Socio-demographic characteristics
A total of 200 patients were included in the final analysis. Of this, 135(67.5%) were male, the mean (SD) age was 67.3 (7.5) years, and the majority (68.5%) of the patients were from rural areas. Two third of the patients did not have a formal education and only 36.5% of the patients had a monthly income of ≥ 800 Ethiopian Birr. Furthermore, 75% of them relied on the caregiver (Table 1).
Table 1 The Socio-Demographic Characteristics of geriatric patients admitted from April to July to Medical and Surgical wards of JUMC, Ethiopia, 2017 (N=200)
Table 1 The Socio-Demographic Characteristics of geriatric patients admitted from April to July to Medical and Surgical wards of JUMC, Ethiopia, 2017 (N=200)
Demographic characteristics
|
N (%)
|
Age, Mean (SD)
|
67.3 (7.3)
|
Sex male
|
135 (67.5)
|
Marital status
Married
Widowed
Divorced
|
158 (79)
36 (18)
6 (3)
|
Religion
Christian
Muslim
|
50 (25)
150 (75)
|
Educational status
No formal education
Primary education
Secondary education
Tertiary education
|
132 (66)
55 (27.5)
8 (4)
5 (2.5)
|
Residence
Rural
Urban
|
137 (68.5)
63 (31.5)
|
Monthly income
< 800 birr
≥ 800 birr
|
127 (63.5)
73 (36.5)
|
Relies on caregiver (yes)
|
150 (75%)
|
Clinical and medication characteristics
The majority (65. 5%) of the patients were admitted to the medical ward. Participants had an average of 2.20 (SD1.57) clinical conditions and they took an average of 3.90 (SD2.11). The most common medical condition was heart failure (24%) followed by stroke (13%) and benign prostatic hyperplasia (11%). Polypharmacy was present in 35.5% of the patients (Table 2).
Table 2. Clinical, and medication related characteristics in geriatric patients admitted from April to July at Medical and Surgical wards of JUMC, Ethiopia, 2017 (N=200)
Characteristics
|
n (%)
|
Admission ward
Medical
Surgical
|
131 (65.5)
69 (34.5)
|
Mean number of disease condition per patient, Mean (SD)
|
2.20 (1.157)
|
Mean number of medications per patient, Mean (SD)
|
3.9 (2.108)
|
Polypharmacy (yes)
|
71 (35.5)
|
Disease conditions
|
|
Heart failure
|
48(24)
|
BPH
|
26(13)
|
Stroke
|
22(11)
|
Acute coronary syndrome
|
13(6.5)
|
Acute abdomen
|
12(6)
|
Type II DM
|
11(5.5)
|
Cancer
|
9(4.5)
|
Pneumonia
|
8(4)
|
Surgical site infection
|
8(4)
|
Chronic kidney disease
|
7(3.5)
|
Trauma
|
6(3)
|
Hernia
|
5(2.5)
|
Hematoma
|
5(2.5)
|
Gangrene
|
5(2.5)
|
Upper GI bleeding
|
5(2.5)
|
Others
|
10(5)
|
Prevalence of drug related problems
A total of 380 DRPs were identified from 81.5% of the study participants. Every patient had an average of 1.90 (SD1.47) DRPs. The most commonly found DRPs belonged to the treatment effectiveness related (effect of drug treatment not optimal, untreated indication, and no effect of drug treatment) with 47.6%, followed by (unnecessary drug treatment, problem with the cost-effectiveness of treatment) 28.2%, and adverse drug event 24.2%. Regarding the number of DRPs, 24.5% had one, 26.5% of patients had two, and 30.5% had three and more DRPs (Table 3).
Table 3 DRP categories and number of DRPs among geriatric patients admitted from April to July to Medical and Surgical wards of JUMC, Ethiopia, 2017
Total number of DRPs =380
|
n (%)
|
Problem domains
|
|
P1: treatment effectiveness (3 categories)
Suboptimal effect of drug treatment
Untreated indication
No effect of drug treatment
|
181(47.6)
102(56.4)
69(38.1)
10(5.5)
|
P2: treatment safety
Adverse drug event (possibly) occurred
|
92(24.2)
92(100)
|
P3: Others
Unnecessary drug treatment
Problem with cost effective treatment
|
107(28.2)
81(75.7)
26(24.3)
|
Number of drug related problems (DRPs)
|
None
|
37 (18.5)
|
One
|
49 (24.5)
|
Two
|
53 (26.5)
|
≥ three
|
61 (30.5)
|
Causes of drug related problems
Four hundred sixty six causes of DRPs were identified. Of this, the most common causes of DRPs were inappropriate drug selection (54.1%) followed by inappropriate dose selection (14.6%) and drug use process (12.2%). Among the inappropriate drug selection causes, the presence of new indication for drug treatment (36.1%) was the most common cause followed by no indication for the prescribed drug (20.6%), and inappropriate drug according to guidelines (16.7%) (Table 4).
Table 4 Causes of DRPs identified in geriatric patients admitted from April to July to Medical and Surgical wards of JUMC, Ethiopia, 2017
Cause domain (8 categories) Total=466
|
n (%)
|
C1: Drug selection causes
New indication for drug treatment
No indication for drug
Inappropriate drug according to guidelines
Contra-indicated
Inappropriate duplication of therapeutic
Inappropriate combination of drugs, or drugs and food
|
252(54.1)
91(36.1)
52 (20.6)
42 (16.7)
30 (11.9)
20 (7.9)
17 (6.8)
|
C2: Drug form causes
In appropriate drug form
|
16(3.4)
16 (100)
|
C3: dose selection causes
Drug dose too high
Drug dose too low
|
68(14.6)
46 (67.6)
22 (32.4)
|
C4: treatment duration causes
Duration of treatment too long
Duration of treatment too short
|
24(5.2)
22 (91.7)
2 (8.3)
|
C5: dispensing causes
Prescribed drug not available
Prescribing error (necessary information missing)
|
20(4.3)
18 (90)
2 (10)
|
C6: drug use process causes
Drug not administered at all
Drug under administered
Drug over administered at all
|
57(12.2)
40(70.2)
11(19.3)
6 (10.5)
|
C7: patient related causes
Patient uses unnecessary drug
Patient administered/uses drug in a wrong way
Patient cannot afford drug
Patient unable to use drug/form as directed
|
22(4.7)
7(31.8)
5(22.7)
5(22.7)
5(22.7)
|
C8: other causes
No or inappropriate outcome monitoring
|
7(1.5)
7(100)
|
The most frequently involved class of drugs in DRPs were cardiovascular agents (38.1%) followed by antibiotics (21%), and hematological agents (19.7%) (Figure 1).
Clinical pharmacist interventions
For identified DRPs, a total of 670 interventions were provided at different levels. Most of the interventions (41%) were provided at the prescriber level, followed by 39.1% at drug level, and 16.1% at patient/caregiver level. At the prescriber level, interventions proposed and discussed with the prescriber were the commonest (82.7%) form of intervention. Out of the interventions carried out at the drug level, the drug stopped and a new drug started was the most common with 30.5% each of them. The prescriber’s acceptance rate was calculated considering the interventions provided at the prescriber level. Accordingly, out of 300 interventions performed at the prescriber level, 275(91.7%) of them were accepted. After the implementation of the interventions, out of the total DRPs, 65.8% of the problems were solved while 27.6% of the problems were not solved (Table 5).
Table 5 Intervention, prescriber acceptance rate, and outcome of intervention for DRPs among geriatric patients admitted from April to July to Medical and Surgical wards of JUMC, Ethiopia, 2017
Intervention domain (N=731)
|
n (%)
|
I0: No intervention
|
61(8.3)
|
I1: intervention at prescriber level
Intervention proposed and discussed with prescriber
Prescriber informed only
|
300(41.0)
248 (82.7)
52 (17.3)
|
I2: intervention at patient /care giver level
Patient drug counseling
Spoken to family /care giver
|
108(16.1)
84 (77.8)
24 (22.2)
|
I3: intervention at drug level
Drug stopped
New drug started
Dosage changed
Drug changed
Instruction for use changed
Formulation changed
|
262(39.1)
80(30.5)
80 (30.5)
40 (15.3)
33 (12.6)
17 (6.5)
12 (4.6)
|
I4: other intervention or activity
|
0
|
Intervention acceptance domain (N=300)
|
|
A1: intervention accepted at prescriber level
Intervention accepted and fully implemented
Intervention accepted but not implemented
Intervention accepted, implementation unknown
Intervention accepted and partially implemented
|
275(91.7)
249 (90.5)
23 (8.4)
0
3 (0.1)
|
A2: intervention not accepted
Intervention not accepted; no agreement
Intervention not accepted not feasible
|
25(8.3)
24(96)
1 (4)
|
A3: other (no intervention on acceptance)
|
0
|
Problem status domain ( N=380)
|
|
O0: problem status unknown
|
5(1.3)
|
O1: problem totally solved
|
250(65.8)
|
O2: problem partially solved
|
20(5.3)
|
O3: problem not solved
Lack of coordination of prescriber
No possibility to solve problem
Lack of coordination of patient
|
105(27.6)
56(53.3)
47(44.8)
2(1.9)
|
Determinants of drug related problems
In the multivariable logistic regression model, number of disease condition (AOR = 1.588, 95% CI= 1.029-2.450) and polypharmacy (AOR= 3.350, 95% CI= 1.212-9.260) have statically significant association with DRPs. Patients who took five or more medications (polypharmacy) are 3.350 times more likely to have DRPs than those who took less than five medications. Moreover, as clinical condition increases by one unit the likelihood of developing DRPs increases by 58.8% (Table 6).
Table 6 Determinants of DRPs among geriatric patients admitted from April to July to medical and surgical wards of JUMC, Ethiopia, 2017
|
Identification of DRPs
N (%)
|
Bivariable logistic regression analysis
|
Multivariate logistic regression analysis
|
Determinants
|
Yes
|
No
|
P value
|
COR (95% C.I)
|
P value
|
AOR (95% C.I)
|
Sex
Male
Female
|
108 (66.3)
55 (33.7)
|
27 (73)
10 (27)
|
0.432
|
1
1.375(0.621-3.044)
|
0.338
|
1
1.6 (0.62-4.12)
|
Marital status
Married
Divorced
Widowed
|
128 (78.5)
4 (2.5)
31 (19)
|
30 (81.1)
2 (5.4)
5 (13.5)
|
0.394
0.475
|
1
0.469(0.082-2.680)
1.453(0.521-4.049)
|
0.720
0.121
|
1
1.2 (0.4-3.9)
5.7 (0.6-52)
|
Educational level
Educated
No formal education
|
56 (34.4)
107 (65.6)
|
12 (32.4)
25 (67.6)
|
0.824
|
1
1.09(0.510-2.332)
|
0.422
|
1
1.2(0.4-3.2)
|
Reliance on care giver
No
Yes
|
39 (23.9)
124 (76.1)
|
11 (29.7)
26 (70.3)
|
0.463
|
1.345(0.610-2.968)
|
0.556
|
1
1.3(0.5-3.5)
|
Economic status
≥ 800 Birr
< 800 Birr
|
61 (37.4)
102 (62.6)
|
12 (32.4)
25 (67.6)
|
0.57
|
1
0.803(0.376-1.713)
|
0.484
|
1
1.4(0.5-3.6)
|
Residence
Urban
Rural
|
52 (31.9)
111 (68.1)
|
11(29.7)
26 (70.3)
|
0.797
|
1
0.903(0.415-1.966)
|
0.468
|
1
0.7(0.3-1.8)
|
Polypharmacy
No
Yes
|
97 (59.5)
66 (40.5)
|
32 (86.5)
5 (13.5)
|
0.004
|
1
4.355(1.613-11.75)
|
0.020
|
1
3.350(1.212-9.260)
|
Comorbidities, mean (SD)
|
2.20 (1.157)
|
0.006
|
1.787(1.179-2.708)
|
0.037
|
1.588(1.029-2.450)
|
COR =crude odds ratio, AOR =adjusted odds ratio, CI= confidence Interval