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5d. Chronic Care: Treatment of Chronic Diseases - The Patient's Perspective
Assessment of Patient Knowledge Regarding Drugs Prescribed and Dispensed in Some Health Insurance Outpatient Clinics in Alexandria
High Institute of Public Health, Egypt
Problem statement: Rational prescription and use of drugs has been a concern in both developed and developing countries during the last two decades and has been promoted by WHO and others. Researchers are generally aware of the relationship between patient knowledge of prescribed and dispensed medications and medication-taking behaviour.
Objectives: To assess patients’ knowledge regarding drugs prescribed and dispensed and to identify its determinants
Design: A prospective cross-sectional study design
Setting: A study was conducted at five randomly selected health insurance outpatient clinics in the Alexandria governorate.
Study population: A random sample of 1,860 patients was interviewed about their knowledge of drugs, immediately after dispensing. Mean knowledge scores were calculated based on patient recall of name, dosage of drug, duration of treatment, and reason for prescription (incorrect recall = 0; 1 point for each correct recall attribute; maximum score = 4).
Results: Results indicated that the mean patient knowledge score of dispensed drugs was 2.49 (a score of 2.40 and above was regarded as an acceptable level of knowledge). The highest percentage of knowledge was for the item of duration of treatment (76.9%), followed by dosage of drug (69.3%), reason for prescription (20.1%), and finally name of drug (49.1%). In relation to factors independently associated with patient knowledge score, multiple regression analysis revealed that two factors were significant, namely patient occupation (where professionals achieved the highest mean knowledge score of 3.63 and housewife groups achieved the lower scores of 1.73) and number of dispensed drugs (where the greater the number of drug items per patient prescribed and dispensed, the lower the mean knowledge score). By contrast, prescribing staff qualification was not independent predictor. The predictors model explained 48% of variance in patient knowledge score. Antihypertensive drugs were the most well-known drugs to patients with the highest mean knowledge score of 2.94.
Conclusions: It was concluded that training of pharmacists to be active members of the health care team and to offer useful advice to patients about health and dispensed drugs is very critical for improvement of the quality of their practice, and it is one of the prerequisites for patient compliance with treatment. Moreover, treatment guides and training courses should emphasize the importance of adequate labeling and instructions to patient.
Funding source(s): None
“I Wish I Had AIDS”: Qualitative Study on Access to Health Care Services for HIV/AIDS and Diabetic Patients in Cambodia
Center for Advanced Study, Cambodia
Problem statement: Poor Cambodians with chronic diseases such as HIV/AIDS or diabetes typically encounter multiple serious barriers to effective care and treatment. This process may extend over many years and involve numerous rounds of diagnosis and treatment as the disease progresses from initial symptoms to longer term complications. Living with both the impact of the disease and this ongoing struggle for care can severely disrupt the everyday life of both sufferers and their families.
Objectives: To explore and document the differences and similarities in the types of barriers to care and treatment at different phases of their illness experience reported by patients with HIV/AIDS or diabetes
Design: This retrospective study adopted qualitative research methods to collect data from HIV/AIDS and diabetic patients enrolled and not enrolled in treatment programs in different institutions in urban and rural setting.
Setting: The study was conducted in urban and rural settings. In the urban area (Phnom Penh), interviewees were selected from patients enrolled in a free care program at the Centre of Hope. This charity hospital is an important provider of treatment and care for both HIV/AIDS and diabetes patients. Similarly, in the rural area (Takeo Province), interviewees were selected from patients enrolled in a free care program at the chronic disease clinic co-managed by the referral hospital and MSF Belgium. Again, this facility provided care and treatment for both disease groups. Patients not enrolled in the treatment program were identified through key informants such as traditional healers and not-for-profit service providers.
Study population: Using purposive and snowball sampling techniques, 25 HIV/AIDS and 45 diabetic patients were recruited. Semi-structured and open-ended interviews were used to collect information on patient experiences of different phases in the ongoing process of seeking care and treatment. Qualitative analysis was done to search for emerging themes, word repetition and local terminology that captured the meaning of patients’ experiences.
Results: The findings indicate that both HIV/AIDS and diabetic patients encounter multiple supply- and demand-side barriers to care at different stages of their illness. Moreover, they strongly suggest that supply-side barriers, for example rationing systems or targeting strategies that limit access to free treatment or social assistance, are substantially higher for diabetic patients. This perceived inequity had a profound impact on diabetic patients to the extent that some “wished they had HIV/AIDS.”
Conclusions: These findings suggest that there is an urgent need to widen the focus of health care to address the substantial and increasing burden of chronic diseases in Cambodia and many other low/middle income countries.
Funding source(s): This study is an output of the EuropeAID project supported by the European Commission.
Household Survey on Medicine Use in Oman
Directorate of Rational Use of Medicines, Ministry of Health, Sultanate of Oman, Oman
Problem statement: Irrational use of medicines in the community is a global problem. No national household survey on medicine use has been conducted in Oman, and the few studies in other countries have rarely been published or not fully documented.
Objectives: To investigate the use and storage of medicines in the community and to identify related problems
Methods: A cross-sectional study was performed using a written pre-tested structured interview questionnaire along with direct observations. 1,050 households were chosen from 12 urban and rural villages in 6 willayat (districts) located in 4 health regions in Oman. The storage and use of medicines in the community were investigated.
Results: The key results showed that most of the drugs were stored in relatively inadequate and unsafe places. There were 44.4% of households with members suffering from chronic diseases. In 52.8% of the households, one or more persons used traditional medicines. The most common types of traditional medicines used were herbal medicines (49.8%), and the most common use of herbal medicines was for gastrointestinal tract problems. Modern medicines were found in 95% of the households. The average number of medicines per household and the maximum number found in one home were 6 and 45 medicines, respectively. The most common therapeutic category encountered was musculoskeletal drugs (24.9%). 45.8% of the households had one or more antibiotics, and the percentage of antibiotics from all medicines found was 12.55%. The percentage of unused and expired medicines were 31.6 % and 12.4%, respectively. The maximum number of antibiotics found in one household was 10. The majority of medicines at homes (86.1% and 70.3%) were advised by physicians and obtained from public pharmacies, respectively. 61.3% of the households kept left-over medicines from previous treatment. The households did not know the indications of 15.4% of the stored medications. 15.5% of the respondents mentioned that they do not check the expiry date, and 12.4% of medicines found were already expired. The percentage of medicines found to be inadequately labeled and the percentage of households’ knowledge of correct dosage were 92% and 65.9%, respectively.
Conclusion: The results show, medications were stored in large quantities at homes and in inadequate places. A large percentage was being wasted. Therefore, the need is compelling for promoting rational use of medicines in the community to enable people to store and use medicines in an appropriate, safe, and judicious way.
Funding source(s): Financial support was received from WHO-EMRO under JPRM.
Polypharmacy Among Older Adults in Tehran
Tehran university of medical sciences/school of public health, Iran, Islamic Republic of
Problem statement: Multiple drug use is frequently considered to be hazardous for the elderly because of their greater vulnerability to the complications. The older population in Iran is increasing and they likely use more drugs than any other age groups. The older adults often suffer from chronic conditions that may require long-term medical treatment, and likely involve multiple drug therapies. These patients may consume up to four times as many defined daily doses as the rest of the population.
Objectives: The purpose of this study was to determine the prevalence of polypharmacy in Tehran and to assess the relative medical and demographic characteristics of patients.
Design and setting: In a cross-sectional descriptive study, the selective patients were interviewed to answer a questionnaire at home and their current medications were reviewed. The information on all medications used was collected. The questionnaire also contained questions regarding personal, social, and medical factors. Polypharmacy was defined as daily intake of three or more drugs. Chi-square and Fisher’s exact tests and determination of odds ratios were used to analyze data.
Study population: Four hundred cases of patients aged 55 and older by cluster sampling were randomly selected from community residents in Tehran.
Results: Median number of drugs used was 3.4 ± 1.9 in studied cases and 39.6% of cases were exposed to polypharmacy. The prevalence of physician prescribed drug usage was observed to be increased by increasing number of total used drugs in each case (P<0.002). The most commonly used drugs were acetylsalicylic acid, atenolol, and propranolol; these drugs were prescribed by physician in over 90% of cases. There were positive correlations between polypharmacy and referring multiple physicians (OR=1.96, CI 95%, 1.28- 2.98) (P<0.002) and adverse drug reactions (OR=2.44, CI 95%, 1.47-4.05) (P<0.001). Polypharmacy was more prevalent in the age group of 65–75 years (P<0.04) and lower levels of education (P<0.004), and less prevalent in the group with moderate income (P<0.001).
Conclusion: Polypharmacy is common among adults aged 55 years and older in Tehran and is affected by age, education level, and economic status. Polypharmacy should be reduced as it has many potential adverse effects.
Funding source: This study was granted by Tehran University of Medical Sciences in Tehran, Iran.
Clinical Impact of Adherence to Pharmacotherapeutic Guidelines on the Outcome in Patients with Chronic Heart Failure
1Faculty of Pharmacy, Payap university, Thailand; 2Faculty of Pharmacy, Chiangmai university, Thailand
Problem statement: There are robust evidences for effective pharmacotherapy of chronic heart failure (CHF) which has been integrated into the guidelines, but many surveys have shown a suboptimal utilization of recommended medications. Furthermore, the impact of guidelines adherence on clinical outcomes has never been evaluated in Thailand.
Objectives: Investigate the impact of adherence to CHF guidelines on the rate of cardiac events
Design: Retrospective cohort observational study
Setting: Nakornping Hospital (tertiary care, provincial hospital, public sector)
Study population: 331 consecutive CHF patients (mean age 68.7; 49.8% males; New York Heart Association I: 16.0%, II: 42.9%, III: 29.0%, and IV: 12.1%) who were admitted to Nakornping Hospital between October 2005 and December 2007 for HF exacerbation were enrolled; patients who were provided health services or HF medications from any other health care facility, contraindicated for all 4 major HF medications (ACEIs, ARBs, beta-blockers, andaldosterone antagonists), or have valvular heart disease were excluded. The guidelines adherence was assessed after hospital discharge for at least 3 months by calculating a guideline adherence indicator (GAI-3, range 0-100%) based on prescription of ACEIs/ARBs, beta-blockers, and aldosterone antagonists
Outcome measure: Cardiac events (composite endpoint of CHF hospitalization or cardiovascular death) were followed-up until June 30, 2009. Survival was analyzed with the Kaplan-Meier method, log-rank test, and Cox regression analysis.
Results: Adherence to guidelines for ACEIs, ARBs, ACEIs/ARBs, beta-blockers, ACEIs/ARBs + beta-blockers, aldosterone antagonists, diuretics, and cardiac glycosides was 67.5%, 100.0%, 71.6%, 41.8%, 28.8%, 76.4%, 100.0%, and 89.0% respectively. The median GAI-3 was 50.0%. High, medium, and low cardiac event rates in GAI-3 categories were 47.4, 67.5, and 97.1 per 100 person-years, respectively. High GAI-3 significantly delayed time to cardiac events compared with medium and low GAI-3 (20.3 vs. 10.6 vs. 4.9 months, respectively, P = 0.004). In multivariable analysis, patients with medium and high GAI-3 had markedly lower cardiac event risks than patients with low GAI-3 (medium GAI-3: HR 0.21; 95%CI:0.10-0.44, P < 0.001 and high GAI-3: HR 0.16; 95%CI:0.03-0.97, P = 0.047).
Conclusions: The present study has demonstrated that adherence to pharmacotherapeutic guidelines for CHF was a significant predictor of fewer cardiac events in clinical practice in Thailand. This information will be useful for guiding and raising the awareness of physicians in practice for the treatment of CHF and will also lead to decreased re-hospitalization and death of patients.
Funding source: Faculty of Pharmacy, Chiangmai University