PREVALENCE AND PREDICTORS OF DRUG-RELATED PROBLEMS AMONG MEDICAL WARD PATIENTS IN A SECONDARY CARE REFERRAL HOSPITAL: A PROSPECTIVE HOSPITAL-BASED INTERVENTIONAL STUDY

PREVALENCE AND PREDICTORS OF DRUG-RELATED PROBLEMS AMONG MEDICAL WARD PATIENTS IN A SECONDARY CARE REFERRAL HOSPITAL: A PROSPECTIVE HOSPITAL-BASED INTERVENTIONAL STUDY

Samhitha Y. Reddy * and Somashekar K. Reddy

Department of Pharmaceutical Sciences, Jawaharlal Nehru Technological University Anantapur, Ananthapuramu, Andhra Pradesh, India.

ABSTRACT: Drug-Related Problem (DRP) affects the hospital stay, healthcare budget, quality of life, morbidity, and mortality. The study aims to assess the prevalence and predictors of DRPs in hospitalized patients and provide intervention. A prospective interventional study was conducted in the in-patient medical department of the NGO hospital. A total of 310 subjects were enrolled and screened for the presence of DRP. The identified DRPs were categorized according to the Hepler and Strands. Depending on DRP, the clinical pharmacist provided an intervention at the patient and physician level and recorded the acceptance. The data was analyzed using SPSS™. Binary logistic regression was employed to associate risk factors with DRPs. The prevalence of DRPs in the medical department was 80.0%, with a 0.93 DRP/patient average. Drug interactions(DI) (28.4%) and adverse drug reactions (ADR) (21.8%) are the most common DRPs. Anti-microbials (78.0%) and Anticonvulsants (81.2%)showed a greater risk of developing DRPs. Variables like advanced age, the habit of alcohol and smoking, hospital stay, and polypharmacy were significantly associated with DRPs. A total of 179 interventions were recommended, and the acceptance rate was 83.7%. Dosage (23.6%), time adjustment (17.9%), and counseling (15.6%) are the most common pharmacist interventions. Patient counseling is a widely accepted and implemented intervention. The prevalence of DRPs in in-patients of the medical ward was 80.0%. DI and ADR are the most common DRPs found in our study. Developing a drug policy focused on factors associated with DRPs may reduce the burden of DRPs and improve patient outcomes.

Keywords: DRPs, Clinical Pharmacist, Pharmaceutical care, Intervention

INTRODUCTION: A drug-related problem (DRP) is an event or circumstance that occurs during the treatment of a disease that actually or potentially interferes with the achievement of optimal health outcomes ¹.

Drugs are considered a double-edged sword, where appropriate drug use can cure the ailments; if not, they can cause harm to the patient in the form of drug-related problems ².

In hospitalized patients, drug-related problems may ensue during prescribing, dispensing, administration of drugs, and treatment follow-up ³. DRPs are classified into eight categories according to Hepler and Strand. They include; untreated indication, improper drug selection, subtherapeutic dosage, overdosage, adverse drug reaction, failure to receive drugs, drug interactions, and drug use without an indication ⁴. Patients admitted to medical wards are at greater risk of developing DRPs due to several factors: acute illnesses, advanced age, comorbidities, younger patients with severe disease, polypharmacy, renal impairment, and frequent change in the drug therapy ⁵. Previous studies suggest that most hospitalized patients will experience at least one DRP during their hospital stay. For example, studies from Southwest Ethiopia, Northern Sweden, Spain, Jordan, and Norway reported that the prevalence of DRPs among hospitalized patients was 73.5%, 66.0%, 45.1%, 41.8%, 98.3% and 81.0%, respectively 3, ^6–9. The DRPs significantly impact hospital stay, healthcare budget, quality of life, morbidity, and mortality ¹⁰. Therefore, early detection and prevention can minimize the negative impact of DRPs on health and economic outcomes. The Indian evidence shows that most DRP studies focused on specific illnesses/drugs/populations or ambulatory patients ^11–13. Also, few studies addressed the predictors of DRP and the medical team's acceptance of recommended clinical pharmacist interventions ¹⁴. There was no study performed to assess the DRPs in Indian rural hospital settings. The study aims to assess the prevalence and predictors of drug-related problems in medical wards of a rural secondary care referral hospital.

MATERIALS AND METHODS: A prospective hospital-based interventional study was conducted in the in-patient medical department of a 330 bedded NGO charity hospital - Rural Development Trust Hospital, situated in a small village of Bathalapalli, in the socio-economically backward district of Anantapur, Andhra Pradesh, India.

Study Criteria: All patients aged 18 years or more and admitted to the in-patient medical wards between December 2018 and August 2019 (9 Months) are eligible for the study. Patients admitted to the Intensive Care Unit (ICU) who refused to give consent, readmitted during the study period, and were discharged before collecting data were excluded from the trial.

Ethical Considerations: The study was conducted after getting ethical clearance from the Institutional Review Board (Reg. No: RIPER-IRB-PP-2018-043). After explaining the study protocol and objectives in an understandable language, oral and written informed consent was obtained from all enrolled subjects. Patients' names and other identifiers were not mentioned in the data collection tool to ensure confidentiality.

Sample size and Sampling Technique: To estimate the number of subjects that need to be included in the study, a single proportional population formula was used with a prevalence of DRPs of 28.0% from else report, 95% confidence interval, 5% of margin of error, design effect 1%, and 80% power, which was calculated as 284. The eligible subjects were chosen for the study using a convenient sampling technique.

Study Procedure: A total of 310 subjects who met the study criteria were enrolled by taking oral and written informed consent. A pre-designed and structured data collection form was used to collect the selective information from the data resources (patient case sheets, medication charts, lab reports, and patient/caregiver interviews). The data collection form mainly contains patient demographics, clinical features, social habits, past medical and medication history, laboratory details, current diagnosis, current medication therapy, and progressive daily report. The current medication therapy details include all drugs' names, route of administration, dose, frequency, duration, indication, and date of drugs started and stopped. The past medical and medication history includes allergies (food and medicine), comorbidities, and previously received drugs. The study investigator evaluated the appropriateness of drug therapy using various resources like primary (standard literature), secondary (Micromedex), and tertiary (e.g., BNF, AHFS, and Martindale), which are available in the Pharmacy Practice department. The identified DRPs were recorded and categorized according to Hepler and Strands classification of DRPs 1990as an untreated indication, improper drug selection, subtherapeutic dosage, overdosage, adverse drug reaction, failure to receive drugs, drug interactions, and drug use without an indication. Depending on the type of DRP, the clinical pharmacist applies the specific intervention to patients/healthcare providers to achieve a better therapeutic outcome. The healthcare providers' acceptance level of clinical pharmacist intervention was categorized as; 1. Intervention accepted therapy changed, 2. Intervention accepted therapy not changed, 3. Neither intervention accepted nor therapy changed and 3. No intervention

Data Analysis: The data wasanalyzed using SPSS™ 23.0 (SPSS™, Chicago, IL, USA). Descriptive statistics like mean, standard deviation, number, and proportion were used to represent the demographics, clinical characteristics, distribution of DRPs, and clinical pharmacist interventions in the study population. A binary logistic regression analysis test was employed to test for significant association between the age, gender, comorbidities, length of the hospital stay, polypharmacy, and route of the administration towards getting DRPs. The findings are considered as a statistically significant association if P < 0.05.

RESULTS: A total of 310 subjects were enrolled in the study. The findings of our research revealed that the majority of the patients are between the ages of 18 and 40 years (129; 41.6%), males (188; 60.6%), normal weight (238; 76.8%), rural residents (252; 81.3%), no allergy (304; 98.1%), no habit of smoking and alcohol consumption (125; 40.3%), not suffering from any co-morbid condition (177; 57.1%), stayed in hospital less than or equal to four days (214; 69.0%), taking drugs less than five (194; 62.6%) and the hospital is at least once in the past 12 months (174; 56.1%).

The distribution of the socio-demographic and clinical characteristics of the study subjects is shown in Table 1.

TABLE 1: SOCIO-DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF THE STUDY POPULATION (N=310)

SD=Standard Deviation

TABLE 2: TYPE OF DRUG-RELATED PROBLEMS IDENTIFIED AMONG PATIENTS ADMITTED IN THE MEDICAL WARD

Among 310 study subjects, 248 (80.0%) had drug-related problems (DRPs). 289 DRPs were identified in the study, with an average of 0.93 DRPs/Patient. Drug interactions (28.4%) and adverse drug reactions (21.8%) are the most commonly identified DRPs in the study. The distribution of the DRPs according to the percentage of total DRPs and patients were represented in Table 2.

TABLE 3: DISTRIBUTION OF THE DRUG-RELATED PROBLEMS ACCORDING TO THE DRUG CATEGORY

UI=Untreated Indication; IDS=Improper Drug Selection; STD=Sub-therapeutic dose; OD=Over Dose; ADR=Adverse Drug Reaction; FRD=Failure to receive drug; DI=Drug Interaction; DWI=Drug without indication.

The distribution of the drug-related problems according to drug category wise was represented in Table 3. Anti-microbials (78.0%), Anticonvulsants (81.2%), Narcotic analgesics (66.6%), ACE Inhibitors (62.1%), and Thyroid hormones (60.9%) show a greater risk of developing DRPs.

TABLE 4: ASSOCIATION OF PATIENT CHARACTERISTICS FOR THE DEVELOPMENT OF DRPs (N=310)

SD=Standard Deviation

Table 4 shows the association of socio-demographic and clinical profiles toward the development of DRPs in patients admitted to the medical ward. Variables like age of more than 40 years, the habit of alcohol consumption and smoking, hospital stay more than four days, and taking drugs more than or equal to five were significantly associated with the development of DRPs with a P value less than 0.05.

TABLE 5: CLINICAL PHARMACIST INTERVENTIONS AND THEIR ACCEPTANCE LEVELS

A total of 179 pharmaceutical interventions were recommended to resolve drug therapy problems. The acceptance rate of the clinical pharmacist recommended intervention was 83.7%.

In our study, dosage (42; 23.6%) and time interval adjustment (32; 17.9) and patient counselling (28; 15.6%) are the most commonly recommended pharmacist interventions to resolve DRPs. Pharmacist-mediated patient counselling is a widely accepted and implemented intervention to DRPs lying at the patient level.

The distribution of clinical pharmacist interventions and their acceptance levels were represented in Table 5.

DISCUSSION: Assessment of the DRP prevalence and identification of risk factors associated with DRPs in in-patient hospital settings is essential for developing interventions at the individual patient level. The study findings revealed that the prevalence of DRPs in the medical department was 80.0%, with an average of 0.93 DRP/patient. The magnitude of DRPs in this study is high compared to the other studies conducted in Gondar (66.0%), Dessie referral hospital (75.5%), Tikur Anbesa hospital (70.4%), Jimma University hospital (73.5%), and Indian hospital (41.8%) ^{12, 15–18}. However, this study shows less rate of DRPs compared to the study conducted in Kenya (93.8%), Norway (81.0%), and Jordan (98.3%) ^{8, 19, 20}. The primary reason for the wide variation in the prevalence of DRPs across countries might be due to changes in their clinical practice, a different classification system for DRPs, and varied healthcare settings. The study recommends providing evidence-based interventions to reduce the burden of DRPs. Also, the study endorses the researchers' use a single classification system in the assessment of DRPs. This helps in the comparison of intra and inter-country variation of the DRP magnitude.

In this study, drug interactions (28.4%) and adverse drug reactions (21.8%) are the most commonly identified DRPs. A study conducted in Adama Hospital Medical College, Ethiopia, and Navie Hospital, Northern Sweden, showed that ADR and drug interaction are the predominant DRPs identified, respectively, nearly similar to the current study ^{18, 21}. However, the study conducted in Ethiopia shows an unnecessary drug therapy is the major DRP10. The least common drug therapy problem observed in this study is failure to receive drugs, similar to the study conducted in Southwest Ethiopia ¹⁰. The low rate of medication non-adherence observed in this study is due to the administration of drugs by the nurses in in-patient hospital settings.

In this study, Anti-microbials (78.0%), Anticonvulsants (81.2%), and Narcotic analgesics (66.6%) drug classes were associated with a high rate of DRPs. Studies conducted in Northeast (28.0%) and Southwest Ethiopia (25.0%) also show that antimicrobials are the primary drugs in developing DRPs ^{10, 16}. In contrast, a study conducted in Gondar revealed proton pump inhibitors are associated with a high rate of DRPs. The wide variability in the drug class involved in developing DRP is due to different practice guidelines and patient and physician preferences across the countries. A total of 179 pharmaceutical interventions were recommended to resolve drug therapy problems. The acceptance rate of the clinical pharmacist recommended intervention was 83.7%. The acceptance rate of pharmacist intervention is not clearly assessed in previous studies on DRPs in clinical practice ^22–24. Few studies show that the percentage of pharmacist-led interventions' acceptance is very inconsistent. In two studies, the acceptance rate of clinical pharmacist interventions was lower (56% and 69%) than in the current study ^{25, 26}. Whereas, in two studies, the acceptance rate was more than 80% which is similar to the findings of the present study ^{7, 27}. In the current study, pharmacist-led patient counselling is the highly agreed intervention in resolving drug therapy problems to achieve a definite outcome. The wide acceptance of recommended interventions in this study is majorly due to the running of clinical pharmacy services in the hospital for 10 years; clinicians trust pharmacist-provided information, clinically relevant recommendations by the pharmacist, and delivery of evidence-based and unbiased information using an authentic software.

Variables like age of more than 40 years, the habit of alcohol consumption and smoking, hospital stay more than four days, and taking drugs more than or equal to five were significantly associated with the development of DRPs with a P value less than 0.05. In the aging process, the patient will suffer from comorbidities, take multiple medications, and hepatic and renal function failure are the few reasons for the development of DRPs. The positive impact of age on the development of DRPs was also observed in various studies conducted in India, Southwest Ethiopia, and Northern Sweden ^{7, 14, 18}.

However, a study conducted in Jordan showed that advanced age is not a predictor of the existence of DRPs ⁸. This might be due to variation in the type of medical care offered to the specific age of the population. The polypharmacy in this study is also one of the major contributing factors to drug interactions. These results were similar to the study conducted by Abdela et al., in which polypharmacy showed a positive association with developing DRPs ²⁸. These findings suggest that control on the number of prescribed medications to treat medical conditions will reduce the risk of the development of DRPs. Prolonged hospital stay is associated with an increased risk of DRPs due to an increased number of drugs to treat hospital-acquired infections.

Strengths and Limitations: The study provides evidence on predictors of DRPs and clinical pharmacist interventions provided to combat DRPs in rural hospital settings of South India. As the study is a cross-sectional study, it identifies associations, not an exact causal relationship, between risk factors and the development of DRP. The study was conducted in a rural secondary care referral hospital.

So, the findings of this study may not be generalized toward primary and tertiary care hospitals. The outcome of clinical pharmacist interventions was not evaluated as this study was not collected data on a regular practice basis. In the future, randomized comparative studies are required to address the impact of clinical pharmacist interventions on economic, clinical, and humanistic outcomes (ECHO)

CONCLUSION: The study concludes that the prevalence of DRPs in medical ward patients was 80.0%. Drug interactions and adverse drug reactions are the most common DRPs found in our study. Developing the drug policy guidelines focused on factors associated with DRPs may reduce the burden of DRPs and improves patient outcomes. In our study, dosage adjustment and patient counselling are the most commonly recommended pharmacist interventions to resolve DRPs. Pharmacist-mediated patient counselling is a widely accepted and implemented intervention to reduce DRPs lying at the patient level. Clinical pharmacist needs to work with the healthcare team in the rationalization of the prescription and to improve the clinical outcomes.

ACKNOWLEDGEMENT: The authors would like to thank all participants involved in this research study. We also thank Dr. Sudheer Kumar, Director, RDT Hospital, Anantapur, for his support in conducting the study in the hospital.

All the authors are wholeheartedly thankful to the people who are directly or indirectly responsible for completing the work.

CONFLICTS OF INTEREST: There are no conflicts of interest.

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    How to cite this article:

    Reddy SY and Reddy SK: Prevalence and predictors of drug-related problems among medical ward patients in a secondary care referral hospital: a prospective hospital-based interventional study. Int J Pharm Sci & Res 2022; 13(6): 2450-57. doi: 10.13040/IJPSR.0975-8232.13(6).2450-57.

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