Screening And Quality Use Of Medicines In Kidney Disease Through Community Pharmacies: Findings From A Large Cluster Randomised Trial

• By: CASTELINO, Ronald (University of Sydney, Australia)
• Co-author(s): Dr Ronald Castelino (University of Sydney, Sydney, Australia)
  Dr Wubshet Tesfaye (University of Sydney, Sydney, Australia)
  
• Abstract:

  Introduction:
  Chronic kidney disease (CKD) is a growing public health problem which affects over 10% of the adult population worldwide. CKD is defined as sustained kidney damage (e.g. proteinuria) and/or reduced kidney function (estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2) lasting for ≥3 months). In Australian primary care, approximately 35% of patients are prescribed potentially inappropriate medications (defined as contraindicated/higher than recommended dose) based on their kidney function. Inadequate recognition of CKD in primary care is one factor that can contribute to the increased risks of inappropriate prescribing. Despite mounting evidence to support pharmacists’ involvement in disease screening and medication management, community pharmacists in Australia currently have limited role in CKD care. Hence the main aim of this study was to evaluate the effectiveness of pharmacy-led screening in enhanced detection of previously unknown CKD and quality use of medicine (QUM) intervention in optimising medication use for patients with CKD.
  
  Methods:
  This cluster randomised controlled trial (CKD-QUM Trial) is being conducted in 4 Australian states; New South Wales, Victoria, Queensland, and Australian Capital Territory. Community pharmacies (clusters) were the unit of randomisation and patients were the unit of analysis. Community pharmacies were selected from geographical groups of co-located postcodes to form clusters within the top 50 kidney disease hotspot areas identified by Kidney Health Australia. The intervention included screening for the risk of developing CKD using the QKidney® risk calculator followed by point of care creatinine test (Novo Max Pro Creatinine meter) for eGFR in people with moderate to high risk as per the Qkidney® risk calculator (a score of ≥3). Patients with reduced eGFR or inappropriate medications were referred to the general practitioner (GP) for further evaluation and management.
  
  Results:
  The CKD-QUM Trial has now enrolled 140 pharmacies from across the four regions in Australia, which collectively have recruited 1,050 patients (51.6% vs 48.4%; Intervention and Control groups, respectively). The mean (SD) age of participants was 63 (13) years, with over half (54%) of them females. Out of the 527 analysable interim patient data, 256 of them had a moderate risk of CKD over five years (QKidney® Score of 3 -14.6), while 90 participants had high-risk (Qkidney® score 15.3-94.5). Based on point-of-care testing data from 247 participants, more than half (n=130) had reduced kidney function (eGFR<90 mL/min/m2), which includes 15 patients with <60mL/min/1.73m2. A total of 66 participants have been referred to their respective GPs due to either having low kidney function (<60 mL/min/1.73m2) or inappropriate medicines. Nine referral outcomes have been received from GPs on additional tests and medication changes made based on the referrals by the pharmacists.
  
  CONCLUSION: While the complete findings will provide a more holistic picture, early findings from the CKD-QUM Trial are indicative of the fact that, with adequate training and preparation, it is feasible to implement a CKD screening and QUM service within community pharmacies. Further findings with more patient data on screening and cost-effectiveness of the approach will inform future practices in pharmacist-led kidney disease care and prevention.