Patients with end-stage renal disease being treated with maintenance hemodialysis are medically complex and commonly have multiple comorbid conditions that require on average 10 to 12 medications. Individuals in that patient population experience nearly two hospitalizations per year, with 35% resulting in readmission. Medication changes are common during transitions of care and may result in patient confusion related to which medications to continue, stop, or modify.
In the general population, 20% of adults experience an adverse event following hospitalization discharge, and 21% of 30-day readmissions are medication related; 69% of those readmissions are preventable. Results of studies among the general population suggest that multidisciplinary medication therapy management (MTM) services involving pharmacists and nurses for discharge planning, medication reconciliation, and postdischarge follow-up reduce rehospitalization. There are few data on the impact of such services in the dialysis population.
Harold J. Manley, PharmD, and colleagues conducted a retrospective observational cohort study designed to examine the association of a multidisciplinary MTM program with 30-day readmission rates among patients receiving maintenance hemodialysis. Results were reported in the American Journal of Kidney Diseases [2020;76(1):13021].
The study cohort included patients on maintenance dialysis discharged to home from acute-care hospitals between May 1, 2016, and April 30, 2017, who returned to End-Stage Renal Disease Seamless Care Organization (ESCOs) dialysis clinics after discharge. In the Centers for Medicare & Medicaid Services Innovation Comprehensive End-Stage Renal Disease Care Model, ESCOs are incentivized to provide coordinated comprehensive care by making stakeholders responsible for hospitalization costs. ESCO quality measures include hospital readmission rates and medication reconciliation postdischarge. Dialysis Clinic, Inc-affiliated ESCOs (DCI-ESCO) developed and implemented a multidisciplinary MTM intervention. The study assessed the effect of the program on 30-day readmission rates.
The study included 27 dialysis clinics across four states (New Jersey, New York, Tennessee, and South Carolina). During the study period, there were 1732 hospital discharges to home: 51% (n=373) had one discharge; 25% (n=181) had two discharges; 11% (n=82) had three discharges; and 12% (n=90) had four or more discharges. Following application of exclusion criteria, 84% of the total discharges (n=1452 in 726 patients) were included in the analyses.
Three DCI-ESCOs contributed 32.9%, 38.8%, and 28.2% of unique patients. Overall, 60% (n=866) of discharges received some level of medication reconciliation. In 41% of discharges (n=595), pharmacist review was provided, and in 34% (n=492) nephrologist review of pharmacist recommendation(s) was provided.
Of the 866 discharges with some level of medication reconciliation, 47% (n=409) had 100% medications reconciled, 31% (n=269) had pharmacist review, and 19% (n=162) had both pharmacist review and nephrologist review of the recommendations within 30 days of discharge. Various combinations of MTM process steps and the timeliness of implementation resulted in full or partial MTM services in 11% (n=162) and 48% (n=704) of the total 1452 discharges included in the analysis, respectively.
Full MTM discharge was defined as completion within 30 days after discharge. Of the 162 full MTM discharges, the mean time to completion of the process was 12 days, including 4 days for nurse medication reconciliation, 2 days for pharmacist medication review and sending recommendations to a nephrologist, and 6 days for nephrologist review, sign off, and return of the action plan.
Mean age of the patients in the analysis cohort was 64 years and 56% had diabetes. Patients experienced a mean of two discharges, each with a mean length of stay of 7 days. At 30 days postdischarge, the number and type of discharge diagnoses were similar among MTM groups. Analysis of facility-level impact demonstrated that for every 0.1 greater facility standardized hospitalization rate, hospitalization rate was greater by 8% (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.00-1.17).
The analysis identified 5466 potential medication-related problems. The top three potential medication-related problems were issues regarding dosing (31%, n=1697), including dose too high for 22% (n=1202) and dose too low for 9% (n=495); real or potential adverse drug reaction (29%, n=1570); and unnecessary drug therapy (17%, n=928).
The top four medication classes were cardiovascular (18%, n=980), gastrointestinal (15%, n=825), analgesic (12%, n=635), and endocrine and metabolic drugs (10%, n=553). Those top four classes accounted for 55% of pharmacist recommendations. Within each medication class, calcium channel blockers (n=145), proton pump inhibitors (n=149), insulins (n=250), and salicylates (n=165) were associated with most potential problems related to medications.
Percentages of 30-day readmissions among full-, partial-, and no-MTM patients were 11% (n=17), 19% (n=135), and 29% (n=170), respectively (P<.001). During the follow-up period, there were 323 readmissions of the 1452 discharges (22%); the majority of those occurred 15 to 21 days after discharge. Compared with patients in the no-MTM group, those in the full- and partial-MTM groups had fewer readmissions within 30-days after discharge. Patients in the full-MTM group had the lowest risk of 30-day readmission (HR, 0.26; 95% CI, 0.15-0.45).
The risk of 30-day readmission was also lower among patients in the partial-MTM group compared with those in the no-MTM group (HR, 0.50; 95% CI, 0.37-0.68). Within the partial-MTM group, 30-day readmission rates for discharges that received medication reconciliation only (47%, n=333) and medication reconciliation and pharmacist review (53%, n=371) were 17% and 21%, respectively (P=.09).
The authors cited some limitations to the study findings, including the retrospective observational design of the study, the inclusion of varied time frames with which patients received the MTM intervention, possible confounding by health status, and the possibility that results are not generalizable to the US dialysis population due to ESCO infrastructure for patient care that may exceed that in other dialysis facilities.
In conclusion, the researchers said, “Using a model of centralized clinical pharmacists with access to clinical data and documentation working in collaboration with local nurses and nephrologists to provide in-depth patient-specific medication reviews, our findings suggest a significant reduction in risk for 30-day readmission for patients receiving MTM. Randomized controlled studies evaluating different MTM delivery models and cost-effectiveness in dialysis populations are needed.”
- Researchers reported results of a retrospective cohort study designed to examine the association between multidisciplinary medication therapy management (MTM) and 30-day readmission rates among patients on maintenance dialysis.
- Thirty-day readmission rates among patients who received no MTM services, those who received partial MTM services, and those who received full MTM services were 29%, 19%, and 11%, respectively.
- Compared with patients with no MTM, those with full MTM had the lowest time-varying risk for readmission within 30 days of discharge.