Role of a Pharmacist in Postdischarge Care for Patients With Kidney Disease: A Scoping Review.

OBJECTIVE: The objective was to explore and describe the role of pharmacists in providing postdischarge care to patients with kidney disease. DATA SOURCES: PubMed, Embase (Elsevier), CINAHL (Ebscohost), Web of Science Core Collection, and Scopus were searched on January 30, 2023. Publication date limits were not included. Search terms were identified based on 3 concepts: kidney disease, pharmacy services, and patient discharge. Experimental, quasi-experimental, observational, and qualitative studies, or study protocols, describing the pharmacist's role in providing postdischarge care for patients with kidney disease, excluding kidney transplant recipients, were eligible. STUDY SELECTION AND DATA EXTRACTION: Six unique interventions were described in 10 studies meeting inclusion criteria. DATA SYNTHESIS: Four interventions targeted patients with acute kidney injury (AKI) during hospitalization and 2 evaluated patients with pre-existing chronic kidney disease. Pharmacists were a multidisciplinary care team (MDCT) member in 5 interventions and were the sole provider in 1. Roles commonly identified include medication review, medication reconciliation, medication action plan formation, kidney function assessment, drug dose adjustments, and disease education. Some studies showed improvements in diagnostic coding, laboratory monitoring, medication therapy problem (MTP) resolution, and patient education; prevention of hospital readmission was inconsistent. Limitations include lack of standardized reporting of kidney disease, transitions of care processes, and differences in outcomes evaluated. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: This review identifies potential roles of a pharmacist as part of a postdischarge MDCT for patients with varying degrees of kidney disease. CONCLUSIONS: The pharmacist's role in providing postdischarge care to patients with kidney disease is inconsistent. Multidisciplinary care teams including a pharmacist provided consistent identification and resolution of MTPs, improved patient education, and increased self-awareness of diagnosis.

SGLT2 Inhibitors to Slow Chronic Kidney Disease Progression: A Review.

PURPOSE: One in seven Americans is at risk for chronic kidney disease (CKD). For decades, the only treatment proven to slow progression of CKD was the use of renin-angiotensin-aldosterone system inhibitors. Based on promising secondary kidney outcomes in the cardiovascular outcome trials with sodium-glucose co-transporter-2 inhibitors, kidney outcome trials in patients with CKD were published for canagliflozin, dapagliflozin, and empagliflozin. METHODS: A literature search was conducted of PubMed using the MeSH terms "Sodium-Glucose Transporter 2 Inhibitors" and "Renal Insufficiency, Chronic" and looking for clinical trials, meta-analyses, or randomized controlled trials in humans between 2015 and 2023. FINDINGS: Primary and secondary outcomes from CREDENCE (Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation), DAPA-CKD (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease), and EMPA-KIDNEY (Empagliflozin in Patients with Chronic Kidney Disease) are described along with complete descriptions of the patient populations studied. IMPLICATIONS: This review describes the role of sodium-glucose co-transporter-2 inhibitors in slowing the progression of CKD, describes guideline changes that have occurred because of these data, and provides information on how these agents may be used clinically.

Pharmacists' perceptions regarding feasibility, acceptability, and usefulness of student-delivered naloxone education services in community pharmacy: A mixed methods study in Alabama.

BACKGROUND: Given that Alabama has the highest opioid prescribing rate in the nation, efforts to promote safe opioid use and reduce overdose mortality are critical. To address this, the Auburn University Harrison College of Pharmacy developed and piloted a didactic-experiential naloxone learning model in the first-year PharmD curriculum in 2020-2021 consisting of lectures, skills laboratory, and 120-hour community pharmacy introductory pharmacy practice experience (IPPE). Student-delivered naloxone education services (SDNES), including naloxone counseling and dispensing, were incorporated into the IPPE. OBJECTIVES: The objective of this study was to evaluate the feasibility, acceptability, and usefulness of SDNES frovm the perspective of community pharmacy IPPE preceptors. METHODS: This study used a mixed methods design including cross-sectional online surveys and follow-up semistructured telephone interviews. Survey measures were informed by validated scales and included feasibility (11 items), acceptability (13 items), and usefulness (6 items) of SDNES. Survey outcomes were assessed via 5-point Likert-type scales (1 = strongly disagree, 5 = strongly agree) and analyzed using descriptive statistics. Follow-up semistructured telephone interview questions were guided by the Consolidated Framework for Implementation Research domains of inner and outer setting and focused on SDNES barriers and facilitators, recommended strategies for service enhancement, and resource needs. Interview transcripts were analyzed using deductive and inductive rapid content analysis to determine themes and subthemes. RESULTS: Twenty-five preceptor surveys were completed (22.52% response rate). Overall, SDNES was rated as feasible (mean [SD] scale score 4.04 [0.77]), acceptable (3.95 [0.83]), and useful (3.87 [0.98]). Interviewees (N = 8) discussed 13 barrier subthemes, 12 facilitator subthemes, 7 recommended strategies, and 8 resource needs across 3 overarching themes, most of which were related to the inner setting. CONCLUSION: Community pharmacy IPPE preceptors found SDNES feasible, acceptable, and useful in their practices. The SDNES model may be used to build capacity for naloxone services delivery in community pharmacies, potentially increasing patient access to naloxone education and distribution.

Impact of a Didactic-Experiential Naloxone Learning Model to Improve Student Pharmacist Skills and Patient Care.

OBJECTIVE: To assess the impact of an integrated didactic-experiential learning model on student pharmacists' knowledge, confidence, comfort, and intention regarding provision of naloxone for patients receiving opioid therapy. METHODS: An integrated didactic-experiential learning model was developed to bridge learning in the classroom and laboratory with application in the experiential setting. Student knowledge, confidence, comfort, and intentions regarding provision of naloxone services were measured via online survey at predidactic, postdidactic, and postexperiential time points, and analyzed using Friedman's analysis of variance. RESULTS: A total of 280 first-year student pharmacists completed the baseline survey. The learning model increased student knowledge, confidence, comfort, and intention regarding naloxone services implementation. Specifically, students reported an increase in mean (SD) knowledge score from 60.85% (17.40%) in the predidactic to 81.47% (13.57%) in the postdidactic period. Similarly, mean (SD) confidence (2.49 [0.75] to 3.56 [0.45]), comfort (2.06 [0.74] to 3.57 [0.45]), and intention (3.46 [0.70] to 3.66 [0.44]) increased from pre- to postdidactic period, and these changes were maintained from postdidactic to postexperiential period. CONCLUSION: The didactic-experiential learning model increased student knowledge, confidence, comfort, and intentions regarding naloxone services implementation. We believe that the model fills gaps in student pharmacist education and is the first step in enhancing and sustaining community pharmacy-based naloxone services. Although this study was limited to a single college, it shows the effectiveness of linking didactic and experiential training in improving students' knowledge and skills.

Pharmacy Practice Standards for Outpatient Nephrology Settings.

Patients with kidney disease represent a medically complex group of patients with high medication burdens that could benefit from clinical pharmacy services as part of the interdisciplinary care team to optimize medication use. The "Advancing American Kidney Health" executive order includes new value-based reimbursement models to be tested by the Center for Medicare and Medicaid Innovation beginning January 2021 and January 2022. Advancing American Kidney Health executive order poses opportunities for the inclusion of comprehensive medication management. Following an iterative process integrating input from a diverse expert panel, published standards, clinical practice guidelines, peer review, and stakeholder feedback, our group developed practice standards for pharmacists caring for patients with kidney disease in health care settings. The standards focus on activities that are part of direct patient care and also include activities related to public health and advocacy, population health, leadership and management, and teaching, education and dissemination of knowledge. These standards are intended to be used by a variety of professionals, from pharmacists starting new practices to practice managers looking to add a pharmacist to the clinical team, to create standardization in services provided.

Education Standards for Pharmacists Providing Comprehensive Medication Management in Outpatient Nephrology Settings.

Chronic kidney disease is a public health problem that has generated renewed interest due to poor patient outcomes and high cost. The Advancing American Kidney Health initiative aimed to transform kidney care with goals of decreasing the incidence of kidney failure and increasing the number of patients receiving home dialysis or a kidney transplant. New value-based models of kidney care that specify inclusion of pharmacists as part of the kidney care team were developed to help achieve these goals. To support this Advancing American Kidney Health-catalyzed opportunity for pharmacist engagement, the pharmacy workforce must have a fundamental knowledge of the core principles needed to provide comprehensive medication management to address chronic kidney disease and the common comorbid conditions and secondary complications. The Advancing Kidney Health through Optimal Medication Management initiative was created by nephrology pharmacists with the vision that every person with kidney disease receives optimal medication management through team-based care that includes a pharmacist to ensure medications are safe, effective, and convenient. Here, we propose education standards for pharmacists providing care for individuals with kidney disease in the outpatient setting to complement proposed practice standards.

Evaluation of weight-based vancomycin dosing for hospitalized hemodialysis patients.

BACKGROUND: Current vancomycin dosing guidelines recommend targeting trough concentrations of 15-20 mg/L in complicated infections to avoid treatment failure and resistance. How to accomplish this in the intermittent hemodialysis (IHD) population has not been adequately described. A weight-based vancomycin dosing protocol for IHD patients was developed to provide standardization of vancomycin dosing for this patient population. Prior to implementation of this protocol, clinical pharmacists used their individual judgment for dosing and monitoring. OBJECTIVE: Compare achievement of goal (15-20 mg/L) pre-IHD vancomycin levels between a group of patients dosed prior to implementation of this weight-based vancomycin dosing protocol and a group dosed after implementation. METHODS: This retrospective study evaluated hospitalized IHD patients who received vancomycin and had an appropriate pre-IHD vancomycin level. Any patients with acute kidney injury or who required continuous renal replacement therapy or peritoneal dialysis were excluded. RESULTS: A total of 145 vancomycin courses (94 pre-protocol and 51 post-protocol) were included in this study. The post-protocol group had an increased percentage of patients who achieved a pre-IHD vancomycin level of 15-20 mg/L. We also found improvement in pre-IHD vancomycin levels attained in patients weighing less than 75 kg and the need for additional study in patients weighing more than 105 kg. CONCLUSION: Simplifying and standardizing vancomycin dosing for hospitalized IHD patients based on weight resulted in 37% of patients achieving goal pre-IHD vancomycin level of 15-20 mg/L with zero patients having a pre-IHD vancomycin level <10 mg/L.