±16.8) | √ | √ | (Not Reported) | 4,5±1,4 DRPs/patient | (Not Reported) | (Not Reported) | |||
( |
1850 CKD patients (Not Reported) | √ | √ | √ | (Not Reported) | 0.65 DRPs/patient | Physicians accepted 92.79% of 1192 recommendations | (Not Reported) | ||
( |
103 CKD patients (45.83±17.7) | √ | √ | √ | √ | 78,6% | 1,94±0,873 DRPs/patient | A total of 218 recommendations, 81.6% were accepted | 79,8% DRPs resolved | |
( |
726 Dialysis patients (64±15) | √ | √ | √ | (Not Reported) | (Not Reported) | (Not Reported) | (Not Reported) | ||
( |
442 CKD without dialysis patients (81.5±6.6) | √ | √ | √ | 22,4% (Community pharmacist) dan 41,6% (Expert pharmacist) | (Not Reported) | The physicians accepted the community pharmacist recommendations were 52.5% of 99 recommendations | (Not Reported) | ||
( |
200 CKD patients (57.95±20.33) | √ | (Not Reported) | 3,61 DRPs/patient | (Not Reported) | (Not Reported) | ||||
( |
833 CKD patients (53.73±12.76) | √ | √ | √ | √ | 29,41% | 1,02 DRPs/patient | Recommendations accepted and applied by nephrologist were 97.6% of 250 recommendations | (Not Reported) | |
( |
125 CKD patients (72±12) | √ | √ | √ | √ | (Not Reported) | (Not Reported) | The nephrologist accepted 81% of 277 recommendations for medication discrepancies. The nephrologists accepted 25% of 422 recommendations on drug selection and dosage issues | (Not Reported) |
Medication reconciliation and medication review are strategies used by pharmacists to detect DRPs. The purpose of medication reconciliation is to detect medication discrepancies in order to get early prevention. In this way, the pharmacists will have a complete and accurate reconciled medication list (
DRPs classification system used as an instrument for evaluating DRPs is essential in medication reviews (
The results of DRPs evaluation are presented in Tables
Studies Results regarding Types of DRPs in CKD Patients based on Hepler and Strand.
No | DRPs Types | ( |
( |
( |
Total (N) |
---|---|---|---|---|---|
1 | Non-adherence | 7 | 219 | 42 | 268 |
2 | Untreated indication | 2 | 62 | 49 | 113 |
3 | Drug use without indication | 1 | 78 | 25 | 104 |
4 | Over dosage | 9 | 66 | 20 | 95 |
5 | Adverse drug reaction | 4 | 29 | 24 | 57 |
6 | Drug interactions | 10 | 6 | 59 | 75 |
7 | Improper drug selection | 3 | 19 | 33 | 55 |
8 | Sub therapeutic dosage | 3 | 30 | 19 | 52 |
Study Results regarding Types of DRPs in CKD Patients based on Norwegian.
No | DRPs Types | ( |
---|---|---|
1 | Incorrect dose | 40 |
2 | Inappropriate drug | 36 |
3 | Other | 8 |
4 | Interaction | 4 |
No | DRPs Types | ( |
( |
Total (N) | |
---|---|---|---|---|---|
CP* (N) | EP* (N) | ||||
1 | Over dosage | 12 | 73 | 133 | 245 |
2 | Subtherapeutic dosage | 27 | |||
3 | Non conformity to guidelines/contraindication | 17 | 26 | 26 | 69 |
4 | Untreated indication | 45 | 45 | ||
5 | Drug monitoring | 6 | 14 | 20 | |
6 | Improper administration | 10 | 6 | 16 | |
7 | Drug use without indication | 11 | 5 | 16 | |
8 | Adverse drug reaction | 14 | 14 |
PCNE V6.02 | PCNE V.8.02 | |||||
---|---|---|---|---|---|---|
Based on Problems | Based on Problems | |||||
Problem |
( |
( |
( |
Total (N) | Problem |
( |
Treatment effectiveness | 483 | 1134 | 101 | 1718 | Treatment safety | 578 |
Adverse reactions | 476 | 18 | 110 | 604 | Treatment effectiveness | 141 |
Treatment costs | 68 | 5 | 39 | 112 | Others | 6 |
Others | 35 | 35 | ||||
Based on Causes | Based on Causes | |||||
Drug selection | 628 | 677 | 77 | 1382 | Drug selection | 641 |
Dose selection | 387 | 459 | 34 | 880 | Other | 58 |
Drug use process | 214 | 6 | 8 | 228 | Dose selection | 12 |
Other | 107 | 114 | 221 | Patient related | 7 | |
Logistics | 148 | 12 | 160 | Dispensing | 2 | |
Treatment duration | 47 | 21 | 5 | 73 | ||
Drug form | 2 | 16 | 7 | 25 | ||
Patient | 17 | 1 | 5 | 23 |
Based on this discussion, the outcomes of the pharmacists’ strategies in detecting DRPs in CKD patients were the number of DRPs/patients and types of DRPs detected. After that, the pharmacists used the DRPs findings to make intervention plans as a form of the follow-up to the DRPs’ findings (
Follow-up plans to resolve and prevent DRPs in CKD patients are aimed at three levels: prescribers, drugs, and patients (
Tables
Additionally, low awareness and inadequate medication adherence were the main obstacles for health professionals in providing CKD management services (
The results of several studies revealed that a process of resolving and preventing of DRPs in CKD patients through interprofessional collaboration, education, and counselling successfully resolve and prevent DRPs in CKD patients. These findings were confirmed by the changed of patients DRPs’ status in 4 studies at Tables
Pharmacists have undergone in conducting a series of detecting, resolving, and preventing DRPs in CKD patients. A study reported that the number of DRPs assessed by expert pharmacists was 1,9 times higher than that of community pharmacists. The pharmacists’ ability to detect the DRPs on CKD patients depends on their experiences and trainings. Besides, this study also reported that 48% of community pharmacists experienced interprofessional communication difficulties. These issues become obstacles in a the series of detecting, resolving, and preventing DRPs in CKD (
Improving the hard and soft skills of pharmacists’ professional is a the way to optimize the process of detection, resolution, and prevention of DRPs in CKD patients. Professional hard-skills cover the knowledge of the disease and management of CKD therapy as well as social knowledge such as culture and economics understanding. Meanwhile, professional soft-skills cover the ability to communicate well and effectively, personal barriers management skills, and the ability to be assertive and empathetic (
Lalonde et al. in 2017 conducted a study about pharmacists’ training impact on DRPs in CKD patients using the ProFil program. The ProFil is a program designed to assist pharmacists in carrying out therapeutic management to CKD patients, consisting of training and communication components. The ProFiL program was given to pharmacists, who provided intervention to the intervention group patients, while the control group only received the usual care. The results showed that through the ProFil program application, the mean of DRPs/patients in the intervention group has decreased as presented in Table
Additionally, modification of the delivery model is an effort to optimize the detection, resolution, and prevention of DRPs in CKD patients. Consultation with a pharmacist before the patient consulted a nephrologist was discussed in two studies of CKD out-patient care. The counselling with pharmacist aims to explore patients’ understanding of CKD, comorbid diseases they have experienced, and the treatment during the consultation session. After that, the pharmacist will perform comprehensive medication reviews. Before the patient attends a consultation session with the nephrologist, a reconciled medication list and recommendations on DRPs findings are given to the nephrologist as consideration for determining patient therapy (
The strategies of optimizing detection, resolution, and prevention of DRPs in CKD patients provide several benefits. It has positively impacted to patients and the health care system such as preventing CKD patients’ unplanned admissions and making the average of LOS shorter (
Pharmacists’ roles in detecting, resolving, and preventing DRPs in CKD patients are part of pharmaceutical cares aiming to optimize patient therapy; therefore, the patients’ effectiveness and safety can be guaranteed. The process of detecting DRPs in CKD patients was carried out through medication reconciliation and medication review. The outcomes of this process are the of number DRPs/patients and types of DRPs can be detected. Further, the processes of resolving and preventing DRPs be done through interprofessional collaboration, education, and counselling for CKD patients or their families. The outcome of this process is the change of patients’ DRPs status. Pharmacists need to improve their professional hard and soft-skills; thus, the process can be optimized. Additionally, modification of the pharmaceutical care delivery model can also be applied as needed. The decrease in the number of DRPs/patient and the change of DRPs status were reported as the outcomes of this optimization process.
The authors especially thank the Faculty of Pharmacy Padjadjaran University and Pharmacy Installation of Dr. Hasan Sadikin General Hospital for support during the manuscript review and preparation.