A Prospective Study on Hospitalization due to Drug-related Problems in a Tertiary Care Hospital.

INTRODUCTION: Drug-related problem (DRP) is any undesirable event experienced by the patient, which is suspected to involve drug therapy and interferes with a desired patient outcome. Most of these DRPs are avoidable with little vigilant effort. DRP admissions need high attention as DRP-related admissions on an average accounted for 8.36%, of which 50% are avoidable. The aim of the study was to identify the risk factors associated with DRPs in tertiary care hospital.
MATERIALS AND METHODS: One year prospective observational study was conducted in the departments of general medicine, dermatology, pediatrics, and gastroenterology of a tertiary care teaching hospital. A total of 148 cases, where a correlation between past medication history and current complaints was established, were included in the study. Exclusion criteria of the study were no correlation between past medication history and current complaints, social habits causing hospitalization, and herbal medication use history. RESULTS AND DISCUSSION: In this study, nonadherence (50.94%) and adverse drug reaction (ADR) (38.36%) were predominant among the identified DRPs. Children and geriatrics showed the higher incidence of nonadherence to the prescribed therapy. ADRs were the DRP with the higher incidence among adults followed by nonadherence to the prescribed therapy. Lack of knowledge about the disease, its complications, and possible adverse reactions with self-medication was identified to be the high incidence risk factor. Higher incidence of DRPs was observed in patients having a past medical history of cardiovascular system and central nervous system diseases, which require long-term management.
CONCLUSION: In this study, nonadherence to prescribed therapy was found to be the DRP causing hospitalization at a higher incidence. The most commonly involved risk factors were lack of knowledge about the disease, need of adherence to the therapy as prescribed, and outcomes of the treatment provided. Copyright:

Introduction

Drug-related problem (DRP) can be defined as a circumstance related to the patient’s use of a drug that directly or indirectly prevents the patient from gaining the intended benefit of the drug. Identifying and addressing the DRPs are considered as the important tasks within the health-care system.[1] Different DRP categorization systems exist but most of these systems target on the issues, which can be identified by reviewing the patient case sheets. Therefore, most commonly observed DRPs are adverse drug reaction (ADR), drug–drug interactions, subtherapeutic dose, nonadherence to the prescribed therapy, overuse of the medications, overdosage of the drug, wrong administration of the medication, drug use without an indication, and therapeutic duplication.[2] DRPs may lead to reduced quality of life, hospital admission, and overall increase in health cost and even increase in the risk of morbidity and mortality.[3]

Medical therapy has emerged to improve patient care to achieve optimal health outcome. However, DRPs represent a major issue leading to hospitalization. This significantly explains the need for assessment of majorly involved risk factors, disease conditions, drug classes, and severity.[4] Most of the patients having chronic diseases are treated as outpatients and their management is challenging (there is a chance of improper medication use) as less time is available for outpatient evaluation.[5] DRPs are common among individuals after hospital discharge is relevant as they threaten patient safety. Most efficient interventions to avoid hospitalization because of DRPs are focus on discharge planning and care transitions. Their effectiveness probably improves with home follow-up strategies. In 2004, the World Health Organization launched the World Alliance for Patient Safety. It is an initiative to assure medication accuracy at transitions of care by means of medication reconciliation. It could be a powerful strategy to reduce DRPs with patients moving through settings of care.[6] Most of the studies were retrospective, multicenter studies carried out internationally. Limited research has been conducted in India to exemplify the impact of DRP that results in hospital admission.

The fact is that most of these DRPs are avoidable with little vigilant effort. As per various researches carried out, DRP admissions need high attention as DRP-related admissions on an average accounted for 8.36%, of which 50% of are avoidable.[7]

Need of the Study

To explain the importance of patient education about disease, drug, and highly possible DRPs, which when neglected may result in severe complications and deterioration of patient’s quality of life. To explain the importance of care needed in prescribing drugs in high-risk patients such as elderly with multiple chronic condition and low immune individuals. To highlight the importance of resolving the risk factors causing DRPs.[8] The main aim was to study DRPs resulting in hospitalization.

Materials and Methods

A prospective observational study was conducted in various departments of 1200-bed tertiary care teaching hospital for 1 year (March 2017 to March 2018). Before the initiation of study, ethical clearance was obtained from the Institutional Human Ethics Committee on June 26, 2017. Objectives of the study include identification of group of people (age, sex, and area) at higher risk, risk factors involved, type of drugs involved in the DRPs, assess the severity, and identify the person responsible for DRPs. Inclusion criteria of this study were an association between the admission and a DRP, patient or patient caretaker being adequately communicable, and patients who were hospitalized in general medicine, pediatrics, gastroenterology, and dermatology departments. Hospital admissions attributed to herbal medicine use, poisoning, and substance abuse or outpatients consulting for DRP were excluded from the study. Data of the patients (demographic details, past medical history, past medication history, laboratory investigations, provisional and conformational diagnosis, treatment, and interviewing patient and patient caretakers) with drug-related admissions to hospital during the study period were collected and analyzed. Case sheets of patients with a past medical history were assessed for the impact of medications used in the past on the current complaints. If a DRP was observed, the case was considered for further study by documenting necessary information in documentation forms (data collection form and DRP assessment form). On the basis of the information available, the type of DRP (based on Hepler–Strand classification)[2] and the associated risk factors were identified. Severity was classified as following: mild (DRP requiring only change in the treatment of existing medical condition), moderate (DRP requiring additional treatment with a change/no change in the treatment of existing medical condition and resulting in no permanent disability), and severe (DRP that was life-threatening, caused organ damage, or resulted in permanent disability or death).

Data analysis: The categorical variables were represented in number and percentage. The data were analyzed using Statistical Software Analysis (SAS), Version 9.1.

Results

A total of 452 cases with a past medical history were reviewed, of which 148 cases were enrolled into the study based on the inclusion criteria. Among the 304 excluded cases, 110 patients had no relation between past medical history and current reasons for admission, 90 cases were herbal medicine–related, 70 cases were due to patient’s social habits that aggravated their medical condition, and 34 cases were due to trigger factors. Among the 148 cases, 159 DRPs were identified, which show the probability of multiple DRPs in a single patient. In this study, adults (80, 54.05%) were predominant over children (42, 28.38%) and geriatric (26, 17.57%) in terms of prevalence, whereas males had higher risk to develop DRPs. Regardless of sex, DRPs were significant in rural areas, remaining details are given in Table 1. In this study, the most commonly observed DRPs were nonadherence to the prescribed therapy (81, 50.94%) followed by ADR (61, 38.36%), and other details are given in Table 2. In this study, risk factors highly responsible for DRPs were patients not having necessary knowledge about the disease (89, 39.73%) followed by inappropriate medication use (35, 15.65%), and other details are represented in Table 3. Patients (75, 47.16%) found to be majorly involved in the development of DRPs and other details are given in Table 4. A total of 159 DRPs were distributed according to the age group of 148 patients considered for the study as shown in Table 5. Nonadherence was the major DRP in children (35, 22.01%) and geriatrics (14, 8.80%), whereas ADR (42, 26.41%) was the major DRP in adults. Distribution of DRPs based on past medical history is described in Table 6. Nonadherence was the most common DRP in patients with past medical history followed by central nervous system (CVS) disease (18, 11.32%), cardiovascular system (CNS) disease (21, 13.20%), skin disease (10, 6.30%), metabolic disease (12, 7.54%), renal disease (12, 7.54%), respiratory disease (2, 1.26%), and ADR was the most identified DRP in patients with immune disease (8, 5.03%) and other conditions (12, 7.54%) (having complaints such as joint pains, cold, fever, and body pains). ADRs were predominant with over-the-counter (OTC) drugs (17, 80.94%), whereas nonadherence was predominant with prescribed drugs (81, 63.78%), and other details are present in Table 7. A total of 159 DRPs were distributed based on their severity as given in Table 8, among which 133 (71.07%) were assessed as moderate followed by 38 (23.90%) as mild and 8 (5.03%) as severe.

Table 1

Distribution according to age, sex, and area of residence

Demographic details		Male	Female	Ratio
Age group	Children	25	17	1.47
	Adults	52	28	1.86
	Geriatrics	13	13	1
	Total	90 (60.81)	58 (39.18)	1.55
Area	Urban	43 (47.78)	35 (60.34)	P value
	Rural	47 (52.22)	23 (39.66)	0.04

Table 2

Types of drug-related problems

Drug-related problem	Frequency	Percentage (%)
Nonadherence to prescribed therapy	81	50.94
Adverse drug reaction	61	38.36
Overuse of the drug	12	7.54
Therapeutic duplication	03	1.90
Wrong administration	02	1.26
Total	159	100

Table 3

Risk factors involved in drug-related problems

Risk factors	Frequency	Percentage (%)
Lack of knowledge	89	39.73
Inappropriate medication use	35	15.65
Hypersensitivity and pharmacology of drugs	33	14.73
Self-medication with non-prescribed medications	22	09.82
Age	17	07.59
Drug with narrow therapeutic index	12	05.35
Infectious and parasitic diseases	08	03.57
Social habits of the patient	06	02.67
Economic status of the patient	02	00.89
Total	225	100

Table 4

Person responsible for drug-related problems

Person responsible	No. of drug-related problems	Percentage (%)
Patient	75	47.16
Patient caretaker	27	17
Patient and patient caretaker	05	3.14
Patient and pharmacist	07	4.40
None	45	28.30
Total	159	100

Table 5

Distribution of drug-related problems according to age group

Age group	Drug-related problems	Frequency	Percentage (%)
Children	Nonadherence	35	22.01
	Adverse drug reaction	07	4.40
Adults	Adverse drug reaction	42	26.41
	Nonadherence	32	20.13
	Overuse of drug	09	5.66
	Therapeutic duplication	03	1.88
	Wrong administration	02	1.26
Geriatrics	Nonadherence	14	8.80
	Adverse drug reaction	12	7.55
	Overuse of drug	03	1.90
Total		159	100

Table 6

Distribution of drug-related problems based on past medical history

Past medical history	Type of drug-related problems	Frequency	Percentage (%)
CVS disease	Nonadherence	18	11.32
	Adverse drug reaction	15	9.43
	Overuse of drug	04	2.52
	Therapeutic duplication	01	0.63
CNS disease	Nonadherence	21	13.20
	Adverse drug reaction	09	5.65
	Therapeutic duplication	01	0.63
Skin disease	Nonadherence	10	6.30
	Adverse drug reaction	10	6.30
	Overuse of drug	01	0.63
Metabolic disease	Nonadherence	12	7.54
	Adverse drug reaction	04	2.52
	Wrong administration	02	1.26
Renal disease	Nonadherence	12	7.54
Immune disease	Adverse drug reaction	08	5.03
	Nonadherence	02	1.26
Gastrointestinal disease	Nonadherence	04	2.52
	Adverse drug reaction	02	1.26
	Overuse of drug	01	0.63
Respiratory disease	Nonadherence	02	1.26
	Adverse drug reaction	01	0.63
Others	Adverse drug reaction	12	7.54
	Overuse of drug	06	3.77
	Therapeutic duplication	01	0.63
Total		159	100

Table 7

Distribution between type of drugs and drug-related problems

Type of drugs	Type of drug-related problem	Frequency	Percentage (%)
Over-the- counter drugs	Adverse drug reaction	17	10.69
	Overuse of drugs	11	6.92
	Therapeutic duplication	02	1.26
Prescribed drugs	Nonadherence to prescribed therapy	81	50.94
	Adverse drug reaction	44	27.67
	Therapeutic duplication	02	1.26
	Wrong administration	02	1.26

Table 8

Severity assessment of drug-related problems

Severity	Frequency	Percentage (%)
Moderate	113	71.07
Mild	38	23.90
Severe	08	5.03
Total	159	100

Discussion

In this study, 159 DRPs were identified among the 148 cases included. Various parameters in relation with the DRPs were evaluated and those are represented henceforth. From our study, it was observed that DRPs were predominant in the age group of 1–10 years. In terms of sex, males have high risk of DRPs when compared with the females. Similar findings were stated in the study conducted by Kumar et al.[9] From our study, it was evident that both the urban and rural individuals have approximately equal risk for DRPs. In our study, nonadherence (50.94%) and ADR (38.36%) are predominant among the identified DRPs. Similar results were stated in the study conducted by Alghamdy et al.,[3] which showed higher incidence of noncompliance (44.3%) followed by ADR (39.3%). To prevent the avoidable ADRs, patients should be informed about the suspected and highly frequent ADRs, so that they can easily report and obtain immediate management. According to our study, children and geriatrics have higher incidence of nonadherence to the prescribed therapy, ultimately leading to further complications. ADRs have higher incidence among adults followed by nonadherence to the prescribed therapy. According to our study, higher incidence of DRPs is observed in patients having past medical history of CVS and CNS diseases, which requires long-term management. Similar results were reported in the study conducted by Hsu et al.[5] To prevent DRPs in such patients, a regular follow-up plan is needed so as to change the therapy as per physician’s assessment toward patient’s need. From our study, risk factors responsible for the DRPs were identified as lack of knowledge about the disease, inappropriate medication use, hypersensitivity to the medications, self-medication with nonprescription medicines, drugs with narrow therapeutic index, presence of infectious and parasitic conditions, social habits, and economic status of the patient. In our study, DRPs were mostly associated with the prescribed medications. From our study, patients were found to be highly responsible for the DRPs. This may be due to inadequate awareness about consequences of improper medication use. Similar result was previously reported by Andreazza et al.[10] In our study, it was observed that individuals with a past medical history are mostly admitted with moderate DRPs. Similar findings were reported in a previous study conducted by Singh et al.[11]

Conclusion

In this study, nonadherence to prescribed therapy was found to be the DRP causing hospitalization at higher incidence followed by ADR. Most commonly identified risk factors in the patients having chronic diseases are lack of knowledge about disease, need of adherence to the therapy as prescribed, and outcomes of treatment provided. Severity of DRPs was majorly assessed to be moderate.

Limitations and future directions

Sample size being very small, certain risk factors could not be assessed adequately. Further study can allow us to elaborately assess the prevalence of DRPs and relative risk of causative factors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.