January 26, 2016 (Ottawa): Pharmacists who screened at-risk patients for chronic kidney disease (CKD) found previously unrecognized disease in 1 of every 6.4 patients tested, according to a study to be published in the January/February 2016 issue of the Canadian Pharmacists Journal.
"It was actually surprising for us," says the study's primary author, Dr. Yazid Al Hamarneh, a pharmacist and the scientific officer for Consultation and Research Services in Alberta's SPOR (Strategy for Patient-Oriented Research) SUPPORT Unit. "We knew that we would find unrecognized cases, but not that many."
The study is one of the first to provide concrete evidence of the benefits of allowing community pharmacists to order laboratory tests and see patients' test results.
CKD is a serious illness defined as reduced kidney function or signs of kidney damage lasting more than three months. It affects an estimated 1 in 10 Canadian adults, according to a 2013 study in the Canadian Medical Association Journal. But it is often missed because patients in the early stages may have no symptoms. Undiagnosed CKD can lead to life-threatening long-term effects, mainly cardiovascular disease — heart disease and stroke. Without changes in lifestyle or medication, as required, patients may eventually develop kidney failure and need dialysis or a kidney transplant. (See Background: What is CKD?)
The study tested a new online decision-making tool, called the "CKD Pathway", to help primary care providers decide which patients to test, identify cases, and give affected patients appropriate lifestyle advice, medication, or a referral to a nephrologist (kidney specialist). (See Background: What is the CKD Pathway?)
"We worked closely with our end-users — primary care physicians, pharmacists and nurses. It took about a year to develop the pathway and was launched one year ago," explains Dr. Brenda Hemmelgarn, a nephrologist involved in the pathway, who is also a co-author of the study.
In the study, pharmacists at 55 community pharmacies across Alberta identified patients at risk of CKD based on recent prescriptions and lab test results. Those who had risk factors outlined in the pathway were sent for blood and urine tests for kidney function, unless they had recent test results (in the previous 12 months) on file. The pharmacists used the online CKD pathway to analyze test results and determine whether patients had CKD.
Of 720 at-risk patients screened during the study, 39% had CKD. Of those with CKD, 60% had already received a diagnosis, but 40% (16% of the total screened) had no record or knowledge of a previous CKD diagnosis ("unrecognized" CKD).
The pharmacists' role in screening those at risk of CKD was possible only because pharmacists in Alberta have been able to order, interpret and view lab tests since 2012. (See Background: How are pharmacists' practices changing?)
Dr. Hemmelgarn comments, "Pharmacists as front-line care providers are in a unique position to identify high-risk patients for CKD, do targeted screening through blood and urine tests, and identify the presence of CKD. They have a unique position in Alberta to participate in care of patients with chronic disease at the community level." Kidney disease is usually managed in primary care, with nephrologists like Dr. Hemmelgarn seeing only the most severe cases, amounting to about 5% of CKD patients.
Dr. Al Hamarneh points out that, in Alberta, patients with certain chronic conditions can meet with their pharmacist to put together a comprehensive annual care plan, or receive a standard medication management assessment. (See Background: How are pharmacists' practices changing?) These occasions give pharmacists a chance to screen patients for CKD as well as other diseases and conditions.
Knowing a patient's CKD status is important for pharmacists, as certain medications are contraindicated for patients with kidney problems, Dr. Al Hamarneh says. Pharmacists may need to review or adjust medication for affected patients.
"When it comes to pharmacists providing such clinical services, it's not taking patients away from family physicians," emphasizes Dr. Al Hamarneh. "Pharmacists see patients with chronic diseases frequently. If the pharmacists are providing those clinical services, they can bring those patients back to their physicians." In the case of CKD, pharmacists can encourage patients with CKD to visit their family physician, or to get a physician if they don't have one. "It's working collaboratively to get the best results for the patient."
About the Canadian Pharmacists Journal
Established in 1868, the Canadian Pharmacists Journal is the oldest continuously published periodical in Canada. CPJ's mission is to support pharmacists in optimizing patient care by linking knowledge to practice. CPJ is an official publication of the Canadian Pharmacists Association. CPhA advocates for pharmacists and supports its members to advance the profession and enhance patient outcomes.
To arrange an interview with Dr. Yazid Al Hamarneh, tel. (780) 492-9608; email [email protected]
To arrange an interview with Dr. Brenda Hemmelgarn, contact Marta Cyperling, Media Relations Manager, Cumming School of Medicine, University of Calgary, tel. (403) 210-3835; email [email protected]
To arrange an interview with co-author Dr. Ross Tsuyuki, tel. (780) 492-8526; email [email protected]
What is CKD?
Kidney disease is defined as reduced kidney function, measured by the estimated glomerular filtration rate (eGFR), which can be determined by a blood test. An alternative measure is a marker of kidney damage called albumin-to-creatinine ratio (ACR), which is determined by a urine test.
Kidney disease is considered chronic (CKD) if it lasts for 3 months or more. In this study, eGFR and ACR tests were taken 3 months apart to determine whether the eGFR and ACR levels had improved.
There are many causes of CKD, but the two most common are diabetes and high blood pressure. Inherited conditions can cause CKD, as can acute infections and other urinary tract problems that develop. A recent study estimates that 1 in 10 adult Canadians has CKD.
The most common outcomes of CKD are cardiovascular disease (heart disease and stroke) as well as severe kidney failure.
In this study, patients were included if they had
- established vascular disease,
- a high risk score for cardiovascular disease, or
- a history of CKD,
plus at least one risk factor:
- high blood pressure,
- high LDL cholesterol,
- high glycated hemoglobin (a sign of diabetes), or
- current smoking.
What is the CKD Pathway?
The impetus for the CKD Pathway was new international clinical practice guidelines for CKD management released in 2012. The pathway was developed by a group called the Interdisciplinary Chronic Disease Collaboration in Alberta, inspired by the UK National Institute for Health and Clinical Excellence (NICE), which develops clinical pathways that health care professionals can use to make decisions about patient care. The pathway incorporates other Canadian and international guidelines as well, to create a harmonized approach that can be used across Canada. It is supported and endorsed by Alberta Health Services, the University of Calgary and the University of Alberta.
The online tool, available at ckdpathway.ca, is designed for use by primary care physicians, pharmacists and nurses. Step-by-step decision guides help these primary care providers to diagnose CKD from test results, manage the condition through lifestyle changes and, if needed, prescribe medication, as well as refer the patient to a kidney specialist (nephrologist) if there are warning signs of serious disease.
The pathway is now in use in Alberta, where primary care providers have been encouraged to use it through a widespread dissemination strategy involving faxed messages, social media, conference presentations, brochures, and the web site.
For more information about the development of the CKD Pathway, see a previous article in the Canadian Pharmacists Journal.
How are pharmacists' practices changing?
In recent years, provincial and territorial laws and regulations that set out what pharmacists are permitted to do have been updated. As a result, pharmacists in many provinces and territories can perform some services that were previously restricted to physicians and, in some cases, nurses.
In this study, pharmacists ordered laboratory (blood and urine) tests for patients. They also checked past and current test results to find signs of CKD or risk factors for the disease. Pharmacists currently have these capabilities in Alberta, Manitoba, Quebec and Nova Scotia. As well, they will soon be able to order tests in Saskatchewan, New Brunswick and Prince Edward Island.
Pharmacists have added many other services to their repertoire:
- Renewing or extending prescriptions (all provinces plus Northwest Territories)
- Changing drug dosages or formulations (all provinces)
- Making therapeutic substitutions (all provinces except Manitoba, Ontario and Quebec)
- Prescribing for minor ailments (all provinces except British Columbia and Ontario)
- Initiating prescription drug therapy, either independently (pharmacists in Alberta with additional prescribing authorization) or in a collaborative practice setting (Alberta, Saskatchewan, Manitoba, New Brunswick and Nova Scotia)
- Administering drugs or vaccines by injection (all provinces except Quebec. Limitations do apply and may differ between jurisdictions)
In Alberta, where this study was conducted, pharmacists have had a widely expanded scope of practice since 2007. For patients with multiple chronic conditions such as diabetes or asthma, or one chronic condition and at least one risk factor such as smoking, obesity or addiction, pharmacists can conduct comprehensive annual care plans that include an assessment, medication history, resolution of drug-related problems and a follow-up and monitoring plan. For patients with one chronic condition who take at least four medications, a standard medication management assessment can be conducted.
With additional authorization obtained through the Alberta College of Pharmacists, a pharmacist in Alberta can assess patients and initiate needed prescription drug therapy for any disease or condition, not solely minor ailments as in some other provinces.
For more information about pharmacists' scope of practice across Canada, see http://www.pharmacists.ca/index.cfm/pharmacy-in-canada/scope-of-practice-canada/