Association between Total Daily Doses with duration of hospitalization among readmitted patients in a multi-ethnic Asian population

Feasibility & Efficacy of Deprescribing rounds in a Singapore rehabilitative hospital- a randomised controlled trial

Background

Deprescribing is effective and safe in reducing polypharmacy among the elderly. However, the impact of deprescribing rounds remain unclear in Asian settings. Hence, we conducted this study.

Methods

An open label randomised controlled trial was conducted on patients of 65 years and above, under rehabilitation or subacute care and with prespecified medications from a Singapore rehabilitation hospital. They were randomised using a computer generated sequence.

The intervention consisted of weekly multidisciplinary team-led deprescribing rounds (using five steps of deprescribing) and usual care. The control had only usual care.

The primary outcome is the percentage change in total daily dose (TDD) from baseline upon discharge, while the secondary outcomes are the total number of medicine, total daily cost and TDD up to day 28 postdischarge, overall side-effect rates, rounding time and the challenges. Efficacy outcomes were analysed using intention-to-treat while other outcomes were analysed as per protocol.

Results

260 patients were randomised and 253 were analysed after excluding dropouts (female: 57.3%; median age: 76 years). Baseline characteristics were largely similar in both groups. The intervention arm (n = 126) experienced a greater reduction of TDD on discharge [Median (IQR): − 19.62% (− 34.38, 0.00%) versus 0.00% (− 12.00, 6.82%); p < 0.001], more constipation (OR: 3.75, 95% CI:1.75–8.06, p < 0.001) and laxative re-prescriptions (OR: 2.82, 95% CI:1.30–6.12, p = 0.009) though death and hospitalisation rates were similar. The median rounding time was 7.09 min per patient and challenges include the inconvenience in assembling the multidisciplinary team.

Conclusion

Deprescribing rounds can safely reduce TDD of medicine upon discharge compared to usual care in a Singaporean rehabilitation hospital.

Trial registration

This study is first registered at Clinicaltrials.gov (protocol number: NCT03713112) on 19/10/2018 and the protocol can be accessed on https://www.clinicaltrials.gov.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02507-0.

A cultural adaptation and validation study of a self-report measure of the extent of and reasons for medication nonadherence among patients with diabetes in Singapore

BACKGROUND

This self-report measure is a new instrument to measure the extent of and reasons for medication adherence separately. However, few studies have assessed its psychometric properties in diabetic patients and also in Asian populations.

OBJECTIVES

To validate this self-report measure in diabetic patients in Singapore.

METHODS

We collected data prospectively using a questionnaire among 393 diabetic patients from hospitals in Singapore from July 2018 to January 2019. Using the COnsensus-based Standards for the selection of health Measurement INstruments framework, we assessed face validity, internal consistency, test-retest reliability, structural validity, and measurement error. We tested four a priori hypotheses on correlation of extent score with patient-reported outcome measures to assess construct validity. We examined cross-cultural validity via measurement invariance across gender, age groups, and languages.

RESULTS

We performed cognitive interviews with 30 consenting English-literate, Chinese-literate, and Malay-literate (10 patients per language) diabetic patients (age range 48-76 years, 53% male, disease duration range 1-30 years) and face validity was supported. Among 393 patients (mean age: 59.4±12.2 years, 50.9% female, 52.4% Chinese), we showed moderate internal consistency (Cronbach's alpha =0.67) and test-retest reliability (intra-class coefficient=0.56 [95% CI 0.37-0.70]). We calculated smallest detectable change as 0.80. We established construct validity by meeting all four hypotheses. We showed structural validity as confirmatory factor analysis confirmed a one-factor model, with excellent fit statistics (Comparative Fit Index=1.0; Tucker-Lewis Index=1.0; Root Mean Square Error of Approximation<0.001; Standardized Root Mean Residuals<0.001). Analysis of cross-cultural validity supported configural invariance model but not metric invariance and scalar invariance model. Caution must be taken against directly comparing extent scores across gender, age groups, and languages.

CONCLUSION

This self-report measure is valid and reliable in measuring medication adherence in diabetic patients in Singapore.

Systematic review of the barriers affecting medication adherence in older adults

Medication adherence is a crucial part in the management of chronic diseases. As older adults form a greater proportion of the population with chronic diseases and multiple morbidities, understanding medication adherence in older adults becomes important. In the present article, we aimed to systematically review the literature for the factors associated with medication adherence in the geriatric population. We carried out a literature search using electronic databases and related keywords. 17 391 articles were reviewed in total. 65 articles were found to be relevant to our objective. A total of 80 factors of five different categories were found to be associated with medication adherence in older adults. The factors, the types of studies and the number of studies that agreed or disagreed were presented. A flower model for medication adherence was also presented to allow clinicians to better understand the complex nature of medication adherence in this population. The 80 factors reviewed were categorized into five main categories; namely, patient factors, medication factors, physician factors, system-based factors and other factors as factors affecting poor medication adherence in older adults. Clinicians need to be mindful of the complex nature of factors affecting medication adherence in this population to optimize therapeutic outcomes. Clinicians have to be more skillful to discover and to optimize the medication adherence factors in geriatric patients. The flower model is presented as a framework for clinicians to better understand the various factors affecting medication adherence in older adults. Geriatr Gerontol Int 2016; 16: 1093-1101.