A recent cross-sectional study conducted by researchers at the University of North Carolina Kidney Center revealed concerning trends in prescription practices among dialysis-dependent patients. The study indicated that non-nephrologists frequently prescribed medications with known risks of Torsades de pointes (TdP) to older patients receiving in-center hemodialysis. Furthermore, a significant portion of these prescriptions originated from nonacute settings, highlighting potential gaps in care and patient safety.
The study found that 52.9% of Medicare patients with kidney failure who were undergoing hemodialysis filled prescriptions for one of the seven most common QT-prolonging medications with known TdP risk. What was particularly alarming was that a majority (78.6% to 93.9%) of these prescriptions were issued outside of acute care events, with less than 25% occurring within 1 week of such an event. Additionally, the data revealed that 80.2% of these prescriptions were written by non-nephrologists. This highlights a need for targeted interventions to address prescribing practices among clinicians outside of nephrology.
Patients receiving in-center hemodialysis already face heightened risks of drug-related harms due to altered drug metabolism and higher rates of comorbid conditions. The use of QT-prolonging medications with known TdP risk further exacerbates these risks, as they have been associated with a higher incidence of sudden cardiac death, a leading cause of mortality in hemodialysis patients. Clinicians must prioritize medication reconciliation and be vigilant for potentially interacting medications when treating this vulnerable patient population.
Opportunities for Improvement
The researchers emphasized the importance of improving care coordination and preventing risky medication prescriptions at the health system level. Recommendations included clinician education on high-risk medications, dedicated resources for medication reconciliation, and enhancements to medication monitoring systems at pharmacies and prescription drug plans. Furthermore, enhancing clinician-to-clinician communication and promoting electronic health data system interoperability were identified as critical steps in addressing the issue.
The study included data on 20,761 Medicare beneficiaries receiving in-center hemodialysis, with the majority being male and having an average age of 74. The most commonly prescribed medications with TdP risk were antibacterials and antifungals, including azithromycin, ondansetron, and levofloxacin. Patients prescribed these medications were more likely to be female, white, and have higher rates of heart failure, arrhythmias, depression, polypharmacy, and hyperpharmacy. Interestingly, a significant proportion of these prescriptions did not originate from nephrologists, underscoring the need for improved collaboration among healthcare providers.
The researchers highlighted the need for further investigation into prescribing patterns of other potentially harmful medications among dialysis patients, such as opioids, benzodiazepines, sedative hypnotics, and muscle relaxants. Understanding these patterns and their implications for patient outcomes is crucial for improving the quality of care in this population. Additionally, future studies should focus on the association between prescription fills and adverse events to inform targeted interventions and preventative strategies.
The study sheds light on the complexities of medication prescribing practices in dialysis-dependent patients and underscores the urgent need for comprehensive interventions to mitigate risks and enhance patient safety. By addressing gaps in care coordination, promoting medication reconciliation, and fostering collaboration among healthcare providers, clinicians can work towards improving the quality of care for this vulnerable population.
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