Medication Therapy Management after Hospitalization in CKD: A Randomized Clinical Trial

Abstract

Background and objectives: CKD is characterized by remarkably high hospitalization and readmission rates. Our study aim was to test a medication therapy management intervention to reduce subsequent acute care utilization.

Design, setting, participants, & measurements: The CKD Medication Intervention Trial was a single-blind (investigators), randomized clinical trial conducted at Providence Health Care in Spokane, Washington. Patients with CKD stages 3-5 not treated by dialysis who were hospitalized for acute illness were recruited. The intervention was designed to improve posthospitalization care by medication therapy management. A pharmacist delivered the intervention as a single home visit within 7 days of discharge. The intervention included these fundamental elements: comprehensive medication review, medication action plan, and a personal medication list. The primary outcome was a composite of acute care utilization (hospital readmissions and emergency department and urgent care visits) for 90 days after hospitalization.

Results: Baseline characteristics of participants (n=141) included the following: age, 69±11 (mean±SD) years old; women, 48% (67 of 141); diabetes, 56% (79 of 141); hypertension, 83% (117 of 141); eGFR, 41±14 ml/min per 1.73 m² (serum creatinine-based Chronic Kidney Disease Epidemiology Collaboration equation); and urine albumin-to-creatinine ratio median, 43 mg/g (interquartile range, 8-528) creatinine. The most common primary diagnoses for hospitalization were the following: cardiovascular events, 36% (51 of 141); infections, 18% (26 of 141); and kidney diseases, 12% (17 of 141). The primary outcome occurred in 32 of 72 (44%) of the medication intervention group and 28 of 69 (41%) of those in usual care (log rank P=0.72). For only hospital readmission, the rate was 19 of 72 (26%) in the medication intervention group and 18 of 69 (26%) in the usual care group (log rank P=0.95). There was no between-group difference in achievement of guideline-based goals for use of renin-angiotensin system inhibition or for BP, hemoglobin, phosphorus, or parathyroid hormone.

Conclusions: Acute care utilization after hospitalization was not reduced by a pharmacist-led medication therapy management intervention at the transition from hospital to home.

Keywords: Acute illness; Chronic; Hospital readmission; Humans; Medication Adherence; Medication Therapy Management; Medication management; Renal Insufficiency; Transitional care; chronic kidney disease; hospitalization.

Graphical abstract

Figure 1.

Consolidated Standards of Reporting Trials (CONSORT) diagram. Study participant flow in the CKD Medication Intervention Trial.

Figure 2.

Survival free of the primary outcome, a composite of first acute care events, did not differ between the intervention group and the usual care group within the 90-day period after index hospitalization. Kaplan-Meier survival curves for time to first hospitalization, emergency department visit, or urgent care center visit. Solid lines are for the intervention group; dashed lines are for the usual care group.

Figure 3.

Survival free of the secondary outcomes did not differ between the intervention group and the usual care group within the 90-day period after index hospitalization. Kaplan-Meier survival curves for time to first: (A) Hospitalization; (B) Emergency department or urgent care visit. Solid lines are for the intervention group; dashed lines are for the usual care group.