Phone App Flags Medication Discrepancies in Kidney Disease

A smartphone app designed to identify potential mistakes in medications for patients with chronic kidney disease (CKD) led to a 60% relative reduction in the incidence of discrepancies with potentially severe clinical consequences in a randomized study with 182 patients.

The findings "highlight the acceptability and sustainability" of the new app, eKidneyCare, and show the app's "effectiveness in reducing medication discrepancies, the forerunner of adverse drug reactions," say Stephanie Ong, MSc, and co-authors in a report published in the Clinical Journal of the American Society of Nephrology.

A reduction in medication discrepancies means "improved patient safety," noted Ong, a clinical nephrology pharmacist with the University Health Network in Toronto, Canada, in an interview. Results from prior studies have shown that the incidence of adverse drug reactions is relatively high among patients with CKD. In part, this is because of the high prevalence of comorbidities in these patients, as well as the many medications they often require.

"The reduction of medication list errors achieved by the app is laudable, and an important step toward safeguarding home care for the vulnerable CKD population," comment Lee-Ann Wagner, MD, and Jeffrey C Fink, MD, both on the faculty of the University of Maryland School of Medicine, Baltimore, Maryland, in an editorial that accompanies the report.

The app's "efficacy here is most likely due to the automated communication between prescribers, pharmacies, and patients," they observe.

The study enrolled patients with CKD stage 3b-dialysis. The estimated glomerular filtration rate (eGFR) of the participants was <45 mL/min/1.73m². They were undergoing treatment at any of six outpatient nephrology clinics run by two academic medical centers in Toronto. Patients linked the app to their healthcare providers as well as their health systems' databases, which provided information on their medications and laboratory results.

An App That Links With EMRs

"To operationalize our system, it is necessary to interface with electronic medical records," explains Alexander J. Logan, MD, senior investigator for the study and a developer of the eKidneyCare app.

"In our opinion, this is achievable" on a larger scale if the app were to become available for routine use, he adds.

The eKidneyCare app targets four self-care behaviors: managing medications, monitoring blood pressure, assessing symptoms, and tracking key CKD laboratory test results: eGFR, and levels of hemoglobin, potassium, and phosphate. The app prompts patients to review monthly their medication list on their smartphone and report changes, additions, or medication problems to their clinical team for reconciliation and, if necessary, interventions.

The app automatically links with the clinic pharmacy database to ensure that patients see their updated medication list on their smartphones. Programs remind patients to take blood pressure measurements and alert clinicians when pressure thresholds are exceeded.

The app also prompts patients to assess the presence and severity of CKD-related symptoms once a month and then alerts the clinical team when action is needed. Key CKD tests results are automatically sent to patients along with an interpretation.

"Ready for Widespread Clinical Use"

The new data that show the potential value of the app for cutting medication discrepancies for patients with CKD mean it's "ready for widespread clinical use," Logan said in an interview.

He noted that eKidneyCare sprang from an app lineage developed and tested by Logan and his associates during more than a decade of work involving patients with various chronic conditions, such as hypertension, heart failure, diabetes, and chronic obstructive pulmonary disease.

"Evaluations of these apps have been published over the past decade, and thus we feel the monitoring components have been adequately tested," says Logan, a professor in the University of Toronto School of Public Health. He envisions patients receiving an app similar to eKidneyCare that clinicians would tailor to each patient's needs for monitoring and managing not only CKD but other chronic comorbidities as well.

The current study randomly assigned 89 patients to use the eKidneyCare app and 93 to use a widely available control app, MyMedRec, which allows patients to enter information on their medications, blood pressure, and laboratory results but does not have the capability of linking with stored records or providers. The average age of the patients was about 57 years, about 60% were men, a third were receiving dialysis, just under a third had diabetes, and about 70% had hypertension. Patients had active prescriptions for a median of 10 medications.

The study's primary endpoint was the incidence of all medication discrepancies 1 year after starting to use the app. After 1 year, clinically relevant medication discrepancies occurred at a rate of 0.33 per patient in the active-app group and 0.50 per patient in the control arm, a significant difference.

Rates of clinically relevant discrepancies with potentially severe consequences were 0.27 per patient in the eKidneyCare arm and 0.63 per patient among the control patients, a 60% relative risk reduction that was significantly associated with use of the eKidneyCare app.

There were no between-group differences in blood pressure, laboratory results, or patient-reported outcomes, and 72% of patients in the active-app arm completed their medication reviews at least once a month.

Is It Generalizable?

"The exciting results from the study unfortunately lack broad generalizability, as the participants were likely of high ehealth literacy, based on high education levels and self-reported technological savviness," comment Wagner and Fink in their editorial, but Logan has a different take.

"We believe that clinicians and patients will be receptive and eager to incorporate [the eKidneyCare app] in day-to-day clinical practice and management of patients with chronic diseases," he says. "We feel confident that the app will be well received across the spectrum of patients" and that its use "is no more complicated than most smartphone apps."

Logan acknowledges, however, that the app "might be overkill for the bulk of patients with milder forms of long-term conditions" and that the CKD app and the apps for other chronic diseases were developed for "high-risk, high-need" patients, possibly the sickest 5% of the overall patient population, he estimates.

Rollout of eKidneyCare and related apps now depends on integrating these disparate app functions into a single product that can be customized for each patient's needs. Such work is now in progress. This project has had no commercial backing or collaboration. Logan foresees that a scalable and sustainable rollout will require collaborating with a yet-to-be-identified business partner.

The study received no commercial funding. Logan has received research funding from Philips Respironics. Ong, Wagner, and Fink have disclosed no relevant financial relationships.

Clin J Am Soc Nephrol. 2021 Mar 18;CJN.15020920. Full text, Editorial

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