Advertisement
American Journal of Kidney Diseases

Effectiveness of Pharmacist Interventions on Cardiovascular Risk in Patients With CKD: A Subgroup Analysis of the Randomized Controlled RxEACH Trial

Published:September 11, 2017DOI:https://doi.org/10.1053/j.ajkd.2017.07.012

      Background

      Affecting a substantial proportion of adults, chronic kidney disease (CKD) is considered a major risk factor for cardiovascular (CV) events. It has been reported that patients with CKD are underserved when it comes to CV risk reduction efforts.

      Study Design

      Prespecified subgroup analysis of a randomized controlled trial.

      Setting & Participants

      Adults with CKD and at least 1 uncontrolled CV risk factor were enrolled from 56 pharmacies across Alberta, Canada.

      Intervention

      Patient, laboratory, and individualized CV risk assessments; treatment recommendations; prescription adaptation(s) and/or initiation as necessary; and regular monthly follow-up for 3 months.

      Outcomes

      The primary outcome was change in estimated CV risk from baseline to 3 months after randomization. Secondary outcomes were change between baseline and 3 months after randomization in individual CV risk factors (ie, low-density lipoprotein cholesterol, blood pressure, and hemoglobin A1c), risk for developing end-stage renal disease, and medication use and dosage; tobacco cessation 3 months after randomization for those who used tobacco at baseline; and the impact of rural versus urban residence on the difference in change in estimated CV risk.

      Measurements

      CV risk was estimated using the Framingham, UK Prospective Diabetes Study, and international risk assessment equations depending on the patients’ comorbid conditions.

      Results

      290 of the 723 participants enrolled in RxEACH had CKD. After adjusting for baseline values, the difference in change in CV risk was 20% (P < 0.001). Changes of 0.2 mmol/L in low-density lipoprotein cholesterol concentration (P = 0.004), 10.5 mm Hg in systolic blood pressure (P < 0.001), 0.7% in hemoglobin A1c concentration (P < 0.001), and 19.6% in smoking cessation (P = 0.04) were observed when comparing the intervention and control groups. There was a larger reduction in CV risk in patients living in rural locations versus those living in urban areas.

      Limitations

      The 3-month follow-up period can be considered relatively short. It is possible that larger reduction in CV risk could have been observed with a longer follow up period.

      Conclusions

      This subgroup analysis demonstrated that a community pharmacy–based intervention program reduced CV risk and improved control of individual CV risk factors. This represents a promising approach to identifying and managing patients with CKD that could have important public health implications.

      Index Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Arora P.
        • Vasa P.
        • Brenner D.
        • et al.
        Prevalence estimates of chronic kidney disease in Canada: results of a nationally representative survey.
        CMAJ. 2013; 185: E417-E423
        • Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group
        KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.
        Kidney Int Suppl. 2013; 1: 1-150
        • Tonelli M.
        • Wiebe N.
        • Guthrie B.
        • et al.
        Comorbidity as a driver of adverse outcomes in people with chronic kidney disease.
        Kidney Int. 2015; 88: 859-866
        • Hemmelgarn B.R.
        • Manns B.J.
        • Lloyd A.
        • et al.
        Relation between kidney function, proteinuria, and adverse outcomes.
        JAMA. 2010; 303: 423-429
        • Zillich A.J.
        • Saseen J.J.
        • Dehart R.M.
        • et al.
        Caring for patients with chronic kidney disease: a joint opinion of the ambulatory care and the nephrology practice and research networks of the American College of Clinical Pharmacy.
        Pharmacotherapy. 2005; 25: 123-142
        • Barylski M.
        • Nikfar S.
        • Mikhailidis D.P.
        • et al.
        Statins decrease all-cause mortality only in CKD patients not requiring dialysis therapy- a meta-analysis of 11 randomized controlled trials involving 21,295 participants.
        Pharmacol Res. 2013; 72: 35-44
        • Grover S.A.
        • Lowensteyn I.
        The challenges and benefits of cardiovascular risk assessment in clinical practice.
        Can J Cardiol. 2011; 27: 481-487
        • Khanji M.Y.
        • Bicalho W.
        • van Waardhuizen
        • et al.
        Cardiovascular risk assessment: a systematic review of guidelines.
        Ann Intern Med. 2016; 165: 713-722
        • Anderson T.J.
        • Gregoire J.
        • Pearson G.J.
        • et al.
        2016 Canadian Cardiovascular Society guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult.
        Can J Cardiol. 2016; 32: 1263-1282
        • Shiu J.R.
        • Simpson S.H.
        • Johnson J.A.
        • Tsuyuki R.T.
        Quantifying opportunities to affect diabetes management in the community.
        Can Pharm J. 2006; 139: 37-38
        • Al Hamarneh Y.N.
        • Hemmelgarn B.
        • Curtis C.
        • et al.
        Community pharmacist targeted screening for chronic kidney disease.
        Can Pharm J. 2016; 149: 13-17
        • Vivian E.M.
        Improving blood pressure control in a pharmacist-managed hypertension clinic.
        Pharmacotherapy. 2002; 22: 1533-1540
        • Scott D.M.
        • Boyd S.T.
        • Stephan M.
        • et al.
        Outcomes of pharmacist-managed diabetes care services in a community health centre.
        Am J Health Syst Pharm. 2006; 63: 2116-2122
        • Santchi S.R.
        • Chiolero A.
        • Burnand B.
        • et al.
        Impact of pharmacist care in the management of cardiovascular disease risk factors.
        Arch Intern Med. 2011; 171: 1441-1453
        • Tsuyuki R.T.
        • Johnson J.A.
        • Teo K.K.
        • et al.
        A randomized trial of the effect of community pharmacist intervention on cholesterol risk management – the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP).
        Arch Intern Med. 2002; 162: 1149-1155
        • McLean D.L.
        • McAlister F.A.
        • Johnson J.A.
        • et al.
        A randomized trial of the effect of community pharmacist and nurse care on improving blood pressure management in patients with diabetes mellitus – Study of Cardiovascular Risk Intervention by Pharmacists-Hypertension (SCRIP-HTN).
        Arch Intern Med. 2008; 168: 2355-2361
        • Al Hamarneh Y.N.
        • Charrois T.
        • Lewanczuk R.
        • Tsuyuki R.T.
        Pharmacist intervention for glycaemic control in the community (the RxING study).
        BMJ Open. 2013; 3: e003154
        • Tsuyuki R.T.
        • Al Hamarneh Y.N.
        • Jones C.A.
        • Hemmelgarn B.R.
        The effectiveness of pharmacist interventions on cardiovascular risk: the multicenter randomized controlled RxEACH Trial.
        J Am Coll Cardiol. 2016; 67: 2846-2854
        • Tsuyuki R.T.
        • Houle S.K.
        • Charrois T.L.
        • et al.
        Randomized trial of the effect of pharmacist prescribing on improving blood pressure in the community: the Alberta clinical trial in optimizing hypertension (RxACTION).
        Circulation. 2015; 132: 93-100
        • Tsuyuki R.T.
        • Rosenthal M.
        • Pearson G.J.
        A randomized trial of a community-based approach to dyslipidemia management pharmacist prescribing to achieve cholesterol targets (RxACT Study).
        Can Pharm J. 2016; 149: 283-292
        • Manns B.
        • Tonelli M.
        • Culleton B.
        • et al.
        A cluster randomized trial of an enhanced eGFR prompt in chronic kidney disease.
        Clin J Am Soc Nephrol. 2012; 7: 565-572
        • Mitra P.K.
        • Bradley J.R.
        Chronic kidney disease in primary care.
        J R Soc Med. 2007; 100: 40-45
        • Curtis C.
        • Balint C.
        • Al Hamarneh Y.N.
        • et al.
        Online clinical pathway for managing adults with chronic kidney disease.
        Can Pharm J. 2015; 148: 257-262
        • Leung A.A.
        • Nerenberg K.
        • Daskalopoulou S.S.
        • et al.
        Hypertension Canada’s 2016 Canadian Hypertension Education Program guidelines for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.
        Can J Cardiol. 2016; 32: 569-588
        • D’Agostino R.B.
        • Vasan R.S.
        • Pencina M.J.
        • et al.
        General cardiovascular risk profile for use in primary care: the Framingham Heart Study.
        Circulation. 2008; 117: 743-753
        • Stevens R.J.
        • Kothari V.
        • Adler A.I.
        • Stratton I.M.
        • Holman R.R.
        The UKPDS risk engine: a model for the risk of coronary heart disease in type 2 diabetes (UKPDS 56).
        Clin Sci. 2001; 101: 671-679
      1. Diabetes Trials Unit: University of Oxford. UKPDS risk engine. https://www.dtu.ox.ac.uk/riskengine/FAQ.php. Accessed May 1, 2017.

        • Wilson P.W.F.
        • D’Agostino R.
        • Bhatt D.L.
        • et al.
        An international model to predict recurrent cardiovascular disease.
        Am J Med. 2012; 125: 695-703
        • Tangri N.
        • Stevens L.A.
        • Griffith J.
        • et al.
        A predictive model for progression of chronic kidney disease to kidney failure.
        JAMA. 2011; 305 (The calculator can be found online at): 1553-1559
        • Grover S.A.
        • Lowensteyn I.
        • Joseph L.
        • et al.
        Patient knowledge of coronary risk profile improves the effectiveness of dyslipidemia therapy. The CHECK-UP Study: a randomized controlled trial.
        Arch Intern Med. 2007; 167: 2296-2303
        • Canadian Diabetes Association
        Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada.
        Can J Diabetes. 2013; 37: S1-S212
        • Hackam D.
        • Quinn R.
        • Ravani P.
        • et al.
        The 2013 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.
        Can J Cardiol. 2013; 29: 528-542
        • Genest J.
        • McPherson R.
        • Frohlich J.
        • et al.
        2009 Canadian guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adult–2009 recommendations.
        Can J Cardiol. 2009; 25: 567-579
        • Anderson T.J.
        • Grégoire J.
        • Hegele R.A.
        • et al.
        2012 Update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult.
        Can J Cardiol. 2013; 29: 151-167
        • Tobe S.
        • Stone J.
        • Brouwers M.
        • et al.
        Harmonization of guidelines for the prevention and treatment of cardiovascular disease: the C-CHANGE initiative.
        CMAJ. 2011; 183: E1135-E1150
        • Cooney D.
        • Moon H.
        • Liu Y.
        • et al.
        A pharmacist based intervention to improve the care of patients with CKD: a pragmatic, randomized, controlled trial.
        BMC Nephrol. 2015; 16: 56-65
        • Chang A.R.
        • Evans M.
        • Yule C.
        • et al.
        Using pharmacists to improve risk stratification and management of stage 3A chronic kidney disease: a feasibility study.
        BMC Nephrol. 2016; 17: 168-177
        • Aspinall S.L.
        • Cunningham F.E.
        • Zhao X.
        • et al.
        Impact of pharmacist-managed erythropoiesis-stimulating agents clinics for patients with non-dialysis-dependent CKD.
        Am J Kidney Dis. 2012; 60: 371-379
      2. KDIGO. KDIGO clinical practice guideline for lipid management in chronic kidney disease. http://www.kdigo.org/clinical_practice_guidelines/Lipids/KDIGO%20Lipid%20Management%20Guideline%202013.pdf. Accessed January 27, 2017.

        • Szczech L.A.
        • Stewart R.C.
        • Su H.L.
        • et al.
        Primary care detection of chronic kidney disease in adults with type-2 diabetes: the ADD-CKD Study (awareness, detection and drug therapy in type 2 diabetes and chronic kidney disease).
        PLoS One. 2014; 9: e110535
        • Donald M.
        • King-Shier K.
        • Tsuyuki R.T.
        • et al.
        Patient, family physician and community pharmacist perspectives on expanded pharmacy scope of practice: a qualitative study.
        CMAJ Open. 2017; 5: E205-E212
        • Marra C.
        • Johnston K.
        • Santschi V.
        • Tsuyuki R.T.
        Cost-effectiveness of pharmacist care for managing hypertension in Canada.
        Can Pharm J. 2017; 150: 184-197
      3. Centers for Disease Control and Prevention. Collaborative practice agreements and pharmacists’ patient care services: a resource for pharmacists. https://www.cdc.gov/dhdsp/pubs/docs/translational_tools_pharmacists.pdf. Accessed May 1, 2017.

      4. Canadian Pharmacists Association. Pharmacists’ expanded scope of practice in Canada. https://www.pharmacists.ca/pharmacy-in-canada/scope-of-practice-canada/. Accessed May 1, 2017.

      5. American Pharmacists Association. Pharmacist scope of services. https://www.pharmacist.com/sites/default/files/files/APhA%20%20PAPCC%20Scope%20of%20Services.pdf. Accessed May 1, 2017.