The Life-Changing Magic of Tidying Up the Medication List

Dialysis patients almost invariably contend with multiple comorbid conditions that lead to complex medication regimens prescribed by multiple physicians and providers. In addition, their lack of renal clearance complicates medication prescribing and increases the risk of medication side effects. The authors of this editorial can recount many examples of dialysis patients' experiences with sedating antihistamines being given for itch, potassium supplements being given by a primary care clinician alerted to a low potassium level drawn just after hemodialysis, or baclofen being prescribed by an urgent care clinician unaware of a patient's ESKD. In these and other cases, multiple factors contribute to this suboptimal prescribing. Tidying up the medication list by deprescribing can be life-changing, but it is also an ongoing and time-intensive task.

In this issue of CJASN, Hall and colleagues¹ report the findings of a qualitative study that assesses perspectives on deprescribing from patients, primary care physicians, nephrologists, and pharmacists. The study gives insights into four challenges, from high-level systems and roles (challenges ascertaining a medication list or conflicts over ownership of the deprescribing task) to individual knowledge and preferences (is a particular medication unsafe, or might symptomatic benefits outweigh risks of a potentially harmful medication?). These findings suggest that any future intervention to operationalize a deprescribing plan would have to be multipronged, multidisciplinary, and iterative because patients receiving dialysis receive new prescription medications from multiple sources over time.

This important study adds rich qualitative observations to an existing body of evidence that demonstrates the overwhelming complexity of a typical dialysis patient's medication regimen with a mean of 6.8 (SD 3.6) medications,² the challenges that clinicians face as comanagers of a regimen they only partially control, and the weighing of risks and benefits that patients undertake as they prioritize among many competing issues.³

The typical medication list is more a hoarder's paradise than a Marie Kondo dream home, thanks, in part, to our disjointed systems of care. In many cases, primary care, urgent care, emergency department, specialist, and hospitalist physicians, as well as pharmacies, use different electronic medical record (EMR) systems than those used to document dialysis care. Although there has been some progress made to share data between EMRs and pharmacy benefit managers, and some attempts to integrate primary care and ESKD care,⁴ these are far from commonplace. As a first step of deprescribing, one needs to have an accurate list of medications that a patient is currently taking. The Centers for Medicare & Medicaid Services moved to promote this by adding a reporting metric for monthly medication reconciliation to the End-Stage Renal Disease Quality Incentive Program. While this is a good initial step, the medication reconciliation in most dialysis units is performed by nurses who have many other responsibilities and often do not have sufficient dedicated time or training to perform a comprehensive and accurate medication reconciliation. This is further exacerbated not only by a lack of EMR interoperability but also by the complex and dynamic nature of medication regimens of patients with ESKD stemming from frequent hospitalizations and multiple specialist visits for comorbid conditions. In one study of geriatric inpatients (a population with multiple comorbidities comparable with patients with ESKD), a comprehensive medication review took an average of 68 minutes.⁵ Repeated monthly assessments would likely be faster but would still add a significant time burden for the staff that may include reviewing patients' hand-written medication lists and pill bottles; obtaining and reviewing records from multiple health systems; and making phone calls to family members, caretakers, and/or various clinics. In line with this complexity, a review of several studies of medication record discrepancies in dialysis patients demonstrated an average of 2–3 discrepancies per patient.⁶

Even if the medication reconciliation issues raised by participants in this study were to be fully addressed, there were still concerns from physicians about modifying medication regimens that they are not fully familiar with. There is a category of definitely inappropriate medications with clear side effects and contraindications in ESKD, which are easy to deprescribe. However, in other patients, a more nuanced approach needs to be used because the benefits of potentially inappropriate medications (PIMs) may outweigh the risks for certain patients, depending on their goals of care. In addition, without easily shared records and communication between clinicians, the rationale behind certain prescriptions may not be readily apparent, thus further impeding deprescribing efforts.

As with any qualitative study in a single system, the results in this study need to be considered in context; however, the international literature strongly suggests that polypharmacy and medication management issues are nearly universal for this population.⁷ More concerning here, from a generalizability perspective, is the list of PIMs the authors used as a starting point for discussion. This list includes medications we would consider never appropriate in kidney failure (baclofen) alongside medications that are routinely used, although not first line (clonidine). It seems that this list of PIMs is more relevant to older adults in general than to dialysis patients in particular. In fact, previous work by the authors demonstrated that different classes of PIMs had different implications for CKD.⁸ It would have been very helpful to know which medications patients, pharmacists, or physicians were referring to in their interviews, to develop a more tailored list for future work, because with limited resources at hand, we might need to focus on the agents with the highest potential for harm.

We agree with the authors that a comprehensive deprescribing program for dialysis patients should reduce fragmentation of care while incorporating shared decision making with patients and engaging the expertise of pharmacists. These ideas have broad implications for policymakers, payors, and clinical systems designers as we move toward value-based kidney care programs. Retrospective studies have illustrated potential benefits of clinical pharmacists in hemodialysis facilities, leading to cost savings⁹ and reduction in medication discrepancies and medication-related problems.¹⁰ However, pharmacists' involvement in US dialysis units is very limited because funding for their services is not included in current payment systems. In addition, to our knowledge, such funding is also not directly included in upcoming value-based dialysis payment models. Larger prospective studies are needed to further elucidate the role of pharmacists in improving outcomes for dialysis patients. At the University of California, San Diego, a hemodialysis pharmacist is funded through our outpatient pharmacy's medication to chair program that uses discounted 340b medication pricing. Our dialysis pharmacist performs medication reconciliations at least biannually and as transitions of care occur, while also providing guidelines and support for monthly medication reconciliations performed by nursing staff. If programs like this can be cost-effective and can lead to successful deprescribing, it may be possible to incorporate them into larger organizations.

For busy nephrologists, there is similarly little additional funding to cover the time commitment that a detailed medication review would require. Currently, transitional care management codes (99495 or 99496) may be used to bill for posthospitalization care management (including a medication reconciliation) in addition to the ESRD monthly capitation payment. However, no such codes exist for routine medication reconciliation and assessment for deprescribing opportunities. We envision that future systems will likely rely on an interdisciplinary approach in which dialysis nurses and pharmacists will perform routine medication reconciliations and provide suggestions to nephrologists about potentially and definitely inappropriate medications (perhaps with the assistance of clinical decision support tools). Nephrologists will then review these recommendations, investigate patients' goals and preferences, communicate with patients' other clinicians when necessary, and determine a collaborative plan for deprescribing. Interoperability of EMR systems and easy-to-use messaging systems between physicians would further facilitate these efforts. Ultimately, nephrologists are in a unique position to have these deprescribing discussions with their patients on the basis of both their expertise in the effects of kidney failure on medication dosing and the strong relationships that they develop with their patients, whom they typically see more frequently than other specialists and primary care providers. The task of tidying up patients' medication lists has the potential to reap many benefits, and it will be most successful if our health care systems and payors find ways to reward and facilitate this valuable yet difficult task.

Disclosures

T. Beben reports research funding from Hydrostasis and honoraria from Cricket Health. The remaining author has nothing to disclose.

Funding

None.

Author Contributions

Writing – original draft: Tomasz Beben, Dena E. Rifkin.

Writing – review & editing: Tomasz Beben, Dena E. Rifkin.