Identification and resolution of drug-related problems among diabetic patients attending a referral hospital: a prospective observational study

The Association between Drug-Related Problems and Length of Stay of Type 2 Diabetes Mellitus Patients

Introduction

Drug-related problems (DRPs) are treatment-related occurrences that affect therapeutic efficacy. In a previous study, approximately 279 out of 330 (84.5%) patients with type 2 diabetes mellitus (T2DM) had experienced at least one DRP, including non-optimal drug effects (n = 240, 52.7%) and indications without medication (n = 137, 30.1%). Patients who were hospitalised for 5-10 days had the highest number of DRPs. Therefore, this study investigates the association between DRPs and length of stay (LoS) in patients with T2DM.

Methods

A cross-sectional study was conducted from January 2020 to May 2023 at Rumah Sakit Akademik, Universitas Gadjah Mada, Yogyakarta, Indonesia. Clinical pharmacists reviewed electronic health data to examine DRPs. The Fisher's exact test evaluated the association between DRPs and LoS.

Results

A total of 60.7% (n = 17) of the participants were females, with the majority falling into the age group ≥ 65 years old (n = 11, 29.7%). A significant portion experienced LoS > 7 days (n = 17, 60.7%). Antidiabetic monotherapy was predominant, and the categories of DRPs included adverse drug reaction (n = 15, 40.5%), dosage too high (n = 6, 16.2%), wrong drug (n = 6, 16.2%), non-adherence (n = 4, 10.8%), need for additional therapy (n = 4, 10.8%) and dosage too low (n = 2, 5.4%). A significant association was observed between non-adherence and LoS (P = 0.016). The possibility of experiencing LoS of 1-7 days increased by 3.43 times with improved non-adherence (OR = 3.43; 95% CI: 1.83, 6.39). In this context, non-adherence refers to DRPs associated with the non-compliance of patients with the prescribed treatment plan.

Conclusion

This study concludes that non-adherence was significantly associated with hospital LoS.

Acute COPD exacerbations and in-hospital treatment-related problems: An observational study

BACKGROUND

Treatment-related problems (TRPs) interfere with the ability to attain the desired goals of treatment, adding cost to healthcare systems. Patients hospitalized with acute conditions are at particular risk to experience TRPs. Data investigating such burden in patients with acute exacerbation of COPD (AECOPD) is generally scarce with no studies ever conducted in Jordan. This study aimed to investigate and categorize TRPs among patients hospitalized with AECOPD in Jordan, and to estimate their cost savings and cost avoidance.

METHODS

This was a retrospective population-based cohort study. Patients' cases of AECOPD admitted to the study site from Jan 2017 to Jul 2021 were identified from the electronic clinical database and screened for eligibility. TRPs were identified/categorized using AbuRuz tool and assessed for their severity. Cost saving was estimated by calculating all the extra costs. Cost avoidance was estimated according to Nesbit method.

RESULTS

A total of 1243 (mean±SD 3.1±1.5) and 503 (mean±SD 1.3±1.2) TRPs were identified during hospitalization and at discharge respectively, of which 49.4% and 66.7% were classified as "unnecessary drug therapy". In 54.5% of the cases, systemic corticosteroid was administered for a period longer than recommended. Most of the TRPs were of moderate severity. The total direct cost saving, and cost avoidance were estimated to be 15,745.7 USD and 340,455.5 USD respectively.

CONCLUSION

The prevalence and cost of TRPs among AECOPD patients is a concern requiring attention. The study results implicate integrating interventions such as embracing clinical pharmacists' role in the respiratory care units to optimize patients' management.

The unmet drug-related needs of patients with diabetes in Ethiopia: a systematic review and meta-analysis

Background

Diabetes is a major health concern globally and in Ethiopia. Ensuring optimal diabetes management through minimizing drug therapy problems is important for improving patient outcomes. However, data on the prevalence and factors associated with unmet drug-related needs in patients with diabetes in Ethiopia is limited. This systematic review and meta-analysis aims to provide a comprehensive analysis of the prevalence of unmet drug-related needs among patients with diabetes mellitus in Ethiopia.

Methods

A thorough exploration of databases, including PubMed, Scopus, Hinari, and Embase and Google Scholar, was conducted to identify pertinent studies. Inclusion criteria involved observational studies that reported the prevalence of unmet drug-related needs in Ethiopian patients with diabetes. The quality of the studies was assessed using Joanna Briggs Institute (JBI) checklists. A random-effects meta-analysis was employed to amalgamate data on study characteristics and prevalence estimates, followed by subsequent subgroup and sensitivity analyses. Graphical and statistical assessments were employed to evaluate publication bias.

Results

Analysis of twelve studies involving 4,017 patients revealed a pooled prevalence of unmet drug-related needs at 74% (95% CI 63-83%). On average, each patient had 1.45 unmet drug-related needs. The most prevalent type of unmet need was ineffective drug therapy, 35% (95% CI 20-50). Type 2 diabetes, retrospective study designs, and studies from the Harari Region were associated with a higher prevalence. Frequently reported factors associated with the unmet drug-related needs includes multiple comorbidities, older age, and polypharmacy. Notably, the results indicated significant heterogeneity (I2 = 99.0%; p value < 0.001), and Egger's regression test revealed publication bias with p<0.001.

Conclusion

The prevalence of unmet drug-related needs among diabetes patients with diabetes in Ethiopia is high with the most prevalent issue being ineffective drug therapy. Targeted interventions are needed; especially patients on multiple medications, advanced age, with comorbidities, and prolonged illness duration to improve diabetes management and outcomes.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42024501096.

Acceptance rate of clinical pharmacists' recommendations-an ongoing journey for integration

Introduction: Multidisciplinary expert team collaboration in the clinical setting, which includes clinical pharmacist involvement can facilitate significant improvements in outcomes and optimize patient management by preventing drug-related problems (DRP). This type of collaboration is particularly valuable in patients with multi-morbidity and polypharmacy such as diabetic foot patients. Evidence regarding the successful integration of a new clinical pharmacist, without previous experience into a unit is still scarce. Therefore, this study aimed to describe and evaluate the actual successful integration process of the clinical pharmacist into a diabetic foot unit by measuring the change in recommendation acceptance rate over time. Methods: A prospective, exploratory treatment effectiveness study based on the recommendation acceptance rate of a new clinical pharmacist introduced into the diabetic foot unit was conducted over a 9- month period. The clinical pharmacist identified medical and drug-related problems (DRP) or any discrepancies in the prescribing and administration of medications. Each identified DRP was documented and formulated as a recommendation by the clinical pharmacist. The main outcome measure was the acceptance rate of recommendations over time. Results: A total of 86 patients, of which 67% were men, averagely aged 66.5 (SD 11.8) years were evaluated. Calculated BMI was 30.2 (SD 6.2). The average number of medical diagnoses was 8.9 (SD3.2), and 11.1 (SD 3.7) prescribed drugs for each patient. Cardiovascular disease was presented by 95% (n = 82) of the patients and 33% of them (n = 28) had uncontrolled hyperglycemia. Averagely, 3.3 (SD 1.9) DRPs were identified pre patient. The efficacy-related DRP recommendation acceptance rate increased over the study period from 37.8% in the first 4 months to 79.4% after a period of 4.75 months. Safety-related DRP recommendation acceptance rate increased from 56% to 67.6%. Conclusion: Improved clinical outcomes and optimized pharmacologic patient management may be achieved by the successful integration of a clinical pharmacist into the team. This study provides evidence of the increasing recommendation acceptance rate of integrated, pharmacist-driven comprehensive medication management in an unexperienced unit. To overcome challenges, team members should collaborate to fully integrate the clinical pharmacist into the team-based structure and utilize proper strategies to minimize and transcend barriers.

Patterns of drug-related problems and the services provided to optimize drug therapy in the community pharmacy setting

Introduction

Drug-related problems (DRPs) are events or circumstances involving drug therapy that actually or potentially interferes with desired health outcomes.

Objectives

To assess community pharmacists' knowledge and practice regarding DRP-reduction services, as well as the barriers and factors associated with decreased provision of these services.

Methods

This cross-sectional study utilized a validated questionnaire to assess pharmacists' knowledge, practice, and barriers to the provision of DRP-reduction services in the community pharmacy setting. Binary regression model was used to assess the variables associated with the practice of DRP-reduction services.

Results

A total of 412 pharmacists participated in the study. The pharmacists demonstrated strong knowledge but inadequate practice of DRP-reduction services. The most reported DRPs were inappropriate combination of drugs, or drugs and herbal medications, or drugs and dietary supplements (52.4%), patients' inability to understand instructions properly (46.1%), inappropriate drug according to guidelines (43.7%), and too high dose (40.3%). The most common barriers to these services were increased workload (60.5%), limited time (53.2%), and lack of good communication skills (49.8%). The presence of a counselling area in the pharmacy increased the practice of DRP-reduction services (OR: 3.532, 95%Cl: 2.010-5.590, P < 0.001), while increased weekly working hours (OR: 0.966, 95%Cl: 0.947-0.986), P < 0.01) and serving < 10 patients daily (OR = 0.208, 95%Cl: 0.072-0.601, P < 0.01) decreased it.

Conclusions

Community pharmacists' practice of DRP-reduction services showed a scope for improvement. Future pharmaceutical care initiatives should increase the number of personnel working in the pharmacy and provide them with opportunities for continued education and training in order to improve the provision of DRP services and optimize patients' outcomes.

Determination of drug-related problems among type 2 diabetes outpatients in a hospital in Vietnam: A cross-sectional study

INTRODUCTION

Drug-related problems (DRPs) are common in clinical practice and occur at all stages of the medication process. The major factor contributing to DRPs is prescription, although patients' poor adherence to treatment is also a significant factor. This study evaluated type 2 diabetes outpatients in a hospital in Vietnam for drug-related problems (DRPs) and related variables.

METHODS

A cross-sectional descriptive study was conducted on 495 outpatients who met the criteria and 157 people agreed to participate in the interview. Medication order review and medication adherence review were used to identify DRPs. The types of DRP were based on the Pharmaceutical Care Network Europe (PCNE) categories version 9.0. The identification and assessment DRPs were carried out by clinical pharmacists and get agreed upon by physicians who had not directly prescribed patients who participated in the study.

RESULTS

A total of 762 DRPs were identified via prescribing review process, the average number of DRP on each prescription was 1.54±1.07, while 412 DRPs were determined through patient interviewing. The most frequent DRPs were "ADR (Adverse Drug Reaction) occurring" (68.8%). The main causes were "patient is unable to understand instructions properly" or "patient is not properly instructed", "patient stores insulin inappropriately", "patient decides to use unnecessary drugs" and "patient intentionally uses/takes less drug than prescribed or does not take the drug at all for whatever reason" which accounted for 65.0%, 41.4%, 38.2%, and 28.7%, respectively. From the prescribing review, the most observed DRPs were "Inappropriate drug according to guidelines/formulary" and "No or incomplete drug treatment in spite of existing indication", accounting for 45.0% and 42.9%, respectively. There was a significant association between age (OR 3.38, 95% CI: 1.01-11.30), duration of diabetes (OR 3.61, 95%CI: 1.11-11.74), presence of comorbidity (OR 5.31, 95%CI: 1.97-14.30), polypharmacy (OR: 2.95, 95%CI: 1.01-8.72) and DRPs. In patients, poor knowledge of antidiabetic agents was the main reason to lack adherence and occurring ADR (OR 2.73, 95%CI: 1.32-5.66, p = 0.007 and OR 2.49, 95%CI: 1.54-4.03, p = 0.001 respectively).

CONCLUSION

DRPs occurred in the prescribing stage and relating to patient's behavior of drug administration was high. Clear identification of DRPs and the associated factors are essential for building the intervention process to improve effectiveness and safety in the treatment of type 2 diabetes mellitus patients.

Pharmacotherapy problems and associated factors among type 2 adult diabetic patients on follow up at Mizan-Tepi University Teaching Hospital, Southwest Ethiopia

BACKGROUND

Over the past few decades, drug therapy problems (DTPs) have become a significant public health concern worldwide. DTPs in patients with diabetes are responsible for uncontrolled glycemia, disease worsening, early development of complications, high healthcare expenses, prolonged and recurrent hospitalizations, and mortality.

OBJECTIVES

This study aimed to identify the prevalence of drug therapy problems and determine the associated factors among patients with type II Diabetes Mellitus at a University Teaching Hospital in Southwest Ethiopia.

METHODOLOGY

Hospital-based cross-sectional study was conducted between September and October 2022. Data were collected through medical record reviews and interviewer-administered structured questionnaires, which were then analyzed using SPSS version 26. Cipolle's method was adapted for classification of DTPs. Bivariate followed by multivariate logistic regression analysis was used to assess the association between predictor variables and the outcome variable. P-value ≤ 0.05 was employed as a cut-off point to determine statistical significance.

RESULT

Among 117 participants, 172 drug therapy problems (DTPs) were identified, with an average of 1.47 DTPs per patient, and83 (70.9%) participants had at least one type of drug therapy problem. Of the seven DTPs identified, need additional drug therapy was the most common, 50 (42.7%), followed by non-compliance with medication, 45 (38.5%) and ineffective drug therapy, 25 (21.4%). Occupational status and comorbidity were factors that associated with the occurrence of DTPs. Farmers were approximately four times more likely to develop DTPs than housewives were (adjusted odds ratio (AOR) = 3.56, 95% CI: 1.12-11.38, P = 0.03). The odds of drug therapy problems were twice as high in those with four comorbid conditions than in those without comorbidities (AOR = 1.95, 95% CI: 0.90-3.76, p = 0.02).

CONCLUSION

In the current study, the proportion of type 2 diabetes patients with drug therapy problems was high. This potentially lead to uncontrolled glycemia and early development of comorbid conditions, increasing morbidity and mortality rates. This could be attributed to the failure to effectively integrate clinical pharmacy services in different hospital wards, which is the case in virtually all hospitals in Ethiopia.

Evaluation of the Prevalence and Risk Factors of Drug-Related Problems in Hypertension and Type 2 Diabetes Mellitus Patients at a Tertiary Care Hospital: A Cross-Sectional Study

Background Drug-related problems (DRPs) potentially interfere with the desired treatment goals which may lead to increased healthcare costs, morbidity, and mortality. Despite the negative consequences of DRPs, there is a lack of comprehensive research on their prevalence and risk factors, particularly in chronic diseases such as hypertension and type 2 diabetes mellitus (DM). This study aims to evaluate the prevalence and contributing factors of DRPs among hypertension, type 2 DM, and hypertension with type 2 DM in the outpatient general medicine department. Methodology A hospital-based, prospective, observational study was conducted over three months. DRPs were classified using the Helper-Strand classification. The potential risk factors contributing to DRPs were assessed using binary and multinomial logistic regression methods. A p-value <0.05 was considered statistically significant. Results Among the 236 study participants, DRPs were more prevalent in males, and the mean age of the participants was 51.73 ± 9.47 years. DRPs were found in 76% of the study participants, and the mean number of DRPs per patient was 1.16 ± 0.45. Among the identified DRPs, suboptimal therapeutic goals (33%) were the most frequently observed, followed by ineffective drugs (32%), medication non-adherence (23%), and drug-drug interaction (5%). Therapeutic duplication and overdose were less commonly encountered as DRPs. The presence of comorbidity (adjusted odds ratio (AOR) = 5.77), and smoking (AOR = 21.07) were found to be significant risk factors (p < 0.05) contributing to DRPs. Conclusions DRPs are more prevalent in hypertension, type 2 DM, and hypertension with type 2 DM. Age range (40-60 years), comorbidity, and smoking were found to be associated with a higher incidence of DRPs. The implementation of a multidisciplinary team approach involving clinical pharmacists and physicians can effectively identify the prevalence and determine the associated risk factors of DRPs and subsequently may help employ targeted interventions to mitigate the development of DRPs.

Prevalence and factors associated with inappropriate anti- diabetic medication therapy among type 2 diabetes mellitus patients at the medical and surgical wards of Mbarara Regional Referral Hospital, Uganda

Background

Inappropriate Anti-diabetic Medication Therapy (IADT) refers to a drug-related problem and includes ‘ineffective drug therapy’, ‘unnecessary drug therapy’, ‘dosage too high’, and ‘dosage too low’. This study aimed to determine the prevalence and factors associated with IADT among T2DM patients at Mbarara Regional Referral Hospital, Uganda (MRRH).

Method

A prospective cross-sectional study was conducted at the medical and surgical wards of MRRH from November 2021 to January 2022. One hundred and thirty-eight adult patients aged 18 years and above, with T2DM, were recruited using consecutive sampling. Patient file reviews and interviewer-administered questionnaire was used for data collection. The data were entered into and analyzed using SPSS version 25. Descriptive analysis was employed to describe the population and determine the prevalence of IADT. Types of IADTs were identified using Cipolle’s DRP classification tool. A univariate and multivariate logistic regression analysis was used to identify factors significantly associated with IADT. The P-value of < 0.05 was considered statistically significant at 95% confidence interval.

Results

A total of 138 hospitalized T2DM patients were studied. Eighty (58.0%) were females, and 70 (50.7%) were ≥ 60 years of age. Out of a total of 138 participants, 97 experienced at least one IADT, with an estimated prevalence of 70.3%. ‘Dosage too high’ (29.2%) and ‘dosage too low’ (27.9%) were the most common type of IADTs. Age ≥ 60 years (AOR, 8.44; 95% CI, 2.09–10.90; P-value = 0.003), T2DM duration of < 1 year (AOR, 0.37; 95% CI, 0.11–0.35; P-value = 0.019), and HbA1c of < 7% (AOR, 9.97; 95% CI, 2.34–13.57; P-value = 0.002) were found to be factors significantly associated with the occurrence of IADTs.

Conclusion

The overall prevalence of inappropriate anti-diabetic medication therapy among T2DM patients admitted to medical and surgical wards of MRRH was 70.3%. The most common type of IADT in this study was ‘dosage too high’, accounting for almost one-third followed by ‘dosage too low’ accounting for a quarter of total IADTs. Age greater or equal to 60 years, T2DM duration of < 1 year, and HbA1c of < 7% during the current admission were found to be factors significantly associated with the occurrence of IADTs in hospitalized T2DM patients.