Nephrology Comanagement and the Quality of Antibiotic Prescribing in Primary Care for Patients With Chronic Kidney Disease: A Retrospective Cross-sectional Study

A Retrospective Cross-Sectional Study

Justin X.G. Zhu; Danielle M. Nash; Eric McArthur; Alexandra Farag; Amit X. Garg; Arsh K. Jain


Nephrol Dial Transplant. 2019;34(4):642-649. 

In This Article


We conducted this study to assess the quality of CKD antibiotic prescribing in primary care and to determine whether patient comanagement with a nephrologist improved prescribing patterns. In approximately two-thirds of cases, the primary care dosing of antibiotics was against recommended practice. Nephrology comanagement improved the quality of primary care antibiotic prescribing in advanced CKD by a modest 4%.

After completing a detailed search of MEDLINE and other bibliographic databases through March 2017, we confirm that this appears to be the first study to examine the effects of nephrology comanagement on the prescribing practices of primary care physicians in CKD. Our study's strength lies in the use of Ontario's broadly inclusive, linked health care databases, which provided us with a large representative sample of patients. We included a large number of relevant variables in our propensity score–matched data to minimize significant biases between the groups to achieve a more representative analysis on the effects of comanagement.

Despite our robust databases, there are some limitations to our study. While we studied prescription patterns, we did not have information on actual drug intake or detailed information on the indications for the antibiotics. Furthermore, we limited our study to the appropriateness of prescription doses, as associated clinical outcomes are beyond the study objectives. Clinical outcomes related to antibiotic use/misuse, such as treatment efficacy or adverse events, may be difficult to study due to multiple factors such as noncompliance, resistant organisms, immunosuppression and drug–drug interactions. The results of observational studies are subject to confounding. Better estimates of the effects nephrologists could have on primary care prescribing may come from future randomized controlled trials comparing different types of education and support provided by nephrology to primary care, possibly with tips provided in the consultation note.

By demonstrating a high prevalence of inappropriately dosed prescriptions, our study highlights an opportunity for quality improvement in CKD primary care. In the literature, many other studies highlight the high prevalence of potentially inappropriate medications in patients with CKD. Most recently, Chang et al.[11] reported that ~30% of US veterans with Stages 3 and 4 CKD are prescribed at least one potentially inappropriate medication. This rate increased to >50% when isolated to patients with Stage 4 CKD.[11] Jones and Bhandari[13] reported that 56% of inpatients with CKD at a British hospital had at least one potentially inappropriate medication prescribed. Additionally, Doody et al.[12] published a retrospective chart review that looked at rates of potentially inappropriate medications in a tertiary hospital in Australia. They found that 32% of inpatients with CKD had at least one potentially inappropriate medication, 16% had a contraindicated medication and 21% had an inappropriately dosed medication in an inpatient setting.

There is a paucity of published literature testing strategies to reduce medication errors in CKD patients. Our results suggest that simply involving a nephrologist in the care of advanced CKD patients is not associated with a dramatic improvement in dosing medications among advanced CKD patients. Instead, perhaps nephrologists should be, through their consult notes to primary care physicians, educating/reinforcing the importance of choosing appropriate medications and doses in patients with advanced CKD. There might also be opportunities for the nephrologist to educate patients and their families about reminding prescribers and pharmacists that they have reduced kidney function and the doses of medications should be adjusted. These strategies warrant testing in future studies.