Evaluation of a Novel Pharmacist-Nephrologist Collaborative Care Service for Patients on Hemodialysis in Singapore

Background: The introduction of Collaborative Prescribing by pharmacists has improved the holistic team-based patient care. The standard care (SC) for stable hemodialysis (HD) patients involves a hospital nephrologist’s consult in 9-month intervals, with community dialysis team titrating medications every 1-2 monthly. With complex medication regimens and multiple care teams involved, HD patients often face complex and potentially confusing medication regimens. Since medication management is the main activity during nephrologist’s consult, we aim to right-site their care with the novel collaborative care (CC) service between nephrologists and pharmacists. In this CC model, stable HD patients are reviewed by a renal pharmacist 6 months after his nephrologist consult. Pharmacist independently conducts a medication review according to patient’s clinical status and their HD centre’s records. Pharmacists optimise, and prescribe their medications and vaccinations based on the collaborative prescribing framework. This study aims to evaluate safety of the new CC model, with the mean ED visits and all-cause unplanned admissions as the primary outcome. Methods: A retrospective study of 104 patients in the CC model and 342 patients in SC model in January 2021 – June 2022 was conducted. The patients are matched by the nearest propensity scores, modeled using a multivariate logistic regression adjusted with baseline variables. The number of all-cause unplanned admission and ED visits were compared using a difference-in-difference approach and a negative-binomial mixed effect model. Results: Mean unplanned admissions was 0.673 and 0.760 for the SC and CC group respectively (p=0.597) with an incidence rate ratio (IRR) of 0.98 (95% CI: 0.58-1.65) for the CC group. The mean ED visits was 0.192 and 0.183 for the SC and CC group respectively (p=0.890) with an IRR for the CC group of 0.73 (95% CI: 0.14-3.81). The differences were not statistically significant. Among patients who require pneumococcal and/or influenza vaccinations, patients in the CC group achieved a higher vaccination rate (pneumococcal: 24.3% vs 3.8%. influenza: 13.5% vs 0.0%). Conclusion: The study findings support the safety of this novel CC service in ensuring the timely and holistic clinical review of stable HD patients. This new CC service was effectively implemented with no differences in primary safety outcome measures.