Clinical Pharmacist Intervention in Cardiac Patients With Renal Impairment Elham Al-Shammari, B.Sc. Pharm . Hisham Abou-Auda, Ph. D . Meshal Al-Mutairi, Pharm. D . Supervised by
Dec 20, 2015
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