Implementation of Pharmaceutical Care Services in a Renal
Cynthia A. Naughton, Pharm.D., M.S.
Heartland Health System
North Dakota State University College of Pharmacy
Fargo, North Dakota
Managing patients with chronic kidney disease (CKD) is frequently
complex due to the presence of multiple medical conditions
along with renal impairment. Dialysis patients generally exhibit
numerous concurrent problems, either due to or as a consequence
of their renal failure. Associated medical problems include
diabetes mellitus, hypertension, anemia, hyper or hypocalcemia,
hyperphosphatemia, secondary hyperparathyroidism, infectious
processes, and cardiovascular morbidity.
Pharmacotherapy management of CKD patients has been optimized
through the addition of pharmaceutical care to the already
existing medical, nursing, dietary, and social work care plans.
The pharmaceutical care service began in 1998 and initially
consisted of erythropoietin dosing. The service has now grown
to include the following:
- Medication history upon admission
- Quarterly drug regimen review
- Maintenance of a computerized patient database
- Renal dosing service
- Erythropoietin dosing protocol management
- Iron dosing protocol management
- Vitamin D dosing protocol management
- Patient and family education
- Participation in monthly care conferences with attending
- Collaboration with the transplant team
The Heartland Health Systems Kidney Dialysis Unit is a regional,
ambulatory dialysis facilities servicing approximately 110
hemodialysis and 30 peritoneal dialysis patients. The average
daily census is 55 patients. Prior to implementing a pharmaceutical
care service, pharmacy services were purely distributive functions.
The pharmacy supplied the erythropoietin, heparin, iron dextran,
and calcitriol injection without looking at appropriateness
of therapy or monitoring.
In 1997 the National Kidney Foundation released their Dialysis
Outcomes Quality Initiative (DOQI) Clinical Practice Guidelines
on Anemia Management. The consensus document targeted a hematocrit
range of 33-36% to improve patient outcomes and survival.
The Health Care Finance Administrations (HCFA) also announced
changes to Medicare reimbursement. Reimbursement for erythropoietin
would be denied if a patients average hematocrit exceeded
36.5%. At the time erythropoietin was the number one pharmaceutical
in dollars spent at Heartland. The cost was $10 per 1000 units,
the typical patient dose was 10-12,000 units/week (range 1000-30,000
units), and approximately $50,000 worth of erythropoietin
was used per month in the kidney dialysis unit.
The clinical and financial impact was great and an erythropoietin
use evaluation was conducted. Criteria included the percent
of patient in DOQI target hematocrit range (33-36%) and the
percent of patients with a hematocrit exceeding 36.5%. The
results were 40% of patients were below target range, 30%
were within the target hematocrit range of 33-36%, and 30%
were above the 36.5% hematocrit. With 30% of the patients
exceeding a hematocrit of 36.5%, it was projected that $16,000
per month would be lost revenue in denied Medicare claims
with the current dosing practice.
A performance improvement team consisting of physicians,
nursing, pharmacy, and finance were convened to study the
problem and identify alternatives to the current practice
of physician directed erythropoietin dosing and monitoring.
From this group a pharmacy managed EPO dosing protocol was
developed, approved, and implemented in January 1998. Pharmacy
also supplied erythropoietin in unit dose syringes to minimize
waste and coordination with finance department for reimbursement
The new EPO protocol was evaluated for medical and finance
outcomes after 12 months. The percentage of patients within
the DOQI target hematocrit range of 33-36% with the new protocol
consistently exceeded the baseline value of 30%. Also the
percent of patients exceeding an average hematocrit greater
than 36.5% declined from 30% to an average of 8.0% and there
were no Medicare denials for erythropoietin.
Due to the success of the EPO project, other opportunities
were explored to expand services in the kidney unit. A telephone
survey of renal units was conducted in the surrounding states.
About 25% of the pharmacys provided some pharmaceutical
services which turned out to be predominately antibiotic dosing.
Service opportunities were identified for pharmaceutical
care at Heartland including:
- Anemia management
- Medication management
- Identification and resolution of drug related problems
- Calcium and phosphorous balance management
- Hyperparathyroidism management
- Patient and Family Education
- Transplant therapeutics
Hospital administration supported the idea of adding pharmaceutical
care services to the kidney unit as long as no additional
staff needed to be hired. An application for a grant was written
and awarded by the Dakota Medical Foundation to fund a pharmacy
resident. Pharmaceutical care services were implemented when
the pharmacy resident started at the facility. Pharmaceutical
care services were provided initially to hemodialysis patients
only and have now been expanded to the peritoneal dialysis
The pharmacy resident position was instrumental in implementing
the program. The resident helped design the computerized database
capable of generating current medication profiles which were
then placed in the medical record. A rotating calendar of
patient appointments was generated so that all patients would
meet with a pharmacist upon admission and then quarterly for
drug regimen review. In the first year alone, 131 drug related
problems were identified during the patient appointments.
Drug related problems identified in dialysis patients
(from July 2000-June 2001.)
Indication with an Incorrect Drug
Adverse Drug Reaction
Failure to Receive or Take a Drug
Drug without an Indication
Sub-therapeutic Drug Dose
Services were expanded in the first year of pharmaceutical
care services to include the development and implementation
of a pharmacist managed iron dosing protocol and a pharmacist
managed Vitamin D dosing protocol.