Saudi Arabia
Saudi Arabia (المملكة العربية السعودية)
Saudi Arabia is riding high in the world of sports and it's no surprise. Never mind that the Kingdom has created a new professional golfing tournament (The LIV Golf Invitational) that is attracting some of the best golfers from around the world. The Kingdom consistently fields one of the best units in all of Asia. The Falcons are considered one of the most successful Asian football teams ever assembled: three Asian Cup championships (on six finals appearances) and now their sixth World Cup. One of the keys to their success: the Saudis mix modern football strategy with old-school fundamentals. That feature has served them well in international competition and is likely to give them a significant edge in this year's NephroWorldCup.
Video 1: Renal Pharmacists | Courtesy of Dr. Linda Awdishu
This year's Saudi NephroWorldCup team highlights the role of renal pharmacists in the care of AKI, CKD and ESRD patients. We've seen a lot of automated mechanisms to alert prescribers of drug-dosing modifications needed for kidney failure patients. Electronic medical record alerts, text messages, and clinical decision support systems all fall under these automated systems. Often forgotten is the key role that non-automated systems....that is, the renal pharmacist...plays in avoiding costly dosing errors. The Saudis bring to the NephroWorldCup a small single-center study that showcases the value of the renal pharmacist and reminds us that not every problem in medicine is only solvable using computers and algorithms (Video 1)!
In this non-randomized study of 278 patients, researchers implemented an educational program that taught general pharmacists the nuances of prescription drug management for patients with kidney disease. Inclusion into the study required some degree of kidney function impairment: mean CrCL (Cockcroft-Gault) for 95% of the study population was between 42 and 45 mL/min (Figure 1). About 25% of patients studied had ESRD and were receiving in-center hemodialysis. The study was divided into a pre-educational and post-educational phase during which general inpatient pharmacists were trained about how to estimate kidney function, the right equations to use for dosing adjustment, and dosing principles in AKI and CKD using real-world examples. The primary outcome quantified the change in prescription 'errors' that were caught and modified by the renal pharmacist before and after the educational intervention.
Figure 1: Baseline characteristics. Note the percentage of ESRD patients included in the analysis!
Note: Interestingly the Saudi team offered very little detail about the nature of the educational intervention.
So what happened? Turns out that nearly 48% of all corrected orders prior to the educational intervention were performed by pharmacists. That number jumped to 67% after the education. Since the number of patients and drug doses were small, it's not a surprise that statistical significance wasn't achieved. The biggest improvement came in the subpopulation with CrCL < 15 and dialysis. Prior to the educational intervention, the odds of having an error in drug dosing was 7.08 (95% CI 2.86-17.54; reference group CrCL 45-59). Those odds improved to 2.76 (95% CI 1.24-6.14) after intervention! (Figure 2)
Figure 2: Change in drug-dosing errors based on CKD status
Where do we stand with the Saudi Arabian NephroWorldCup team? It's refreshing to see renal pharmacists reclaim some of the stage (Figure 3). The Nephrology community has been focused on automated systems to detect drug dosing errors in kidney failure patients for quite some time. Constrained resources and a diminishing supply of nephrology-focused pharmacists have justified our attention towards algorithmically-based alerting systems. This year's team, however, lacks some of pizzaz of prior teams. It's concerning to see the number of drug-dosing errors increase in the CrCL 40-59 subgroup. Did the educational intervention help pharmacists identify more errors? To know the answer to that question we would need more details about the intervention itself. Very little detail is offered about the what constituted the intervention and how it was performed. Third, the trial isn't randomized. There really isn't any way to conclude if the educational program, and all the resources required to deploy it, was better than an automated system.
Figure 3: The role of the renal pharmacist | Presented at the 2017 British Renal Society annual meeting | Courtesy of Dr. Siva Sridharan (zoom in for details)
Don't sell renal pharmacists short (Video 1). They perform a critical function in the care of patients as complex as those with kidney failure (see Tweetorial by Dr. Siva Sridharan). The Falcons have fielded a wonderful NephroWorldCup team but have obvious deficiencies that shouldn't take away from the value-add of the renal pharmacist.