Drug utilization patterns among elderly hospitalized patients on poly-pharmacy in Punjab, Pakistan

Assessment of disease pattern and drug utilization among neurology intensive care unit patients in a developing country: an observational analysis

OBJECTIVE

This study aimed to assess the disease pattern and drug utilization among admitted patients in a tertiary-care hospital's neurology intensive care unit (neuro ICU).

METHODS

A prospective observational cohort study was conducted between August 2022 and January 2023. Patients of any age and gender admitted to the neuro ICU were included, but those who declined to participate were excluded. Demographics, clinical, and medication details were consistently gathered and maintained until discharge. The World Health Organization (WHO)/International Network of Rational Use of Drugs (INRUD) prescribing indicators and the Anatomical Therapeutic Chemical (ATC) classification/Defined Daily Dose (DDD) system were used to evaluate drug use.

RESULTS

A total of 516 patients were included, predominantly male (65.1%), with an average age of 54.62 ± 15.02 years. The most common diagnosis was stroke [72.3%, comprised of hemorrhagic (46.7%) and ischemic (25.6%)], followed by seizure disorders (6.6%), and central nervous system infections (5.4%). Patients received an average of 7.8 medications, 32.3% prescribed by generic name, 16.0% antibiotics, 74.1% injections, and 100% essential drugs. A (28.5%), C (19.2%), N (17.3%), J (19.2%), B (13.5%), and R (2.3%) were commonly prescribed ATC classes of medications. Number of DDDs was maximum for pantoprazole and furosemide. Based on discharged status, 41.0% were discharged on request, 24.8% against medical advice, 23.8% routine, and 10.2% mortality during hospitalization.

CONCLUSION

Our study reveals a high prevalence of hemorrhagic stroke, especially among men, diverging from global ischemic stroke trends. Irregular hypertension treatment is the primary cause, exacerbated by low healthcare knowledge in rural areas, where patients often discharge on request, probably due to poor socio-economic conditions. Urgent public awareness campaigns and further research are needed to address this elevated hemorrhagic stroke incidence.

Are there socioeconomic inequalities in polypharmacy among older people? A systematic review and meta-analysis

BACKGROUND

Socioeconomic status (SES) may influence prescribing, concordance and adherence to medication regimens. This review set out to investigate the association between polypharmacy and an individual's socioeconomic status.

METHODS

A systematic review and meta-analyses of observational studies was conducted across four databases. Older people (≥ 55 years) from any healthcare setting and residing location were included. The search was conducted across four databases: Medline (OVID), Web of Science, Embase (OVID) and CINAHL. Observational studies from 1990 that reported polypharmacy according to SES were included. A random-effects model was undertaken comparing those with polypharmacy (≥ 5 medication usage) with no polypharmacy. Unadjusted odds ratios (ORs), 95% confidence intervals (CIs) and standard errors (SE) were calculated for each study.

RESULTS

Fifty-four articles from 13,412 hits screened met the inclusion criteria. The measure of SES used were education (50 studies), income (18 studies), wealth (6 studies), occupation (4 studies), employment (7 studies), social class (5 studies), SES categories (2 studies) and deprivation (1 study). Thirteen studies were excluded from the meta-analysis. Lower SES was associated with higher polypharmacy usage: individuals of lower educational backgrounds displayed 21% higher odds to be in receipt of polypharmacy when compared to those of higher education backgrounds. Similar findings were shown for occupation, income, social class, and socioeconomic categories.

CONCLUSIONS

There are socioeconomic inequalities in polypharmacy among older people, with people of lower SES significantly having higher odds of polypharmacy. Future work could examine the reasons for these inequalities and explore the interplay between polypharmacy and multimorbidity.

Potentially inappropriate medication among older patients with diabetic kidney disease

Objective: Potentially inappropriate medications (PIM) contribute to poor outcomes in older patients, making it a widespread health problem. The study explored the occurrence and risk factors of PIM in older diabetic kidney disease (DKD) patients during hospitalization and investigated whether polypharmacy was associated with it. Methods: Retrospective analysis of the patients ≥ 65 years old diagnosed with DKD from July to December 2020; the PIM was evaluated according to the American Beers Criteria (2019). Factors with statistical significance in univariate analysis were included in Logistic multivariate analysis to explore the potential risk factors related to PIM. Results: Included 186 patients, 65.6% of patients had PIM, and 300 items were confirmed. The highest incidence of PIM was 41.7% for drugs that should be carefully used by the older, followed by 35.3% that should be avoided during hospitalization. The incidence of PIM related to diseases or symptoms, drug interactions to avoid, and drugs to avoid or reduce dose for renal insufficiency patients were 6.3%, 4.0% and 12.7%, respectively. The medications with a high incidence of PIM were diuretics (35.0%), benzodiazepines (10.7%) and peripheral ɑ1 blockers (8.7%). Compared with hospitalization, there were 26% of patients had increased PIM at discharge. Multivariate Logistic regression analysis showed that polypharmacy during hospitalization was an independent risk factor for PIM, OR = 4.471 (95% CI: 2.378, 8.406). Conclusion: The incidence of PIM in hospitalized older DKD patients is high; we should pay more attention to the problem of polypharmacy in these patients. Pharmacists identifying the subtypes and risk factors for PIM may facilitate risk reduction for older DKD patients.

Analysis of the prescription pattern of psychotropics in an outpatient department of a general hospital psychiatry unit

BACKGROUND

World Health Organization has prescribed drug use indicators for evaluating rational prescribing. Very few studies have been conducted on rational prescriptions for psychotropic drugs; hence, this study was undertaken at a tertiary care center of North India.

METHODS

After obtaining approval of the Institutional Ethics Committee, all prescriptions deposited with the dispensary of the psychiatry department of the hospital between 01 October 2017 and 31 December 2017 were included in the study. The prescriptions were analyzed for drug use indicators, namely the average number of drugs per encounter, percentage of prescriptions with generic name, percentage of prescriptions from the essential drug list, percentage of prescriptions with antibiotics, and percentage of prescriptions with an injection. In addition, the prescriptions were analyzed for patterns of psychotropics prescribed.

RESULTS

A total of 3770 prescriptions were analyzed. On an average, 2.35 medicines were prescribed per prescription. Injectable comprised 2.39% of prescriptions and fixed drug combinations were 0.16% of the total. Of all prescriptions, 91.3% were by generic name, while 55.02% of prescriptions were from the essential drug list. Polypharmacy constituted 4.53% of prescriptions. Risperidone, escitalopram, sodium valproate, and clonazepam were the most commonly prescribed drugs.

CONCLUSION

While we fared well with respect to the percentage of prescriptions with injections and those with an antibiotic, we have not been able to achieve the prescribed standards in prescription with generic names, number of drugs per prescription, and prescriptions from the essential drug list. The study emphasizes that there is scope for improvement.

A Systematic Review of Potentially Inappropriate Medications Use and Related Costs Among the Elderly

OBJECTIVE

Potentially inappropriate medications (PIMs) use is a common phenomenon among older adults. This paper aimed to perform a systematic literature review to assess PIMs use and related costs among elderly persons.

METHODS

This study was a systematic review. PubMed, Scopus, and the Institute for Scientific Information engines were used to search for all relevant studies published until 2020. Studies were excluded if they did not estimate the cost of PIMs for the elderly. In addition, non-English articles, editorials, letters, and review articles were excluded. All eligible articles were assessed for methodological quality. Finally, we extracted general characteristics from each eligible study.

RESULTS

This study showed that the prevalence of PIMs use among older adults was more than 30%. Drugs related to the central nervous system and cardiovascular disease, benzodiazepines, analgesics, and nonsteroidal anti-inflammatory drugs were most commonly used as PIMs. These studies concluded that PIMs could impose a high economic burden on the elderly and society. The mean cost for older adults with PIMs use was almost USD$2000 more than the mean cost for older adults without PIMs. Additionally, the total cost of PIMs use for all elderly persons in Canada in 2013 was estimated at USD$419 million.

CONCLUSIONS

Focusing on the most common PIMs, such as benzodiazepines and nonsteroidal anti-inflammatory drugs, helps implementing cost-effective strategies for reducing PIMs use and decreasing their clinical and economic effects.

Why is Pakistan vulnerable to COVID-19 associated morbidity and mortality? A scoping review

The scoping review was undertaken to outline the vulnerabilities of Pakistan's public health and healthcare system, which put the population at increased risk of coronavirus disease 2019 (COVID‐19) associated morbidity and mortality. The major electronic databases were searched using both “text words” and “thesaurus terms,” focusing on viral infections, COVID‐19 and healthcare systems in Pakistan. The content of the selected articles was analyzed by using thematic approach. Out of the total 171 potentially relevant citations, 24 articles were included in the data synthesis. We found that the recent COVID‐19 outbreak is a major threat to Pakistan's public health and healthcare system, and the country is not in a position to control spread of disease and provide required standards of care deemed necessary by the World Health Organization. A number of intertwined reasons that expose the Pakistani population at increased risk of COVID‐19 associated morbidity and mortality, include public related demurrals, healthcare workforce related demurrals, organizational and regulatory voids, and travel patterns. To cope with the upsurge of COVID‐19 in Pakistan, the regulators need to re‐examine and recognize deficiencies in the healthcare system, and thereafter reinforce core capacities in workforce and monetary resources, surveillance, laboratory services, and hospital preparedness for isolation and ventilation of patients.

Pharmacy Services beyond the Basics: A Qualitative Study to Explore Perspectives of Pharmacists towards Basic and Enhanced Pharmacy Services in Pakistan

Enhanced pharmacy services have been identified as a mechanism to address medicines and drug-related problems. The aim of the study was to explore the perspectives of practicing pharmacists on the scope of pharmacy service provision in Pakistan. This qualitative study was conducted at the Department of Pharmacy, the Islamia University of Bahawalpur (IUB). Face-to-face, in-depth interviews were conducted with practicing pharmacists at the university who were undertaking postgraduate studies. All interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis. A total of 13 pharmacists were interviewed. The analysis of data yielded four themes and 12 subthemes. The themes included the current scenario of pharmacy services, the benefits of pharmacy services, barriers to implementation of pharmacy services, and strategies to improve their delivery. Pharmacist participants reported that patient-oriented pharmacy services have not been properly implemented in Pakistan. Pharmacists appear to be undertaking only conventional roles at various levels within the healthcare system. The participants indicated multiple benefits of patient-oriented pharmacy services, including safe and effective use of medicines, minimization of drug-related problems, and financial benefits to the healthcare system. Based on the findings, policy-makers are required to take the necessary steps to overcome pharmacist-related and policy-related barriers associated with the implementation of patient-oriented pharmacy services in Pakistan.

Assessment of prescribing potentially inappropriate medications listed in Beers criteria and its association with the unplanned hospitalization: a cross-sectional study in Lahore, Pakistan

BACKGROUND AND OBJECTIVES

Due to physiological and pharmacological variations, geriatrics are at high risk of experiencing life-threatening outcomes related to the use of potentially inappropriate medications (PIMs). Thus, the present study aims to evaluate prescribing practices of PIMs among elderly patients who may lead to unplanned hospitalization and associated risk factors.

METHODS

A cross-sectional study was conducted in different hospitals of Lahore, Pakistan. The study population consisted of geriatric patients aged ≥65 years. Data were collected from the medical records of geriatric patients, who attended these selected hospitals between December 1, 2017, and February 28, 2018. Data were analyzed using SPSS (IBM SPSS Statistics for Windows, Version 21.0) and Microsoft Excel (MS Office 2010).

RESULTS

The records of 385 geriatric patients were investigated. More than half (60.8%) of the patients were subjected to polypharmacy, which can be defined as the utilization of 5-9 drugs by the patient at the same time, whereas 36.4% were prescribed with one PIM and 56.4% were hospitalized due to PIMs. Majority of them were prescribed with PIMs including N02BA01 (aspirin, 32.4%), A02BC01 (omeprazole, 23.6%), A10AB02 (insulin, 17.4%), A02BC05 (esomeprazole, 8.5%), C08CA01 (amlodipine, 8.3%), and R06AA02 (diphenhydramine, 5.9%). Results of regression analysis revealed that patients exposed to polypharmacy (OR=2.556, 95% CI=1.579-4.135, P-value≤0.001) and excessive polypharmacy (OR=37.828, 95% CI=4.754-300.9, P-value≤0.001) were significantly associated with unplanned hospitalization, whereas factors such as age 75-84 years (OR=0.343, 95% CI=0.156-0.756, P-value=0.008) and polypharmacy (OR=2.480, 95% CI=1.219-5.048, P-value=0.012) were significantly correlated with PIMs.

CONCLUSION

The utilization of PIMs listed in Beers criteria among geriatric population can cause unplanned hospitalization. As the patients receiving polypharmacy are at high risk of unplanned hospitalization, so caution must be exercised in prescribing PIMs for elderly people.

Influence of Education Level of Older Patients on Polypharmacy, Potentially Inappropriate Medications Listed in Beer's Criteria, and Unplanned Hospitalization: A Cross-Sectional Study in Lahore, Pakistan

Objective: To evaluate influence of education level of older patients on polypharmacy, potentially inappropriate medications (PIMs) listed in Beer’s Criteria, and unplanned hospitalization. Methods: A cross-sectional study was conducted among older people aged ≥65 years between 1 December 2017 and 28 February 2018. For data analysis, descriptive statistics and logistic regression analysis were employed. Results: Among 385 older patients, 88.8% were prescribed PIMs and 56.4% underwent PIMs associated unplanned hospitalization. Older people were less exposed to polypharmacy or excessive polypharmacy as their education levels increased (no formal education vs. primary vs. secondary vs. tertiary, 74% vs. 69.8% vs. 60.5% vs. 58.1%). Patients having higher education were also accompanied by significantly lower prescription of PIMs (no formal education vs. primary vs. secondary vs. tertiary, 96% vs. 87.3% vs. 84.5% vs. 79.1%) as well as unplanned hospitalization (no formal education vs. primary vs. secondary vs. tertiary, 64.7% vs. 76.2% vs. 40.3% vs. 46.5%). Results of regression analysis revealed that no formal education (OR = 1.202, 95% CI = 1.032–2.146, p-value = 0.003) and primary education level (OR = 1.175, 95% CI = 1.014–1.538, p-value = 0.039) were significantly associated with the use of polypharmacy among older people. On the other hand, no formal education was significantly associated with the prescription of PIMs (OR = 1.898, 95% CI = 1.151–2.786, p-value = 0.007). Furthermore, older people with no formal education (OR = 1.402, 95% CI = 1.123–1.994, p-value = 0.010) and primary education level (OR = 1.775, 95% CI = 1.281–3.018, p-value = <0.001) were significantly more likely to undergo unplanned hospitalization. Conclusions: Patients having low literacy level are more likely to receive PIMs, polypharmacy, and undergo unplanned hospitalization in comparison to highly educated patients. Hence, promotion of health literacy for patients is crucial to overcome these problems.

Causality and preventability assessment of adverse drug reactions and adverse drug events of antibiotics among hospitalized patients: A multicenter, cross-sectional study in Lahore, Pakistan

Background and objectives

Adverse drug events (ADEs) are the fifth leading cause of death and thus responsible for a large number of hospital admissions in all over the globe. This study was aimed to assess the antibiotics associated preventability of ADEs and causality of adverse drug reactions (ADRs) among hospitalized patients.

Methods

A prospective, cross-sectional, observational study was conducted in four tertiary care public sector hospitals of Lahore, Pakistan. Study population consisted of hospitalized patients who were prescribed with one or more antibiotics. Data were collected between 1^st January, 2017 and 31^st June, 2017 from 1,249 patients (384 patients aged ≤ 18 years and 865 patients aged >18 years). Schumock and Thornton scale was used to assess the preventability of the ADEs. Medication errors (MEs) that caused preventable ADEs were assessed by MEs tracking form while Naranjo score was used to evaluate the causal relation of ADRs with the antibiotics. Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) and Microsoft Excel (MS Office, 2010) were used for data analysis.

Results

2,686 antibiotics were prescribed to 1,249 patients. Among them, fluoroquinolones (11.8%), macrolides (11.6%) and cephalosporins (10.9%) were the most frequently prescribed antibiotics. The most affected organ system by antibiotics associated ADEs was gastrointestinal tract. A total of 486 ADEs were found. The preventability assessment revealed that most of the ADEs (58.4%) were preventable (43.6% of the ADEs were definitely preventable while 14.8% were probably preventable) and caused by MEs including wrong drug (40.1%) and monitoring errors (25.0%), during the stage of physician ordering (22.2%) and patient monitoring (21.1%). The errors were caused due to non-adherence of policies (38.4%) and lack of information about antibiotics (32%). Most of the non-preventable ADEs or ADRs among adults and children were “probable” (35.5%) and “possible” (35.8%), respectively. Logistic regression analysis revealed that ADEs were significantly less among females (OR = 0.047, 95%CI = 0.018–0.121, p-value = <0.001), patients aged 18–52 years (OR = 0.041, 95%CI = 0.013–0.130, p-value = <0.001), tuberculosis patients (OR = 0.304, 95%CI = 0.186–0.497, p-value = <0.001), patients with acute respiratory tract infections (OR = 0.004, 95%CI = 0.01−0.019, p-value = <0.001) and among the patients prescribed with 2 antibiotics per prescription (OR = 0.455, 95%CI = 0.319–0.650, p-value = <0.001).

Conclusion

According to preventability assessment most of the ADEs were definitely preventable and caused by MEs due to non-adherence of policies and lack of information about antibiotics. The causality assessment of non-preventable ADEs showed that most of the ADRs were probable and possible.

Causality and preventability assessment of adverse drug events of antibiotics among inpatients having different lengths of hospital stay: a multicenter, cross-sectional study in Lahore, Pakistan

BACKGROUND

A large number of hospital admissions are attributed to adverse drug reactions (ADRs) and they are the fifth leading cause of death worldwide. The present study aimed to assess the causality and preventability of adverse drug events (ADEs) of antibiotics among inpatients having different lengths of hospital stay.

METHODS

A prospective, observational study was conducted in four tertiary-care public sector hospitals of Lahore, Pakistan. Study population consisted of hospitalized patients who were prescribed one or more antibiotics. Data were collected between 1st January, 2017 and 30th June, 2017 from 1249 patients. Naranjo score, modified Schumock and Thornton scale were used for causality and preventability assessments, respectively. Medication errors (MEs) were assessed by MEs tracking form. SPSS and Microsoft Excel were used for data analysis.

RESULTS

A total of 2686 antibiotics were prescribed to 1249 patients and 486 ADEs were found. The preventability assessment revealed that most of the ADEs (78.8%) were found among patients having long length of stay (LOS) in hospital and were preventable (59.3% of the ADEs were definitely preventable while 44.7% were probably preventable) and caused by MEs including wrong drug (40.1%) and monitoring errors (25%). The errors were caused due to non-adherence of policies (38.4%) and lack of information about antibiotics (32%). Most of the non-preventable ADEs or ADRs among patients having long and short LOS in hospital were "probable" (35.5%) and "possible" (35.8%), respectively. Logistic regression analysis revealed that ADEs were significantly less among females (OR = 0.047, 95% CI = 0.018─0.121, p-value = < 0.001), patients aged 18─52 years (OR = 0.041, 95% CI = 0.013─0.130, p-value = < 0.001), patients with ARTIs (OR = 0.004, 95% CI = 0.01-0.019, p-value = < 0.001), patients prescribed with 2 antibiotics per prescription (OR = 0.455, 95% CI = 0.319─0.650, p-value = < 0.001) and patients with long LOS (OR = 14.825, 95% CI = 11.198─19.627, p-value = < 0.001).

CONCLUSION

Antibiotics associated definitely preventable ADEs were more commonly found in patients having long LOS in the inpatient departments because of MEs and lack of proper pharmacovigilance system. The ADRs showed a probable and possible causal association with both β-lactams and non β-lactams antibiotics.