Clinical Pharmacist Intervention in Cardiac

Patients With Renal Impairment

Clinical Pharmacist Intervention in Cardiac

Patients With Renal Impairment

Elham Al-Shammari, B.Sc. Pharm.Elham Al-Shammari ,B.Sc. Pharm.

Hisham Abou-Auda, Ph. D.Hisham Abou-Auda, Ph. D.

Meshal Al-Mutairi, Pharm. D.Meshal Al-Mutairi, Pharm. D.

Supervised bySupervised by

Having clinical pharmacist during physician rounds will decrease preventable adverse drug events especially in intensive care unit.

Adverse drug events were the sixth leading cause of death in USA in 1994 with 10.9% of all hospital patients.

IntroductionIntroduction

Pharmacists working beside the dispensing windows miss the opportunity to assist physicians in rational prescribing.

Addressing medical errors is one strategy to improve safety of medication

For every $1 invested in clinical pharmacy services, $4 in benefit is expected

IntroductionIntroduction

$45.6 billion in direct health care costs would be avoided even when this kind of service led to 4-fold increase in fee association.

A review of the economic benefit of clinical pharmacy services through 59 articles published between 1996 to 2000 performed by Center for Pharmacoeconomics Research and Department of Pharmacy Practice, University of Illinois at Chicago, USA

IntroductionIntroduction

Evaluate the role of clinical pharmacist in dosage adjustment in patients with renal impairmentEvaluate the role of clinical pharmacist in dosage adjustment in patients with renal impairment

ObjectivesObjectives

Through clinical observation, patients with cardiac problems were in high risk to develop renal impairment.Therefore, this study was conducted to:

Assess the cost impact of clinical pharmacist’s intervention.Assess the cost impact of clinical pharmacist’s intervention.

Prince Sultan Cardiac Center in Riyadh.

160 full-capacity beds5,304 admissions / year.

Patients with cardiac problems.

Scheduled procedures and also serves outpatient and emergency clinics.

Prince Sultan Cardiac Center in Riyadh.

160 full-capacity beds5,304 admissions / year.

Patients with cardiac problems.

Scheduled procedures and also serves outpatient and emergency clinics.

Study SettingStudy Setting

MethodologyMethodology

Study DesignStudy DesignProspective, observational and interventional study.

Five days a week for four weeks during July 2004.

Approved by the P&T Committee to be provided by PSCC Pharmacy Department.

Prospective, observational and interventional study.

Five days a week for four weeks during July 2004.

Approved by the P&T Committee to be provided by PSCC Pharmacy Department.

MethodologyMethodology

Institutional Board Review was obtained.Institutional Board Review was obtained.

The study was also approved by the Ethical Committee in PSCC.The study was also approved by the Ethical Committee in PSCC.

The study was conducted according to Helsinki Declaration and the safety of all patients was insured.

The study was conducted according to Helsinki Declaration and the safety of all patients was insured.

Ceftazidime, Cefuroxime,

Ciprofloxacin,

Digoxin,

Piperacillin/tazobactam (tazosin),

Ranitidine.

(extensive use & high acquisition cost).

Ceftazidime, Cefuroxime,

Ciprofloxacin,

Digoxin,

Piperacillin/tazobactam (tazosin),

Ranitidine.

(extensive use & high acquisition cost).

MethodologyMethodology

Drugs to be Monitored:

Identify patients receiving these drugs on daily basis ,

Review their demographic data andassess laboratory findings .

Recommended appropriate dosingadjustment according to renal function.

Identify patients receiving these drugson daily basis ,

Review their demographic data and assess laboratory findings .

Recommended appropriate dosing adjustment according to renal function.

Intervention Protocol:Intervention Protocol:MethodologyMethodology

Inclusion and Exclusion Criteria

Inclusion and Exclusion Criteria

All hospitalized cardiac patients 18 years of age or older.

Receiving one or more of the study medications.

All hospitalized cardiac patients 18 years of age or older.

Receiving one or more of the study medications.

MethodologyMethodology

Outcome MeasuresOutcome Measures

MethodologyMethodology

Ethical considerations.

Clinical outcome.

Cost avoidance will be determined by calculating the difference between the costs of the original and adjusted regimens.

Ethical considerations.

Clinical outcome.

Cost avoidance will be determined by calculating the difference between the costs of the original and adjusted regimens.

Data CollectionData Collection

Demographic data.

Lab findings:

Scr, drug levels, BUN, etc.

Diagnosis and underlying disease (e.g. CHF).

Demographic data.

Lab findings:

Scr, drug levels, BUN, etc.

Diagnosis and underlying disease (e.g. CHF).

MethodologyMethodology

Cockcroft and Gault equationCockcroft and Gault equation

Data Collection, cont’Data Collection, cont’

MethodologyMethodology

Female; 85%

[140 – age ]W

72 Scr

CLcr ( Males) =

Data Collection, cont’Data Collection, cont’

MethodologyMethodology

Jellife methodJellife method

CLcr = 98 – 0.8 (age – 20)

Scr

Female; 90%

Appropriate dose adjustment when needed.

Calculation of cost avoidance and extrapolation of the results to one year.

Appropriate dose adjustment when needed.

Calculation of cost avoidance and extrapolation of the results to one year.

MethodologyMethodology

Data Collection, cont’Data Collection, cont’

Statistical AnalysisStatistical Analysis

MethodologyMethodology

SPSS version 13.0

Frequencies

Condescriptives

Parametric or Nonparametric tests.

MaleMale FemaleFemale

AgeAge

WW

IBWIBW

HtHt

52.9 ± 15(N = 45)

52.9 ± 15(N = 45)

52 ± 15(N = 42)

52 ± 15(N = 42)

p (sig.)p (sig.)

0.773 )NS(

0.773 )NS(

44 ± 17(N = 44)44 ± 17(N = 44)

63.2 ± 12.6(N = 42)

63.2 ± 12.6(N = 42)

0.001(S)

0.001(S)

63.5 ± 5.6(N = 42)

63.5 ± 5.6(N = 42)

64.3 ± 98.3(N = 39)

64.3 ± 98.3(N = 39)

0.959(NS)0.959(NS)

77.5 ± 35(N = 43)

77.5 ± 35(N = 43)

79.5 ± 38.5(N = 38)

79.5 ± 38.5(N = 38)

0.839(NS)0.839(NS)

CHFCHF

ICUICU27.6% 27.6%

72.4% 72.4%

42.5

% 4

2.5

%

57.5

% 57.5

%

CL

Cr

(m

l/m

in)

CL

Cr

(m

l/m

in)

0

20

40

60

80

100

120

020

40

60 8010 30 50 70

Ejection fraction)%( Ejection fraction)%(

r = 0.374, p = 0.002r = 0.374, p = 0.002

CLCr=35.23 + 0.605 (Ejection Fraction)

p<0.0001

00

2040

60

80100120140160

100 200 300 400

CR

CL

(m

l/m

in)

SCR (umol/L)

p < 0.0001

010

20

30

40

50

60

70

80

9020 40 60 80

100120140160

CR

CL

(m

l/m

in)

AGE

35.6%5.7%

28.7%

29.9%

Normal

Mild

Moderate

Severe

Renal Impairment CategoriesRenal Impairment Categories

Renal Impairment CategoriesRenal Impairment Categories

Dose Adjustment13.8 %

2.3%

34.5%

3.4%

44.8%

23%

63.2%

Drugs InvolvedDrugs Involved

287,609287,609

384,358384,358

Min. savingMin. saving

Max. savingMax. saving

869.59869.59

650.66650.66

During studyDuring study Annual savingAnnual saving

Digoxin CL = CLcr + 20Without CHF

Digoxin CL = CLcr + 40With CHF

200

100

100

200

300

12040 60 80CRCL (ml/min)

Dig

oxi

n C

L (

ob

serv

ed)

p = 0.878

p = 0.256

Dig

oxi

n C

L (

ob

serv

ed)

Digoxin CL (predicted)

40 60 80

100

100 120 140 1600

200

300

Equations for predicting Digoxin CL cannot be applied to our population ?

Future investigation ?

Saving lives, reducing adverse events

Pharmacist intervention can save between SR 287,609 and SR 384,358

Equations for predicting Digoxin CL cannot be applied to our population ?

Future investigation ?

Saving lives, reducing adverse events

Pharmacist intervention can save between SR 287,609 and SR 384,358

Discussion & conclusionDiscussion & conclusion

Role of pharmacist:

prescription monitoring,

reduction in length of hospital

stays,

incidence of adverse drug

reactions

total cost.

Discussion & conclusionDiscussion & conclusion