Study On The Establishment Of Pharmaceutical Care Pathway And Its Long-term Effect For Patients With Nephrotic Syndrome

Objective: The study was to establish the grading pharmaceutical care pathway in patients with nephrotic syndrome,by retrospectively analyzing the disease and treatment characteristics in our hospital patients with nephrotic syndrome and combining with establishing experiences of pharmaceutical care pathway at home and abroad.We would design a prospective randomized controlled trial to implement the grading pharmaceutical care for the patients in hospital.Comprehensively evaluated the standardized pharmaceutical care effect of clinical pharmacists on the hospitalized and discharging patients with nephrotic syndrome.We hope to provide the supports and methods for clinical pharmacists to participate in the pharmaceutical care for patients with nephrotic syndrome.Methods: The first part: Retrospective analysis of the disease treatment characteristics and outcomes of patients with nephrotic syndrome Retrospectively screened the clinical information of patients with nephrotic syndrome admitting in department of nephrology in a grade-three hospital from January 2014 to January 2015.The collected patients information of general demographic characteristics,disease and treatment situation,laboratory testing and referral status etc.were double-checked and entered into the database with the spss20.0 software.Thecollected quantitative data described as x ± s if the data are normally distributed,described as M ± QR if the data are not normally distributed.Summarized the disease and drug characteristics in patients with nephrotic syndrome.The second part: Establishment of pharmaceutical care pathway for patients with nephrotic syndrome Therapeutic drug monitoring: Summarized commonly used drugs of patients with nephrotic syndrome,including drugs for the diuretic swelling,immunosuppression,reducing urinary protein,treating high blood pressure and high cholesterol treatment and developed the pharmacy care content of various drugs.Compliance assessment: Assessed the patient compliance by the Morisky-Green medication compliance evaluation scale and nephrotic syndrome treatment compliance scale.Grading pharmaceutical care assessment: Comprehensive analyzed the liver and kidney function,disease status and medication regimen etc.to assess the patient's medical care level.Set up the primary caring,secondary caring and tertiary caring.Established grading pharmaceutical caring evaluation scale for patients with nephrotic syndrome.Follow-up parameters: Regular follow-up was carried out in the discharge 1,3,6 months by the follow-up model of We Chat and telephone,recording the patient's relevant circumstances and outcomes,assessing the patient compliance and timely summarizing the relevant information.Establishment of grading pharmaceutical care pathway: Developed the drug service flow in patients with nephrotic syndrome and established the grading pharmaceutical care pathway for patients with nephrotic syndrome.The pathways mainly include: Inpatient pharmacy consultation,compliance assessment,drug reorganization,prescription review,medication account,drug counseling,adverse events monitoring and lifestyle guidance etc.The third part: Prospective study the effect of standardized pharmaceutical care on the hospitalized and discharging situation for patients with nephrotic syndromeDepartment of nephrology in a grade-three hospital was taken as the study site,collected patients with nephrotic syndrome from January 2016 to June 2016 as the object of study.Inclusion criteria:(1)24 h urinary protein ? 3.5 g/24 h,serum albumin ? 30 g/L.(2)clear consciousness,communication without difficulty.(3)patients of informed consent.Remove criteria:(1)cognitive dysfunction.(2)Severe disturbance of consciousness.(3)severe mental disorders and dementia patients.(4)patients with malignant tumors or ongoing anti-tumor therapy.(5)patients suffering from severe systemic disease for estimate survival < 90 days.(6)patients refused to sign informed consent.(7)patients cannot be followed up.According to the method of complete randomized design,selected cases were randomly divided into experimental group and control group.The control group was conventionally treated by physician and nurses.On the basis of the control group,the experimental group also received the grading pharmaceutical care.According to the pre-established grading pharmaceutical care pathway for patients with nephrotic syndrome,the grading pharmaceutical care was implemented for patients.Collected the occurrence of disease control,outcome,compliance,and adverse events,the re-admission rates and satisfaction etc.The collected data were analyzed by spss 20.0 statistical software.Inspection level a = 0.05.The difference was statistically significant if P<0.05.Investigated the grading pharmaceutical care effect of clinical pharmacists on the hospitalized and discharging situation for patients with nephrotic syndrome.Results: The first part: Retrospective analysis of the disease treatment characteristics and outcomes of patients with nephrotic syndrome General demographic information:Totally collected 215 subjects,including 147 males and 68 females.They aged from 11 to 89 years old,and mean age was 47 ± 27 years old.Health insurance of the patients mainly came to the new rural cooperative,accounting for 46.98%.Also provincial medical insurance accounted for 6.05%,city health insuranceaccounted for 11.16%,railway medical insurance accounted for 1.40% and 74 patients at their own expense,accounting for 34.42%.There are 79 farmers,23 workers,7 civil servants,13 students,93 other patients.There are 98 patients living in the city and 117 patients living in rural areas.The disease and treatment characteristics: The main cause of hospitalized came to the initial disease,accounting for 48.84%.Others included 11.16% of disease recurrent,32.09% of review,7.91% of other reasons.Pathologic types of patients with nephrotic syndrome were various,including 29.3% of membranous nephropathy,8.37% of minimal change nephropathy,3.26% of Ig A nephropathy,0.93% of other pathological types,6.05% of clinical manifestations to nephrotic syndrome from secondary factors and 52.09% of unknown pathological types.The results show that patients with nephrotic syndrome often combined with 1 to 3 diseases.Nephrotic syndrome patients were infected 53 in 215 cases and the infection rate was 24.65%.Patients were treated on average with 7 therapeutic drugs.80% of patients were treated with glucocorticoids during hospitalization and 28.84% patients were treated with immunosuppressants.The average length of hospital stay was 15 ± 7 days.Laboratory examination: About 90% of patients had varying degrees of electrolyte disturbances.Serum albumin averaged 20.65 ± 6.159 g/l.24 h urine protein quantitative averaged 4.218 ± 2.569 g.Regular referral and outcome: The patients number of referral after discharging 1 month only accounted for 65.12% of the total patients number,referral after discharging 3 month accounted for 57.21%,referral after discharging 6 month accounted for 53.95% and referral after discharging 12 month accounted for 33.95%.Patients generally showed a better trend.Patients re-admitted after discharging 1 year were 24 cases,the reasons came to the exacerbation and infection occurrence.The second part: Establishment of Pharmaceutical Care Pathway for Patients with Nephrotic SyndromeThe establishment of pharmaceutical care pathway for patients with nephrotic syndrome was combining the commonly used drugs,compliance with grading pharmaceutical care etc.The pathway provided the clinical pharmacists must timely carry out the pharmacy inquiry in the first admission day to assess the patient medication compliance.The medical care level of the patients should be dynamically assessed during the hospitalization,and the corresponding medical monitoring was carried out according to the assessment results.The medication education was carried out on the discharging day.Regulated the pharmacological service behavior of clinical pharmacists.The third part: Prospective study the effect of standardized pharmaceutical care on the hospitalized and discharging situation for patients with nephrotic syndrome Analysis of demographic information: Totally collected 61 individuals in this study,there were 31 patients in the experimental group and 30 patients in the control group.There were no statistically significant differences between the two groups.Assessment of grading pharmaceutical care: Grading pharmaceutical care for the study patients were assessed by the developed assessment table of grading pharmaceutical care,the patient condition differences between the two groups were comprehensively assessed.Two groups of patients in the level of medical monitoring were equally balanced(P>0.05).Screening risk factors of Chronic kidney disease(CKD): CKD risk factors screening and life health education were carried out in the experimental group.The impact on compliance: The compliance of the two groups both decreased with the extension of the discharge time,and the descending degree of the control group was more obvious.The compliance in discharging for 6 months between the two groups was significantly different(P=0.048).The impact on regular referral and outcome: The referral rate at discharging for 1 and 6 months of the experimental group were all significantly higher than that of the control group,the difference was statistically significant.There was no significantdifference in the disease outcome between the two groups during the observation period.The impact on the medication safety of patients: There were no statistically significant differences in the number of adverse events between the two groups(P>0.05)during the observation period.The misuse case number of dosing schedules in the experimental group was lower than that in the control group,the difference was statistically significant(P=0.017).The impact on re-admission: There were significant differences in re-admission between the two groups,the number of re-admission in the experimental group was lower than that in the control group(P=0.010).The impact on satisfaction: There were significant differences in satisfaction between the two groups(P=0.046).Conclusion: The study established the pharmaceutical care pathway for patients with nephrotic syndrome,and proposed a grading pharmaceutical care method for clinical pharmacists to participate in the treatment of nephrotic syndrome.These results could help to train the clinical pharmacists in the department of nephrology and to carry out the daily work,laid the foundation of the service homogenization for nationwide clinical pharmacists.At the same time,the results showed that the establishment of the hospitalized grading pharmaceutical care pathway in patients with nephrotic syndrome can significantly reduce the medication errors caused by the wrong dosing schedules during the hospitalization and discharging time,and the re-admission rate,and improve patients satisfaction.What's more,the results have a positive meaning for improving patient compliance and protecting patients with drug safety.