Pilot Study of the Pharmacist-led Haemodialysis Out-Patient Medicine Review Clinic

A Lau, R Thuraisingham, G Glass,

The Royal London Hospital

Problem: Drug related problems (DRPs) are a common cause of hospital admission¹. Most dialysis patients are on multiple drugs. Drug dosage and formulations are regularly adjusted by clinicians. Hospital drug records are often incomplete or inaccurate and can lead to confusion between patient, physician and pharmacist.

Purpose: The aim of the study was to clarify haemodialysis patients’ drug histories; to tailor the medicines to suit the individual; and to compare and investigate any discrepancies between the hospital record and what the patients were taking.

Design: he study was conducted over 4 consecutive weeks in the summer of 2003 in the haemodialysis unit at the Royal London Hospital. A weekly multidisciplinary review clinic was run by the consultant nephrologist and/or registrar and the renal pharmacist. All patients who were seen in the clinic were eligible for inclusion in the study; between 5 and 14 patients were seen weekly, and all patients were interviewed by the renal pharmacist before being seen by the nephrologist. The following areas were documented: the current drug list; the correct durg list; any interventions and problems resolved with the nephrologist; and any documented education or communication.

Findings: Thirty-two patients were seen at the clinic during the study, 2 patients were excluded as they were seen by the nephrologist first. For the 30 recruits, with mean age of 52.7 +/- SD 14.7, a total of 281 drugs were taken (mean = 9.37 +/-SD 3.38). Hospital drug records were compared against what the patients were actually taking at home and there were discrepancies in 120 (38.8%) of drugs documented. Of these, the most common BNF categories included 26.7% cardiovascular drugs (e.g. antihypertensives) and 32.5% nutrition and blood (e.g. phosphate binders). Nineteen (63.3%) patients were identified with 23 non-drug related problems. In 25 (83.3%) patients, 47 drug related problems (DRPs) were identified (e.g. adverse drug reaction, untreated indication etc.). Of these, too little drug (e.g. sub-therapeutic dose) and untreated indication were the most common DRP identified. 70% of the patients had 2 or more DRPs while 50% of patients had non-drug related problems (e.g. complaint of chronic back pain). Thirty-six (76.6%) of the DRPs were ranked by the nephrologist. Of these, 19 (52.8%) were ranked as either significant or very significant. A total of 188 interventions around drug discrepancies, DRPs and non-drug related problems were made; an average of 6.2 interventions per patient. There was an association between the interventions and the significance of the problem.

Conclusion: Drug records do not always concur with the drugs patients are actually taking. Input from the renal pharmacist at the out-patient clinic improved the drug history accuracy and helped to resolve DRPs.

Relevance: This study highlighted that haemodialysis patients take large number of medications. Since the hospital records are not always a reliable source for an accurate haemodialysis patient’s drug history, the pharmacist taking a full drug history is essential. The pharmacist is in an ideal position to provide such professional advice to the patients and to improve their medicines adherence by giving patients an opportunity to raise any medication concerns at the clinic. The pharmacist-led medication review clinic also allowed the nephrologists to use their time more effectively; the service is therefore relevant for all tertiary care clinics.

Reference:

Room for review. A guide to medication review: the agenda for patients, practitioners and managers. 2002. Task Force on Medicines Partnership.