Medication Management

Medication management is a patient-centered care process that optimizes safe, effective, and appropriate drug therapy. Medication management is a repeating process that involves patient assessment, creating and implementing a care plan, and follow-up and evaluation ( Fig. 59.1 ). Care is provided through collaboration with patients and their health care teams, including physicians, nurses, pharmacists, dietitians, social workers, and patient care technicians.

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Medication management process.

An average dialysis-dependent patient has five or six comorbid conditions, requiring 10 to 12 medications, resulting in an average of 19 pills (range, 17–25 doses) daily. This polypharmacy does not necessarily reflect poor medical management or overuse of medications. However, the sheer number of medications, the presence of kidney altered drug disposition, and the challenges involved with tracking, monitoring, managing, and actually taking all these medications place dialysis patients at high risk for medication-therapy problems (MTPs). In addition to complex polypharmacy, the average dialysis patient also experiences “polyprovider” issues. The typical dialysis patient has nearly five different prescribers (e.g., nephrologist, primary care provider, endocrinologist, cardiologist, gastroenterologist, and psychiatrist) and uses several pharmacies (e.g., mail order, specialty, chain drug store, large retailer, food market, or independently owned pharmacy) to obtain access or afford their medications. In a cross-sectional analysis of Medicare claims data (January 1–December 31, 2016), including over 25,747,560 patients who were 65 years of age or older and who were prescribed at least one medication for at least 30 days were analyzed. Overall, patients had 5.6 (1.1) different prescribers, and mean concurrent medications per patient was 5.6 (range, 1–46; SD, 3.3), and mean number of unique medications per patient was 6.3 (range, 1–59). Fifty-seven percent of patients were prescribed five or more medications. The most significant factor associated with polypharmacy was patient medical complexity, including those with a history of HIV/AIDS, diabetes mellitus, solid organ transplant, or systolic heart failure. In a separate Medicare-managed care study, 405 patients (age, 74 [5.1] years) had a mean (SD) of 2.9 (1.3) prescribing physicians, and 98 (24%) of patients reported having experienced an adverse drug event (ADE) in the previous 6 months. In a multivariable logistic regression model, each additional provider prescribing medications increased the odds of reporting an ADE by 29% (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.0–1.6). The number of chronic health conditions was also associated with ADEs. Having four or five self-reported chronic conditions doubled a person's odds of experiencing an ADE (OR, 2.1; 95% CI, 1.0–4.1), and having six or more conditions tripled the likelihood of experiencing an ADE (OR, 3.4; 95% CI, 1.6–6.9). The number of prescribing physicians was an independent risk factor for patients self-reporting an ADE. The authors suggest that one possibility for higher ADEs is poor communication among multiple providers.

The complex medical management of various comorbid conditions and the fragmented health care system with inadequate communication among multiple prescribers and pharmacies, as well as the frequent care transitions between ambulatory care sites (e.g., dialysis center, ambulatory primary care practice, ambulatory specialty practice) and the hospital, skilled nursing facility, or long-term care facility, places dialysis patients at high risk for MRPs. Previous reports illustrate that risk factors for experiencing MRPs include three or more concurrent disease states, medication regimen changed four or more times during the past 12 months, taking five or more medications or 12 or more doses per day, noncompliance history, drugs that require therapeutic monitoring, and the presence of kidney disease or diabetes as a chronic condition. Dialysis patients have all of these risk factors. Providing medication management services is critically important to avoid adverse clinical events and the high costs associated with MRPs, often resulting in avoidable hospitalizations.

Medication-related problems can be classified into nine categories: (1) indication without drug therapy (IWD); (2) drug without indication (DWI); (3) improper drug selection (IDS); (4) subtherapeutic dosage, that is, (5) underdose (UD), (6) overdosage (OD), (7) or adverse drug reaction (ADR); (8) drug interaction (DI; failure to receive drug [FRD]); and (9) inappropriate laboratory monitoring (LAB). Table 59.1 provides examples for each MRP type.