Avoiding acute kidney injury in primary care: attitudes and behaviours of general practitioners and community pharmacists in Hawke’s Bay

Keywords: General Practitioners; pharmacy services; primary health care; counselling practice

Acute kidney injury (AKI) affects kidney structure and function and is described as an abrupt onset of renal dysfunction ranging from minor loss of function to organ failure.^1,2 It is associated with increased health-care costs and is a predictor of adverse outcomes, including mortality.^1–5 It has been suggested that as many as two-thirds of all AKI cases begin prior to hospitalisation, termed ‘community-acquired AKI’.¹

AKI is associated with ageing, acute illness, chronic conditions, and certain medicines.^1–3 International clinician guidance recommends advising patients taking an angiotensin-converting enzyme inhibitor (ACEi), angiotensin-II receptor blocker (ARB), or a non-steroidal anti-inflammatory drug (NSAID) to pre-emptively discontinue these medicines temporarily when experiencing acute dehydrating illnesses, as part of a ‘sick day plan’.^3,6–8

The use of a NSAID in combination with an ACEi or ARB or a diuretic is known as a Double Whammy, or Triple Whammy if all three drug types are used; these combinations are associated with increased AKI risk.^9–11 The Health Quality & Safety Commission’s Atlas of Healthcare Variation shows that >22,000 New Zealanders aged >65 years take the Triple Whammy combination annually.¹² New Zealand clinicians are recommended to review the appropriateness of medicines for patients at risk of AKI and be prepared to stop treatment if AKI develops.^13,14 Primary care clinician educational material encourages discussing a ‘sick day’ plan with patients taking a Triple Whammy combination and for pharmacists to discuss NSAID-associated risks with patients already taking an ACEi or ARB, with or without diuretics.¹⁵ At present, it is unknown how New Zealand general practitioners (GPs) and pharmacists have incorporated international and New Zealand guidance into their practices to minimise community-acquired AKI.

Community pharmacists professionally support prescribers and patients in the safe and quality use of medicines.¹⁶ The New Zealand Pharmacy Action Plan 2016–2020 focuses on pharmacists collaboratively working within integrated teams to support public health interventions that improve health literacy and reduce medicine harm.¹⁷ In some other countries, pharmacists have professional direction on their role in AKI-associated medicine management and have available to them specific training to support them to undertake this.^6,8,18

This study aimed to explore the current practices and views of Hawke’s Bay GPs and community pharmacists regarding patient education about medicines with potential for contributing to community-acquired AKI, with a focus on community pharmacists educating people to temporarily withhold ‘at-risk’ medicines during acute dehydrating illnesses. This is phase one of a three-phase study investigating this issue.

Cross-sectional surveys of GPs and community pharmacists working in Hawke’s Bay, New Zealand, were undertaken between 2015 and 2016 using online anonymous questionnaires hosted on the SurveyMonkey platform (SurveyMonkey, San Mateo, CA, USA).

General practitioners: In September 2015, 167 Hawke’s Bay GPs were invited to complete an anonymous questionnaire, with reminders delivered in the Health Hawke’s Bay Primary Health Organisation (PHO) weekly email and via the PHO internal Information Portal. GPs who met with the PHO Clinical Advisory Pharmacist (Dianne Vicary) until August 2016 were sent a personal email invitation.

Pharmacists: In September 2015, an email invitation was sent by the Hawke’s Bay Chief Pharmacist to two pharmacy email distribution lists consisting of 95 individual pharmacists and community pharmacy owners. Reminders were emailed and the survey was promoted at monthly pharmacist meetings until November 2015.

Both questionnaires consisted of a mixture of Likert scale, multiple choice, and open-ended questions (see Supplementary Materials Tables S1 and S2, available at the journal’s website). Although both questionnaires explored current practices around patient education, questions relating to views on pharmacists as patient educators, management of Triple Whammy risk and demographics reflected the roles of the two groups. Three pharmacists and a GP piloted the surveys for question clarity and face validity, resulting in wording changes to remove ambiguity.

Descriptive statistics were generated from analysis of all closed question responses using Microsoft Excel (2007) (Microsoft Corporation, Redmond, WA, USA). Free-text responses describing perceived barriers to providing education regarding patient pre-emptive temporary ‘at-risk’ medicine discontinuation were categorised and quantified using an inductive approach and manifest content analysis.^19,20

Thirty-seven GPs and 32 pharmacists completed questionnaires. Although considerable demographic data were missing, respondents tended to be older (aged 51–60 years) and GP respondents tended to be employers who completed their undergraduate studies overseas, whereas pharmacist respondents tended to be employees having completed undergraduate training in New Zealand (Table 1).

Table 1. Demographic characteristics of respondents

Thirty-four GPs and 25 pharmacists felt they had the expertise to provide patient education about temporarily discontinuing ‘at-risk’ medicines during acute dehydrating illnesses.

Table 2 shows Likert scale responses to statements about their current practices regarding patient pre-emptive temporary ‘at-risk’ medicine discontinuation education. Most GP respondents (28/34) provided this education ‘sometimes’ when prescribing ACEi or ARBs (n = 27), NSAIDs or diuretics, and other medicines (n = 20), whereas pharmacists never (n = 14), sometimes (n = 12) or always (n = 5) provided it. In comments analysed qualitatively, both groups reported the need for additional knowledge, the importance of a collaborative approach, a challenging community pharmacy business model, time constraints, concerns about patient medicine literacy, a lack of printed resources and compliance packaging limitations (Table 3).

Table 2. Educating patients to temporarily withhold medicines to reduce risk of acute kidney injury

Table 3. Categories from free-text comments related to challenges or barriers to providing patient education on temporarily withholding medicines during acute dehydrating illness

Community pharmacists’ current workplace practices when NSAID sales are being made are reported in Table 4. Most responding pharmacists had the perception that non-pharmacist staff were unlikely to ask customers purchasing a NSAID about concurrent medicines, acknowledging that if purchasers indicated taking other medicines, referral to a pharmacist would occur. Pharmacist respondents’ general approach to the sale of NSAIDs was to provide advice, counselling on NSAID-associated risks and recommending an alternative if appropriate.

Table 4. Supply of NSAIDs in community pharmacies

Twenty-nine GP respondents considered that community pharmacists were capable of educating patients; 24 supported pharmacists advising patients prescribed an ACEi or ARB to temporarily withhold it during acute illnesses. GP perceptions around practicalities of pharmacists providing this education included: not all had the skills; the community pharmacy business model limitation; and pharmacists’ lack of time.

Twenty-three pharmacists would be prepared to provide this patient education (Table 2). Barriers indicated by pharmacists include: challenges of speaking directly with prescribers in a timely manner; lack of current GP–pharmacist collaboration on this topic; concerns about patient health literacy; and lack of time and remuneration (Table 3).

Current practices regarding patient advice provided for self-medicated NSAID when co-prescribed with ACEi, ARB and diuretic medicines are shown in Table 5. Similar responses were found for GPs and pharmacists regarding providing no patient advice (n = 3 and 2, respectively); advising not to use NSAIDs at all (n = 7 and 5, respectively); and modifying advice depending on a patient’s age (n = 17 and 10, respectively). Thirteen pharmacist respondents indicated patients may collect dispensed medicines without speaking to a pharmacist; in these cases, no advice would be provided about NSAID self-medication that would cause a Triple Whammy combination.

Table 5. General practitioner and pharmacist advice provided to patients about NSAID self-medication, which would cause a Triple Whammy combination

Current pharmacist actions taken and GP views on pharmacist actions when a Double or Triple Whammy combination occurs due to a NSAID being prescribed when ACEi, ARB and diuretic medicines are concurrently prescribed are shown in Table 6. No GP respondents expected pharmacists to dispense a NSAID prescription, resulting in either a Double or Triple Whammy combination, and not provide patient advice. However, one GP was unsure whether patients would accept the pharmacist’s advice. Approximately half of the GP respondents expected pharmacists to provide patient education about temporarily withholding NSAIDs, ACEis, or ARBs during acute illnesses; however, less than one-quarter of pharmacists indicated that they provided this education with prescriptions.

Table 6. General practitioners’ expectations of pharmacists and pharmacist actions taken when a Double or Triple Whammy combination occurs due to a NSAID being prescribed when ACEi, ARB or diuretic medicines are concurrently prescribed

Twenty GP respondents expected pharmacists to contact them before dispensing a prescription that resulted in a Triple Whammy combination. One GP noted the increased importance if the NSAID was not prescribed by the GP, whereas another considered communication was only necessary if the pharmacist had a specific individual concern. Eleven pharmacist respondents would contact the prescriber prior to dispensing a Triple Whammy combination (Table 6). Barriers to pharmacists contacting prescribers if concerned about a prescribed Triple Whammy combination are shown in Table 7. Barriers reported reflected uncertainties around GP expectations and their acceptance of pharmacist communication; patient considerations; and operational barriers including time, inability to discuss prescriptions with prescribers in a timely manner, and insecurities about pharmacists’ professional roles.

Table 7. Community pharmacist barriers to contacting prescribers if concerned about a prescribed Triple Whammy combination

Although our study respondents consider they have the skills and knowledge to educate people about temporarily withholding ‘at-risk’ medicines during acute dehydrating illnesses, it is not a routine practice for either professional group. There is general support for community pharmacists providing patient education, but both groups identified challenges to operationalisation. Education about safe NSAID self-medication, particularly for patients at risk of AKI when concurrent medicines lead to either a Double or Triple Whammy combination, is varied, along with GP misperceptions about the extent of patient education provided by pharmacists during the dispensing process.

We found that some GPs never provide pre-emptive temporary ‘at-risk’ medicine discontinuation education and most provide it ‘sometimes’. This may reflect New Zealand’s focus to stop ‘at-risk’ medicines when AKI has been established and raise awareness of risks associated with the Triple Whammy combination, together with the weak evidence reported for reducing net harm, limited evidence within primary care, and potential risks of this approach.^13,14,21,22 How New Zealand clinicians implement the guidance to stop ‘at-risk’ medicines if AKI develops is a potential area for future research.

The barriers we found to providing pre-emptive temporary ‘at-risk’ medicine discontinuation education identified in our study are consistent with international research.^23,24 The need for an agreed patient message and professional collective engagement between general practice and community pharmacy noted in our findings are reflected in international studies, which also recommend collaboration with secondary care and training of other providers such as carers and nursing staff.²⁴ A parallel barrier is resourcing; incorporating this patient education into existing services and incentive structures suggested in international studies may need to be considered in New Zealand to support sustainability.^23,24

Our findings of GPs’ support for pharmacists’ advisory roles is reflected in previous research, which found that GPs are generally supportive of the pharmacist’s role in new medicine review services.^25–27 Although more accepting of pharmacists’ dispensing roles, acceptance has also grown for their medicine management services.^25–27 In New Zealand, GPs have been reported to value pharmacists highlighting potential interactions and safety issues and support pharmacists having a greater role in providing medicine education to patients; pharmacists also report a keen awareness of GP sensitivities.²⁸

A limitation of our study is that regular promotion of the survey over a long period of time may have drawn attention to the topic and influenced practice. Data were collected for this study in 2015 and 2016; practices may have changed between data collection and publication. Our study did not survey practice nurses who play a significant role in patient care and education in general practice, so their contribution to current practice is missing. We asked pharmacists about their staff’s actions; responses reflect pharmacists’ perceptions rather than actual staff actions. There was a low response rate from both groups and not all respondents answered all questions, resulting in the potential for non-responder and non-response bias limiting generalisability.

Our study highlights the expectations that GPs may have about current pre-emptive temporary ‘at-risk’ medicine discontinuation education provided by community pharmacists as part of the dispensing service, which is unlikely to occur routinely. Our study also reveals an interprofessional misunderstanding where GPs welcome pharmacists highlighting patients taking a Triple Whammy combination to them prior to dispensing the prescription, whereas community pharmacists believe this level of intervention could be unwelcome.

Some NSAIDs are classified as General Sale medicines, enabling public purchase without health professional education. Evidence suggests that the public have little knowledge about safe use of NSAIDs when purchased over-the-counter.²⁹ Professional advice is a key point of difference for pharmacy. Overseas, campaigns promoting pharmacists as educators about the safe use of NSAIDs have increased pharmacist and public knowledge.^30,31 Our study suggests that not all pharmacy businesses ensure customers receive key medicine information from well-trained staff; such campaigns may be of value in New Zealand.

This study suggests there is GP support for community pharmacists to provide patient education about pre-emptive temporary ‘at-risk’ medicine discontinuation during acute dehydrating illnesses, but barriers reported by both GPs and pharmacists will need consideration. New community pharmacy services are recommended to be developed and piloted in collaboration with primary and secondary care.^24,25 Could the Integrated Health Care Framework, developed by The Pharmaceutical Society of New Zealand and the New Zealand Medical Association, be used to develop a collaborative approach for the provision of this patient education?³² The Royal Pharmaceutical Society of Great Britain has endorsed pharmacists providing pre-emptive temporary ‘at-risk’ medicine discontinuation patient education as an AKI harm-reduction strategy, supported by continuing education.^6,30 Neither the New Zealand Pharmaceutical Society nor the Pharmacy Council of New Zealand have position statements on pharmacists’ roles in AKI management.

There is a role for both medical and pharmacist professional groups to strengthen prescriber–pharmacist relationships at both governance and operational levels. Although the Pharmacy Council and Nursing Council have the joint statement ‘Roles and Responsibilities of Pharmacists and Nurses’, there is no Pharmacy Council joint statement with the Medical Council.³³ There has been much investment in patient portal and health pathway technology; is there now value in focusing on clinical portals for sharing information between general practice and community pharmacy, as well as secondary care?^34,35 If health pathways and clinical portals are enablers for providing this patient education, these may be valuable to implement in Hawke’s Bay.

Concerns were raised about message complexity and patient health literacy. Therefore, a patient information resource to facilitate consistent messaging by multiple health providers is recommended.^23,24 In New Zealand, Health Navigator and Kidney Health NZ provide AKI information, but this is not contextualised for New Zealand.^36,37 There may be value in culturally appropriate resources being developed for the New Zealand population.

Study respondents were confident in their capability to provide pre-emptive temporary ‘at-risk’ medicine discontinuation education to reduce the risk of community-acquired AKI. GP respondents had confidence in pharmacists providing this education and pharmacist respondents were willing to provide it if additional training, prescriber support, and specific remuneration were provided.

Both GPs and community pharmacists have different expectations regarding the level of patient education provided by pharmacists as part of the dispensing function and the pharmacist interventions occurring when a Triple Whammy combination is prescribed. Collaborative planning between Hawke’s Bay health-care clinicians would be beneficial to clarify professional roles and develop consistent patient education regarding the ‘at-risk’ medicines to temporarily withhold during acute dehydrating illnesses, thus ensuring provision in a coordinated manner.

The Health and Disability Ethics Committee’s scope of review determined that national ethical approval was not required for this research; registration with the Research Office at Hawke’s Bay District Health Board occurred.

Dianne Vicary currently works for Hawke’s Bay District Health Board as a Portfolio Manager. On behalf of other authors, the corresponding author states that there are no competing interests.

This research did not receive any specific funding.