Development of a Theory-Informed Behavior Change Intervention to Reduce Inappropriate Prescribing of Nephrotoxins and Renally Eliminated Drugs

Abstract

Background:

Goals of managing patients with acute kidney injury (AKI) are mitigating disease progression and ensuring safety while providing supportive care because no effective treatment exists. One strategy recommended in guidelines to meet these goals is optimizing medication management. Unfortunately, guideline implementation appears to be lacking as observed by the frequent occurrence of medication errors and adverse drug events.

Objective:

To address this performance gap in the care of hospitalized patients receiving nephrotoxins and renally eliminated drugs, we sought to provide a potential intervention based on theory-informed behavior change.

Methods:

Formative research with a qualitative analysis identifying what needs to change in patient care was completed by obtaining clinician opinion and expert opinion and reviewing the published literature. Frontline providers, including 8 physicians, 4 pharmacists, and a multiprofessional group of authors, provided insight into possible barriers to appropriate prescribing. Capability, Opportunity, Motivation and Behavior model and Theoretical Domain Framework were applied to characterize behavior change interventions and inform a potential implementation intervention for changing inappropriate prescribing behaviors.

Results:

Lack of knowledge about appropriate drug management in patients at risk for adverse outcomes was provided as a major barrier. Other reported barriers included a lack of: (1) tools to assist with drug management, (2) motivation to make changes, (3) routinization, and (4) an accountable clinician.

Conclusions and Relevance:

Assigning a designated clinician to execute a stepwise, routine care process following the checklist provided is a recommended intervention to overcome barriers. The intended impact is behavior change that reduces inappropriate prescribing.

Introduction

Acute kidney injury (AKI) affects up to 20% of hospitalized patients.^1,2 Problems that patients with AKI encounter include kidney disease progression and compromised patient safety from complex medication regimens. Disease progression from AKI to chronic kidney disease (CKD) occurs in 30% of patients.³ One modifiable exposure to reduce disease progression is appropriate management of nephrotoxins for patients with unstable kidney function or rapidly changing serum creatinine.^4,5 Patient safety concerns in patients with kidney disease include mismanagement of nephrotoxins and renally cleared drugs. Remarkably, one-third of potential adverse drug events (ADEs) in patients with AKI are a result of the continuation of a contraindicated nephrotoxin.⁶ Also, ADEs result from inappropriate dosing of renally eliminated drugs. Medication orders are dosed excessively for 19% to 67% of patients with kidney disease.⁷ Underdosing of medications in patients with recovering kidney function is also a concern because of the potential for therapeutic failure.⁸

Because no specific therapy exists, the goals of managing patients with AKI are mitigating kidney disease progression and ensuring patient safety while providing supportive care. These goals are reinforced in recommendations provided by various guidelines (Table 1).^9–11 Unfortunately, although recommendations for improving medication management in patients with kidney disease exist, guideline implementation appears to be lacking as observed by the frequent occurrence of medication errors and ADEs.^5–7

Table 1.

Recommendations Provided by International Guidelines for Nephrotoxin and Renally Eliminated Drug Management.

Guideline	Recommendations for patient care
National Institute for Health and Care Excellence Guidelines9	Seek advice from a pharmacist about optimizing medicines and drug dosing in people with, or at risk of, AKIa
Kidney Disease Improving Global Outcomes10	Apply a patient-centered team approach that includes a pharmacist to prevent medication-related problems and enhance safe and effective medication use
Acute Dialysis Quality Initiative11	Appropriate medication management of patients following an episode of AKI during the time of AKDb include the following:
	(a) medication reconciliation at intensive care unit/hospital admission and discharge
	(b) medication regimen assessments at AKD diagnosis and change in AKD stage (ie, unstable kidney function); and
	(c) reassessment when patient condition changes

Abbreviations: AKD, acute kidney disease; AKI, acute kidney injury.

^aAKI is defined as “an abrupt decrease in kidney function occurring over 7 days or less.”³

^bAKD refers to the ongoing pathophysiological processes occurring after the course of AKI disease.³

To address this performance gap in care for hospitalized patients receiving nephrotoxins and renally eliminated drugs, we sought to characterize the barriers and facilitators that underlie the inappropriate prescribing behaviors (ie, medication errors) in patients with AKI (de novo or AKI on CKD) and/or unstable kidney function and provide a perspective on an intervention using theory-informed behavior change. Theoretical frameworks are utilized in the social sciences to understand and interpret behavior change. We selected 2 conceptual models to approach the interpretation of prescribing behaviors for patients. The first model used was the Theoretical Domain Framework (TDF) to explain the determinants (barriers, facilitators) of the current and desired behavior that will support a newly proposed intervention.^12–14 The second model was the Capability, Opportunity, Motivation and Behavior (COM-B) model, a part of the Behavior Change Wheel (BCW). This approach is very common when evaluating approaches to change health care professionals’ behavior. We sought to provide a pragmatic perspective by providing a proposed intervention on how to overcome the practice barriers we identified using theoretical models founded in behavioral change techniques for improving prescribing behavior in patients with AKI and unstable kidney function.

Methods

Model Used

COM-B model and TDF were the formative evaluation to designing a potential intervention for changing inappropriate prescribing behaviors.¹⁵ TDF was selected because of its comprehensive representation of 33 behavior change models that were finalized by consensus, resulting in 14 applicable domains such as memory, social influences, and reinforcements.¹³ An example connecting barriers to domain is the lack of knowledge or skill is a barrier, and in this case, the associated domain is knowledge. The COM-B/BCW model complements TDF and is used to categorize and map behavior determinants to techniques to change behaviors for the purpose of implementing a successful behavior-targeted intervention.^12,15 Returning to the previous example of a lack of knowledge or skill, this is a psychological capability per the COM-B model, and an intervention function is providing education to overcome the barrier that is delivered using the technique of providing information about a health consequence, or the technique could be a prompt to the provider at the time the knowledge or skill will be used. This approach to combining COM-B and TDF in the BCW was designed by Michie et al¹⁵ and involved an 8-step process including the following:

1. Defining the behavioral problem

2. Selecting the target behavior

3. Specify the target behavior

4. Identify what needs to change

5. Identify intervention functions

6. Identify the policy categories

7. Identify behavior change techniques

8. Identify the mode of delivery

Steps 1 to 4 pertain to understanding the behavior, steps 5 to 6 identify the intervention options, and steps 7 to 8 guide the decision for intervention options.

Behavior for Change: Steps 1 to 3

For steps 1 to 3, as described in the introduction, medication errors in hospitalized patients with AKI and unstable kidney function are a significant problem, and we are targeting inappropriate prescribing as a behavior change. Appendix 1 (available online) provides examples of the behavioral determinants from TDF and the behavior change functions/techniques from COM-B that are used for steps 4, 5, and 7.

Understanding the Behavior: What Needs to Change (Step 4)

We identified what needs to change in patient care by obtaining frontline clinician opinion/stakeholders (n = 12), obtaining expert opinion (n = 4), and reviewing published literature.¹⁵ We solicited input via email with a Microsoft forms link from the following 12 stakeholders (8 physicians, including nephrologists, hospitalists, internists, and intensivists plus 4 pharmacists) using a qualitative survey conducted as a quality improvement project with appropriate institutional approval from the Quality Review Committee. Clinician respondents were selected from a convenient sample of frontline workers from a single academic tertiary care hospital. Questions (n = 6) were open-ended and directed at care during hospitalization (Appendix 2, available online). This unstructured approach was applied so that answers were unanticipated and insight was not overlooked. Stakeholders were asked to summarize barriers to appropriate medication prescribing in patients with unstable kidney function. Moreover, individuals were asked to describe factors to facilitate improved medication management. Two questions were asked to assess barriers and facilitators to appropriate prescribing at hospital discharge for patients with persistently unstable kidney function. Unstable kidney function was described to the survey participants as fluctuating serum creatinine or kidney function improving or declining rapidly. After survey completion, the stakeholders’ responses were coded by categorizing the barriers to change and then relating the barriers to theoretical domains and COM-B components.

To ensure that no major barriers were missed, we completed a literature search using PubMed to identify reasons for medication prescribing errors. The search terms used were acute kidney injury OR acute renal failure AND medication errors (n = 88 articles). Also, a search was conducted for systematic reviews (n = 148) that described general reasons/causes for prescribing errors (n = 48), not necessarily kidney disease specific. The goal was to be comprehensive in identifying determinants; thus, concepts from the general medication safety literature were applicable.

Finally, opinions of the multiprofessional expert group of authors (n = 4, including an intensivist, a nephrologist, and pharmacists experienced in medication safety) reviewed the aggregated list of barriers for scope and completeness. The experts were added to the list based on consideration of the COM-B model and TDF from the BCW. To reemphasize, the components of the COM-B model include physical and psychological capability, reflective and automatic motivation, and social and physical opportunity. TDF consists of 14 domains: knowledge, skills, memory/attention and decision processes, behavioral regulation, social/professional role and identity, beliefs about capabilities, optimism, beliefs about consequences, intentions, goals, reinforcement, emotion, social influences, and environmental contexts and resources.¹⁶ The final list of barriers representing what needs to change was unanimously agreed upon by the experts.

Intervention Options: Identification of Intervention Function and Policy Change (Steps 5 and 6)

Subsequently, we mapped “what needs to change” to 1 of the 9 intervention functions, which included education, persuasion, training, restriction, incentivization, coercion, enablement, modeling, and environmental restructuring.¹⁶ These intervention functions are possible behavior changes for an individual person. The summary of what needs to change was also plotted to the supporting policy changes needed at the institutional level. Seven policy changes were considered, including communication/marketing, guideline, fiscal measures, regulation, legislation, environmental/social planning, and service provision.¹⁶

Behavior Change Techniques (Step 7)

We linked the intervention function and policy changes to behavior change techniques. A behavior change technique is the precise proposed mechanism for making change in clinical practice. Behavior changes are “an active component of an intervention designed to change behavior.”¹⁵ There are 93 possible behavior change labels (see Appendix 1) within 16 groupings consisting of goals and planning, feedback and monitoring, social support, shaping knowledge, natural consequences, comparison of behavior, associations, repetition and substitution, comparison of outcomes, reward and threat, regulation, antecedents, identity, scheduled consequences, self-belief, and covert learning.¹⁶

Mode of Delivery (Step 8)

The mode of delivery for the intervention evaluates what should be delivered, who should deliver it, and in what setting. There could be additional considerations with intensity, duration, and fidelity; however, this was not included because it depends on the institution and should be evaluated further at the time of implementation.

Proposing an Intervention for Implementation in Response to Steps 1 to 8

Consistent with our goal on how to overcome the practice barriers we identified using theoretical models founded in behavioral change techniques, we then applied the acceptability, practicality, effectiveness, affordability, safety, and equity (APEASE) criteria to make context-based decisions on a pragmatic intervention.¹⁶ The APEASE criteria were originally developed and intended for the design and evaluation of interventions. So using the information from the intervention functions and policy change, specific clinical practice interventions were proposed by the authors in alignment with the APEASE criteria.¹⁶

Results

Barriers to guideline implementation for optimal prescribing of renally eliminated and nephrotoxic drugs is provided in Table 2. The COM-B components for changes in behavior included psychological capability, physical opportunity, social opportunity, reflective motivation, and automatic motivation. First-person quotes of the qualitative analysis from respondents related to the COM-B components, and specific domains from the TDF are provided in Table 2. A total of 8 of the 14 possible domains from TDF were applicable from the results of the questionnaire. Psychological barriers are linked to the theoretical domain of knowledge or, in this case, lack thereof. Lack of knowledge about appropriate drug management in patients at risk for adverse outcomes was a major concern provided by stakeholders. Other reported barriers include lack of tools to assist with drug management, lack of motivation to make a change in patient care, lack of routinization, and lack of an accountable clinician.

Table 2.

Categorizing Barriers to Appropriate Medication Management for Patients With Unstable Kidney Function Using the COM-B Model and Theoretical Domain Framework.

COM-B component	Domain	Barriers to changea	Examples of participant responses and supportive data from the literature
Psychological capability	Knowledge	Knowledge about the benefits of appropriate dosing (fewer adverse drug events and hospitalizations)	“Lack of knowledge by prescribers about need to dose adjust”
		Knowledge and skills to determine there is a dosing error	“Unfamiliarity with renal dosing of medications both which ones require it and how to do it.”
		Knowledge of the benefits of avoiding nephrotoxins in a patient with AKI or at risk for developing AKI (prevent AKI or mitigate AKI severity)	Need “education to both providers and pharmacists regarding medications most significantly affected in AKI”b
		Knowledge and skills to determine a patient who is at risk for developing AKI with the addition of a nephrotoxin	Need “prediction scores/scales that a healthcare professional might quickly use to calculate AKI risk in a patient prior to an intervention”
			“Greater understanding of who is at high risk for AKI if there are criteria. I personally was/ am not aware of what constitutes high risk features for AKI”
		Knowledge of calculations for estimating clearance (ie, CrCl or eGFR) in a patient with unstable kidney function	“Lack of knowledge of a patient’s true estimated baseline GFR” “Lack of clarity about definitions of unstable kidney function”
	Memory attention and decision processes	Competing priorities in patient care so attention is on other activities	“Miss medications/dose adjustments for complex patients with a long list of medications on a busy service”
			“Patient loads are very high and calculating dose changes is easy to forget when managing 25 patients each on large numbers of medications”
			“Forgetting to re-adjust medications as renal function improves”
		Clinician memory does not have the capacity to retain information on the number of drugs requiring dosage adjustment or number of nephrotoxic drugs	Need “development of an alert that fires when a nephrotoxic medication is ordered”
Physical opportunity	Environmental context and resources	Lack of clinical decision support for nephrotoxin burden assessment in a patient at risk for AKI or who has AKI/unstable kidney function	“More consideration into the combination of medications we are giving and their nephrotoxicity risks” “Consideration for effective point of care decision support in the ordering of medications in at-risk patients”
		Lack of effective clinical decision support for dosing errors (over- and underdosing)	“Poor linkage of EHR data to decision support and alert fatigue for poorly functioning decision support”
		Lack of automated approach for estimating kidney function in a patient with unstable serum creatinine	“No monitoring eGFR as AKI resolves”
		Appropriate drug information resources for dosing and nephrotoxicity information	“Find appropriate information for medications/dose changes in AKI”
		Lack of pharmacist	Need “implementation of pharmacists on care teams to assist with renal dosing adjustments, provide education related to medication use in fluctuating renal function, serve a resource to recommend alternative therapies that may not be (as) nephrotoxic”
			“Not having sufficient pharmacy support or guidance in appropriate prescribing”
			“Lack of pharmacy input”
			“Available resources to review discharge meds”
		Lack of complete clinical picture (ie, no serum creatinine)	“Creatinine may not be flagged in the computer”
			Monitor “changes in renal function on the day of discharge”
			“Incomplete information about patient prior medical and medication history”
		Lack of protocols/checklist for process-of-care management	“Discharge medications are incorrect because the primary team did not do a medication reconciliation”
			“Prediction scores/scales that a hc professional might quickly use to calculate AKI risk in a patient prior to an intervention”
			“No monitoring eGFR as AKI resolves”
			All previous statements in this section support the lack of protocol for medication management
Social opportunity	Social influences	Lack of prioritization by physician leaders, so this is not passed on to trainees Lack of prioritization by the patient or medical community	Added by expert opinion
Reflective motivation	Belief about capabilities	Lack of perceived control over changing the current process for patient care	“Lack of comfort.” Beliefs, attitudes were highlighted in a previous evaluation of barriers to managing potentially inappropriate medications53
	Belief about consequences	Belief that dosing errors are rare or inconsequential Belief that nephrotoxin-related AKI or AKI progression is rare or inconsequential
	Intentions	Thought that drug management was handled by others Devolve responsibility
Automatic motivation	Reinforcement	Lack of routine care process for patients with AKI or at risk for AKI	“There are no pharmacists that regularly review discharge medications before a patient goes home”
			“Dedicated pharmacist that rounds with us every day and they catch things that we miss,” but this is not available in all units or at discharge
			“Lack of pharmacy services during transitions of care”
		No report of how often medication errors occur	“Physicians need to know the frequency of the problem (how often are we actually making errors)”
		No report of resultant consequences of adverse drug events from medication errors	“Physicians need to know the magnitude of impact (what is the result to patients, costs, etc)”

Abbreviations: AKI, acute kidney injury; COM-B, Capability, Opportunity, Motivation and Behavior; CrCl, creatinine clearance; eGFR, estimated glomerular filtration rate; EHR, electronic health record; hc, health care.

^aObtained from frontline workers, the literature, and author expert opinion.

^bAKI is defined as “an abrupt decrease in kidney function occurring over 7 days or less.”³

Common reasons for medication errors and preventable ADEs summarized from the kidney disease literature were lack of adaptation of drug therapy during intercurrent illness,¹⁷ not following prescribing guidelines,¹⁸ lack of knowledge of specific drugs and drug combinations causing patient harm,¹⁹ lack of early AKI detection,⁴ lack of monitoring, and lack of clinical decision support.²⁰ Systematic reviews emphasized the need for factors related to the patient, medication, and the related interactions to be taken into account for effective prevention.²¹ The general medication safety literature consistently described a lack of drug knowledge and protocol nonadherence as reasons for errors.^22,23 The intervention functions we determined are provided in Table 3 and primarily involve education to overcome the knowledge barriers and environmental restructuring to prompt the clinician to evoke change.^4,24–36 Broader policy categories were also considered to provide support from an institutional perspective. Providing information about consequences, prompts/cues, and restructuring the environment were the primary approaches proposed in Table 3 for behavior change techniques. We identified 7 behavior change techniques as possible interventions out of the 93 options. The link between the behavior change technique and the TDF is primarily directed at knowledge, environmental context/resources, reinforcement, and to a lesser extent social influence.

Table 3.

Mapping Barriers or “What needs to Change” to the Intervention Function and Behavior Change Techniques With Specific Recommendations for Kidney Disease Management.

Potential barrier/lack of	Intervention function	Policy category	Behavior change technique	Intervention with consideration of APEASE criteria
Knowledge about nephrotoxicity of a drug	Education	Guidelines	Information about the health consequences Prompts/cues	Education on a standardized list of nephrotoxins to avoid, if possible, and consequences in patients at risk for AKI or those who have AKI.24 Use the list for clinical decision support
Knowledge about appropriate dosing of renally eliminated drugs (over- and underdosing)	Education Enablement	Guidelines	Information about the health consequences Prompts/cues	Education on a standardized list of renally eliminated drugs to dose appropriately based on kidney function and consequences.25 Use the list for clinical decision support26
Time to thoroughly assess medication regimens	Environmental restructuring Restriction	Environmental planning Regulation	Adding an object/person to the environment Restructuring the physical environment	With environmental planning, a pharmacist is assigned to evaluating patients at high risk for AKI and unstable kidney function to perform a medication review. Assigning a pharmacist provides accountability and a commitment to overcoming competing priorities. This will address the concern for remembering to perform this activity.
				Pharmacist reduces medication errors when participating in care for patients with kidney disease.4,27,28 This is an activity that is in the skill set of the pharmacist making overcoming psychological capability and making this activity practical. Focusing the intervention on high-risk patients and those with unstable kidney function contributes to practicality
Protocol for management and lack of information for clinical picture	Environmental restructuring	Guidelines	Restructuring the physical environment	Include in the checklist kidney function monitoring when necessary and actionable to ensure safety.29,30 Encourage monitoring by choosing wisely.32 This provides more information on the clinical picture. Checking kidney function in patients at risk for AKI is effective and improves patient outcomes4
Knowledge of information necessary for appropriate drug dosing selection	Education and training		Information about the health consequences Demonstration of behavior Feedback on behavior	Educate the pharmacist and train the pharmacist on the standardized lists. The pharmacist will educate the provider when making dosing recommendations on rounds or telecommunication for a longer-lasting effect that may influence decisions in other patients
Knowledge of risk assessment for high-risk patients	Education and training		Information about the health consequences Demonstration of behavior Feedback on behavior	Educate the pharmacist and train the pharmacist on risk assessment. The pharmacist will educate the provider and patient care team during rounds and/or when making recommendations
Tools for estimating kidney function and lack of information for clinical picture	Environmental restructuring		Adding an object to the environment	Automated information providing eGFR in electronic health record because of improvement in patient care.31 This provides more information on the clinical picture Provide automated tools for calculation of Cockcroft-Gault, CKD-EPI and kinetic eGFR calculations in electronic health record for clinicians and the assigned pharmacist to use. Use the knowledge of the standardized list of renally eliminated drugs to dose appropriately based on kidney function
Tools for appropriate medication management	Environmental restructuring Enablement	Guidelines	Restructuring the physical environment with antecedents Prompts/cues	An automated or manual alert sent to the pharmacist to stimulate a stepwise routine process for patient care. Alerts would include warnings for nephrotoxin burden and under- and overdosing based on kidney function. Alerts have been used frequently to assist successfully with medication dosing adjustments in patients with kidney disease and reduce nephrotoxin exposure.33–35 It is acceptable, practical, effective, affordable, safe, and equitable
Tools for effective risk assessment	Environmental restructuring Enablement	Guidelines	Restructuring the physical environment with antecedents Prompts/cues	An alert sent to the pharmacist to assist with the restriction concept and stimulate a stepwise routine process for patient care. Current risk assessment clinical decision support has potential36
Motivation for patient care change	Education		Information about the health consequences	Education about the possibility for improvements in care by providing a plan for change, including a structured, routine process in care for patients with unstable kidney function
				Educating team members (RN, MD, MD residents) on the assigned responsibility of the pharmacist and the planned checklist for care
Motivation for significance and frequency of the problem	Education		Information about the health consequences	Educating the health care professionals (RPh, RN, MD, MD residents) and other team members on the frequency and consequences of dosing errors and the assigned responsibility of the pharmacist to aid in prevention
				Education about the patient safety concerns (ie, injury to the patient, mortality, resource burden) through reports summarizing national and institutional events to change perception about consequences and highlight how frequent medication errors occur
Routine process for motivation	Environmental restructuring Enablement	Regulation	Restructuring the physical environment Prompts/cues	Change the process of care, including a pharmacist who applies a stepwise, routine approach for patient care with checklistt Implement a stepwise, routine process, including prompting with alerts to perform a structured care plan for patients at risk for AKI to prevent AKI occurrence and for patients with unstable kidney function to prevent adverse drug events and kidney disease progression. Implementation of protocols and checklists to standardized care have been shown to be effective in improving patient outcomes30

Abbreviations: AKI, acute kidney injury; CKD-EPI, chronic kidney disease epidemiology equation for glomerular filtration estimate; eGFR, estimated glomerular filtration rate; MD, Doctor of Medicine; RN, Registered Nurse; RPh, Registered Pharmacist.

The implementation intervention was selected based on the APEASE criteria with supporting evidence (Table 3).¹⁶ We propose an intervention that accounts for the fact that this is a complex system and requires consideration of all components of the COM-B model to expect a change in behavior. The intervention based on the findings from our evaluations is a pharmacist-led comprehensive medication management service applied in a stepwise, routine manner, including a checklist for the assigned pharmacist who works with various patient care teams when caring for patients at risk for AKI or with unstable kidney function to reduce medication errors. We suggest the mode of delivery in the intervention proposed in Table 3 be provided with consideration to what is delivered (information about medication management), who is delivering it (pharmacist), and in what setting (hospital, including at the time of patient discharge).

Table 4 provides a detailed process to guide the assigned pharmacist executing the stepwise, routine care. Clinical decision support is recommended for the identification of targeted patients for surveillance because this will help ensure accuracy and decrease workload and costs.^26,37 This could be applied with manual efforts as well. The drug stewardship component includes modifying nephrotoxin use or adjustment of renally cleared drugs and contacting the attending physician (or designee) directly. Recommendations may include stopping or changing a drug, changing dose or schedule, ordering laboratory tests, taking no action, or other (eg, adding a drug, changing formulation).

Table 4.

Stepwise, Routine Process Including a Checklist for the Assigned Pharmacist When Caring for Patients at Risk for AKI^a and Unstable Kidney Function.

Stepwise, routine process
At risk for AKI
Clinical decision support alert implemented to identify patients at risk for AKI
Clinical decision support alert implemented for new nephrotoxins using a standardized list
Educate Notify patient care team of risk and educate on consequences Recommend Provide recommendations for therapeutic alternatives to nephrotoxin to reduce exposure, if appropriate Provide recommendations for discontinuation of nephrotoxins, if appropriate Provide recommendations for preemptive changes of nephrotoxins and renally eliminated drugs based on risk (eg, dose aminoglycoside or vancomycin to drug concentration instead of a scheduled regimen) Recommend evidence-based prevention strategies when administering drugs with known toxicity (eg, hydration for drugs causing crystalluria) Recommend discontinuation of home medications as appropriate (eg, ACE inhibitor/ARB) Monitor Perform diligent drug monitoring of narrow therapeutic drugs that are renally eliminated Perform diligent monitoring of functional and damage kidney biomarkers, as appropriate Communicate Contact the physician/provider and communicate recommendations for changes Change Make adjustments consistent with the provider’s accepted recommendations Document Document recommendations and changes in the electronic health record
Unstable kidney function
Apply stepwise, routine process for at risk of AKI (above) because at risk for progression of AKI
Clinical decision support alert implemented to identify patients with unstable kidney function and possible medication error (over- and underdosing)
Monitor Check if a serum creatinine is available; if no serum creatinine, then order (this step applies especially at hospital discharge) Check need for other functional or damage biomarker monitoring Recommend Recommend renal dose adjustment (increase and decrease) based on standardized list Restart Cautiously restart necessary drugs from home medication list (eg, ACE inhibitor, ARB) Communicate Contact the physician/provider and communicate recommendations for changes Communicate changes in medications, avoiding over-the-counter nephrotoxins, education on kidney disease, and the importance of follow-up with the patient before hospital discharge Change Make adjustments consistent with the provider’s accepted recommendations Document Document recommendations and changes in the electronic health record

Abbreviations: ACE, angiotensin converting enzyme; AKI, acute kidney injury; ARB, angiotensin II receptor blocker.

^aAKI is defined as “an abrupt decrease in kidney function occurring over 7 days or less.”³

Discussion

A detailed evaluation was used to develop an intervention to reduce inappropriate medication prescribing of nephrotoxins and renally eliminated drugs during hospitalization. This focus permits an opportunity to provide care to patients at risk for AKI and prevent drug-associated AKI development and progression. Currently, effective approaches to prevent AKI in clinical practice are limited.^4,31,38,39 Medication management has been recommended, but no studies have focused on preventing progression from AKI to CKD.^11,40 The proposed intervention provides diligent monitoring of nephrotoxins when kidney function may be unstable and potentially rescuable.

It is important to apply interventions to patients with unstable kidney function during hospitalization and at hospital discharge to prevent untoward events during transition of care. This is still a time when AKI is an ongoing pathophysiological process considered acute kidney disease.³ Nephrotoxin exposure is common in predialysis patients.⁴¹ Also, prescribing errors occur in 20% to 47% of patients with unstable kidney function at hospital discharge.^18,42–44 To date, most interventions during transition of care from hospital to home include medication reconciliation and discharge counseling but not a comprehensive medication regimen review.^45,46 Ultimately, better medication management throughout the patient’s hospitalization and at the time of discharge should reduce patient harm and readmissions, similar to programs directed at other diseases.⁴⁷

A reduction in inappropriate prescribing was the target behavior to limit exposure to medication errors known to be associated with ADEs. ADEs are injury to a patient related to a drug.⁴⁸ More precisely, ADEs from medication errors are preventable. ADEs occur commonly in patients with an elevated serum creatinine during hospitalization.^6,26 The potential to cause moderate to severe harm occurs in 71% of cases of inappropriate prescribing at hospital discharge in patients with kidney disease.¹⁸ We proposed a process to overcome the barriers related to appropriate prescribing, thereby leading to a reduction in ADEs. This could have an important impact on mortality, hospital length of stay, and resource use.^27,49,50

Implementation of the proposed intervention will require a setting with the readiness to adopt the new service. A baseline site assessment of readiness may assist with this decision. Also, evaluating the magnitude of inappropriate prescribing for the intervention will assist with targeting goals and determining resource commitment. A thorough assessment of the intervention for implementation can be accomplished with planning and evaluation frameworks such as Reach Effectiveness Adoption Implementation Maintenance (REAIM) and Precede-Proceed.^51,52 This fore-thought of implementation will allow successful adoption of an effective, sustainable intervention.

Limitations

To identify what needs to be changed (step 4 of the BCW)¹⁵ in patient care, we could have expanded the pool of participants to other key stakeholders; however, we included both physicians (various specialties) and pharmacists for an interdisciplinary representation. Also, a more formal solicitation of opinion through structured, in-depth interviews with questions based in the TDF could add additional insight into social opportunities and reflective and automatic motivations. A thorough assessment of beliefs and attitudes was highlighted in a previous evaluation of strategies to manage potentially inappropriate medication prescribing, which we felt was applicable to kidney disease as well.⁵³ The intervention could vary depending on perception of the APEASE criteria for a specific institution, especially because of available technology and resources. Finally, this evaluation was based on individual implementation strategies selected; other considerations may be provided if sociotechnical frameworks were added such as the HOT-fit (Human, Organization and Technology-fit), and UTAUT (Unified Theory of Acceptance and Use of Technology).^54–56

Conclusion and Relevance

Applying the BCW and the TDF was useful for the design of a potential intervention to reduce inappropriate medication prescribing for nephrotoxins and renally eliminated drugs during hospitalization. Assigning a designated clinician to execute a stepwise, routine care process is a recommended intervention to overcome barriers to inappropriate prescribing. Applied use of this intervention is the next step to evaluate its impact on patient care.