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Chronic kidney disease and adherence improvement program by clinical pharmacist-provided medication therapy management; a quasi-experimental assessment of patients’ self-care perception and practice

BMC Nephrology volume 25, Article number: 463 (2024) Cite this article

Abstract

Rationale

One of the critical roles of pharmacists in the field of community and hospitals is to provide medication therapy management (MTM) services and reconciliation.

Objectives

This study aimed to assess the perceptions, adherence, and performance of the patients with chronic kidney disease (CKD) to the clinical pharmacist-provided MTM before and after receiving this service.

Method

A cross-sectional survey was conducted from June 2023 to January 2024. A validated questionnaire assessed patients’ knowledge, attitude, and performance, and the Morisky medication adherence scale evaluated the medical adherence of the patients before and after the clinical pharmacist-provided MTM. Inclusion criteria were patients with CKD according to NKF KDOQI guidelines and GFR < 60 mL/min/1.73 m2. Before and after the MTM service, CKD patients’ knowledge, attitude, performance, and adherence to their pharmacotherapy were assessed.

Results

A total of 100 patients enrolled in the study and completed the questionnaire. Before and after the MTM service, total knowledge was 3.38 ± 1.82 and 7.59 ± 1.11, respectively. Before and after the MTM service, the attitude score was 54.53 ± 5.05 and 59.24 ± 4.68, respectively. Before and after the MTM service, the mean performance score was 30.15 ± 4.27 and 34.54 ± 2.56, respectively. Adherence score to medications before and after the MTM service was 4.86 ± 1.99 and 6.22 ± 1.39, respectively. In all fields, outcomes significantly improved (P < 0.05).

Conclusion

The current study showed the critical role of clinical pharmacists in training patients about medications and improving adherence to their pharmacotherapy.

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Introduction

Nowadays, the role of pharmacists in the health system has extended from mere medication counseling and medication application to the management of pharmacotherapy and efforts to enhance adherence of the patients [1,2,3]. The principles of good pharmacy practice seek to improve health-related quality of life (HRQoL) and drug safety in collaboration with other treatment team members [4,5,6].

One of the critical roles of pharmacists in the field of community pharmacies and hospitals is to provide medication therapy management (MTM) services. MTM means a thorough review of the patient’s medication therapy, including a comprehensive review of medication history (including all over-the-counter, prescribing drugs, and supplements used or currently used by the patient), solving medication-related problems (MRPs), optimizing complex treatment strategies, management of polypharmacy, designing high-adherence medication regimes, and cost-effective treatment schedules [3, 7,8,9,10,11]. The ultimate goal of MTM is to optimize pharmacotherapy consequences, minimize medication errors, and improve the HRQoL and the patient’s health status [12, 13]. According to the epidemiology of medication error in Iran, the nationwide incidence of medication error in hospitals was 0.35% in 2005–2019. Physicians and nurses committed 31% and 37% of them. Errors were distributed at different stages of medication processing. As a result, it is recommended to use clinical pharmacist-provided MTM services to prevent the incidence of current medication errors [14, 15].

One of the diseases in which MTM and pharmaceutical care are essential is chronic kidney disease (CKD) [16,17,18]. Due to the irreversible and complex etiology of CKD, the treatment approach is to manage and break the progression of the disease [19]. The role of clinical pharmacists in providing MTM for CKD patients is crucial because these patients face high rates of MRP and medication rejection, more vulnerability to drug poisoning, a high probability of drug-drug interactions (DDIs), comorbidities (such as diabetes, hypertension, osteopathy, anemia, and electrolyte instabilities) due to the possible progression of CKD, and the need to dose adjustment of medications with renal elimination [9, 20, 21].

This survey was aimed to assess the knowledge, attitude, performance, and adherence of CKD patients to the clinical pharmacist-provided MTM in Tehran, Iran, before and after receiving this service.

Method

Overview of the study

A single-center cross-sectional analytical survey was conducted from June 2023 to January 2024. This study was performed among outpatients attending the nephrology clinic at in Labbafinejad hospital, Tehran, Iran. A questionnaire assessed patients’ knowledge, attitude, and performance toward CKD treatment. Finally, the medical adherence of the patients was evaluated by the Morisky medication adherence scale (MMAS) [22,23,24,25]. Medication adherence was assessed using the validated Persian version of the MMAS (α = 0.83).

The MTM intervention consisted of structured clinical pharmacist services: [26]

  1. 1.

    Comprehensive medication review (CMR) to resolve medication-related problems.

  2. 2.

    Personalized care plan.

  3. 3.

    Patient education sessions.

  4. 4.

    Follow-up care.

Sample size

G-Power software was used to estimate the sample size. With an effect size of 0.25, 0.05 margin of error, and 80% power and a 10% non-response rate, the sample size calculated as 105 patients.

Study criteria

Inclusion criteria

according to NKF KDOQI clinical practice guideline [27], the inclusion criteria were patients aged 18 years or older with CKD stage 3–5 (GFR < 60 mL/min/1.73 m2), on stable medication regimen for over 3 months and willing to participate in follow-up sessions.

Exclusion criteria: participants were excluded from the study based on the following criteria: cognitive impairment affecting comprehension, acute kidney injury, hospitalization during the study period and end-stage illness.

Data collection and clinical consultation

We informed the patients about the study process and explained how to complete the questionnaire in the first step. In addition, to collect data through the questionnaire, we gathered the patients` medical history and previous medicine consumption. After data collection, medical consultation services were provided by a clinical pharmacist. A questionnaire was conducted to evaluate the CKD patients’ knowledge, attitude, and performance. After extracting the main criteria of the subject by searching texts and interviewing experts, the questionnaire was structured. To confirm internal consistency, Cronbach’s alpha was calculated. The questionnaire showed an acceptable internal consistency with the Cronbach’s alpha of 0.706.

The questionnaire was divided into five parts. Patients’ demographic information was asked, including age, height, weight, lean body weight (LBW), body mass index (BMI), gender, occupation, education, geographic area, marriage status, and the number of drugs consumed per day in the first section. The second section assessed the patients’ knowledge about CKD by nine (two options: correct, incorrect) items. In the third section, the attitude of the patients toward CKD was evaluated by 17 items. The attitude section was designed in a five-point response scale (strongly agree, agree, not sure, disagree, and strongly disagree).

To evaluate the performance, patients were scored in eight items. The score of responses was ranged from one to five. To determine patient adherence, MMAS was used. In the first seven questions, each negative response and each positive response is given one and zero point, respectively, except for the fifth question in which the scoring process is inverse. The last question has five scales (0, 0.25, 0.5, 0.75, and 1). The final scores are classified as poor (less than 6), average [6,7,8], and high (more than 8) adherence.

Statistical analysis

Finally, collected data were analyzed using SPSS v.25 software. Descriptive results were reported using frequency, mean ± standard deviation (SD). To check the parametricity of the data, the Kolmogorov-Smirnov test was used. Paired T-test was used to compare the subgroup outcomes. Kruskal-Wallis and Mann-Whitney tests were used to compare non-parametric data. Pearson correlation coefficient was used to assess relationships between continuous variables including age and variations in attitude, performance, and adherence scores.

Results

Participant characteristics

A total of 105 patients enrolled in the study and 100 ones completed the questionnaire before and after the MTM service. The mean ± SD for age, height, weight, LBW, and BMI were 64.26 ± 13.29, 167.67 ± 10.14, 79.07 ± 14.65, 53.59 ± 9.97, and 28.18 ± 5.34, respectively. Table 1 shows the continuation of the demographic information.

Table 1 Demographic information
Full size table

Knowledge

Before and after the MTM service, total knowledge was 3.38 ± 1.82 and 7.59 ± 1.11 (out of 9), respectively (P < 0.001). Knowledge improved after the MTM service in both men and women (P < 0.001). Due to the uneven distribution between married (n = 89) and single (n = 11) participants, comparisons based on marital status were not performed. Patients with high-school education had the most change in knowledge (P < 0.001). In terms of medication history, patients who took less than five medications showed the most significant change in knowledge (P < 0.001). Figure 1 shows the questions in the knowledge section as well as the frequency of correct answers before and after the MTM service. In all questions, after providing the service, the number of people who chose the correct answer increased markedly (P < 0.001).

Fig. 1
figure 1

Correct answers before and after the MTM Service

Full size image

Attitude

Attitude score before and after the MTM service was 54.53 ± 5.05 and 59.24 ± 4.68 (P < 0.001), respectively. Women showed more improvements in attitude scores (P < 0.001). Illiterate patients had the highest change in attitude (P < 0.001). In terms of medication history, patients who took less than five medications changed their attitude more than others (P < 0.001). Table 2 shows the questions in the attitude questionnaire and the frequency of participants’ answers and statistical changes after clinical pharmacist-provided MTM service.

Table 2 Attitude of participants before and after MTM Service
Full size table

Performance

The mean performance score before and after the clinical pharmacist-provided MTM service was 30.15 ± 4.27 and 34.54 ± 2.56 (P < 0.001), respectively. Performance score increased in men and women (P < 0.001). Patients with elementary education enhanced their performance more than other subgroups (P < 0.001). In terms of medication history, patients who took less than five medications indicated the most improvement in performance score (P < 0.001). Figure 2 shows the section of performance in the questionnaire and the frequency of participants’ answers and statistical changes after clinical pharmacist-provided MTM service.

Fig. 2
figure 2

Results of Performance of Participants in the Study before and after the MTM service

Full size image

Adherence

Table 3 shows the questions in the adherence section to a therapy regimen and the frequency of participants’ answers and statistical changes after clinical pharmacist-provided MTM service. Adherence score to medications before and after the MTM service was 4.86 ± 1.99 and 6.22 ± 1.39 (P < 0.001), respectively. While both genders were improved their drug adherence, the difference between genders was not statistically significant (P > 0.05). Patients with elementary and high-school education scored better than illiterate patients and bachelors (P < 0.001). Most progress in terms of medication history belong to patients who have taken more than ten medications (P < 0.001).

Table 3 Morisky medication adherence scale (MMAS-8) results
Full size table

Descriptive results

Pearson correlation analysis reported significant relationships between patients’ age and variations in attitude (r = 0.28, P = 0.009), performance (r = 0.31, P = 0.003) and adherence scores (r = 0.25, P = 0.019). No significant relationship was found between age and variation in patients’ knowledge scores (r = 0.15, P = 0.174). Table 4 shows the descriptive results as well as the relationship between the demographic variables and the variation in knowledge, attitude, practice and adherence scores.

Table 4 Descriptive results and relationship between patients’ demographic variables and variations in scores of knowledge, attitude, performance, and adherence
Full size table

Discussion

Clinical pharmacists are well placed with their clinical and practical proficiency to offer pharmacologic as well as nonpharmacological recommendations and interventions in CKD. In a prospective controlled study published by Schütze et al. in 2021 in Germany, CKD medicines optimization by clinical pharmacists was done. In six months of intervention, among 256 patients (intervention: 96, control: 160), MRPs were significantly reduced (P < 0.001) and concluded that adding clinical pharmacists to the treatment team promoted the implementation of nephrologists’ pharmacotherapy and reduced MRPs [28]. Another prospective observational study was performed in 2018–2019 in India, which aimed to detect DDIs in critically ill CKD patients and evaluate clinical pharmacist’s interventions in DDI management. Clinical pharmacists delivered diverse forms of modifications to manage and minimize DDIs. 92% of pharmacists’ interventions were accepted by prescribers [29]. The findings of all the studies showed the critical role of clinical pharmacists in training patients about medications and making patients loyal to their pharmacotherapy.

The deterioration in attitude scores for specific items (Q-3, 4, 9, 12, 13, 15) after MTM services suggests the need for revision of the MTM educational content for these specific aspects, additional follow-up sessions focusing on these particular areas and implementation of a patient feedback system to better understand these changes.

Our study had some limitations. First, being a mono-centric survey affected the generalizability of our results. Second, the cross-sectional nature of our study design limits our ability to establish causal relationships between the MTM service and observed changes. Third, the uneven distribution of participants across marital status groups limited our ability to make meaningful comparisons based on this demographic factor.

Conclusion

This study demonstrates the critical role of clinical pharmacist-provided MTM on CKD patients’ knowledge, attitude, performance, and medication adherence. The findings suggest that integrating clinical pharmacists into the nephrology care team could enhance patient outcomes through improved medication management and patient education. Future multi-center studies with longer follow-up periods are needed to establish the long-term impact of MTM services on patient outcomes. Additionally, addressing the identified areas of attitude deterioration through targeted interventions could further optimize the effectiveness of MTM services in CKD patient care.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The MMAS-8 Scale, content, name and trademarks are protected by US copyright and trademark laws. Permission for use of the scale and its coding is required. A license agreement is available from MMAR, LLC., www.moriskyscale.com. We appreciate the efforts of Morisky Medication Adherence Research group for giving us the license to use the MMAS scale (Certificate Number: 7799-8371-5354-4091-1040).

Funding

This study was funded by Shahid Beheshti University of Medical Sciences Research Center.

Author information

Authors and Affiliations

  1. Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Ghader Mohammadnezhad & Shadi Ziaie

  2. School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Sadaf Ehdaivand

  3. Faculty of Pharmacy and Pharmaceutical Science, Islamic Azad University Medical Branch of Tehran, Tehran, Iran

    Mehrshad Sebty

  4. Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Behniya Azadmehr

  5. Imam Hussain Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Hadi Esmaily

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  1. Ghader Mohammadnezhad
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Contributions

G.M. conducted the sampling and survey design, S.E. and S.Z. drafted the manuscript, G.M., M.S., and B.A. interpreted the statistical analyses, M.S., H.E., S.A., and G.M. collaborated in idea generation, conceptualizing the survey, and editing the manuscript. All authors reviewed the manuscript.

Corresponding author

Correspondence to Hadi Esmaily.

Ethics declarations

Ethics approval and consent to participate

The Ethics Committee of the Faculty of Pharmacy of Shahid Beheshti University of Medical Sciences approved this study with the ethics code IR.SBMU.PHARMACY.REC.1398.045. Informed consent to participate was obtained from all of the eligible patients.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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Mohammadnezhad, G., Ehdaivand, S., Sebty, M. et al. Chronic kidney disease and adherence improvement program by clinical pharmacist-provided medication therapy management; a quasi-experimental assessment of patients’ self-care perception and practice. BMC Nephrol 25, 463 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12882-024-03902-6

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Keywords

BMC Nephrology

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