Medication - A boon or bane: Emergencies due to medication-related visits.

BACKGROUND: Medication-related visits (MRV) to the Emergency Department (ED) are substantial though weakly recognized and intervened. Data from developing countries on the prevalence of MRV-related ED admissions are scanty. This study is first of its kind in India to estimate the prevalence of MRV, its severity and the factors contributing to these visits.
METHODOLOGY: This prospective observational study was done in the ED of an apex tertiary care center in August 2018. A convenient cross-sectional sample of patients presenting with emergencies regarding drug use or ill-use were included and a questionnaire filled after obtaining a written informed consent.
RESULTS: During the study period, a cross-sectional sample of 443 patients was studied and the prevalence of MRV was 27.1% (120/443). The mean age was 55 (standard deviation: 15) years with a male preponderance (60.8%). Triage priority I patients comprised 39.1%. Common presenting complaints included vomiting (25%), seizure (20.8%), giddiness (20%), and abdomen pain (17.5%). Less than ½ (43.3%) were compliant to prescribed medication. The most common reasons for MRV were failure to receive drugs/noncompliance (47.5%), subtherapeutic dosage (25%), and adverse drug reaction (16.7%). Severity of MRV was classified as mild (50%), moderate (38.3%), and severe (11.7%). Out of these visits, 71 (59.2%) were deemed preventable. Three-fourths (73.3%) were stabilized and discharged from the ED.
CONCLUSION: The fact that a quarter of the ED visits are due to MRV and that more than half of them are preventable is quite alarming. Diligent patient education by the treating physicians may perhaps help in decreasing the incidence of this deleterious event.

Introduction

The use of medication is increasing worldwide, this could be due to the launch of wide range of drugs by the expanding pharmaceutical companies to address large variety of diseases that mandated escalating therapeutic challenges.[1] An array of outcomes are possible when people use medications. Any deviance from the anticipated favourable effect of a medicine would lead to drug-related crisis and visits to the Emergency Department (ED) for those issues are deemed as medication-related visits (MRV).[2] Previous studies on MRVs to the ED demonstrated that 16%–30% of overall visits were attributed to inappropriate use of drugs.[345] The majority of details available on MRVs were from developed countries and such data are lacking from India. Most data were retrospective studies which may underestimate the true prevalence. To achieve a realistic portrayal of ED related MRV, we have conducted a prospective interviewing of patient or their accompanying relatives during patient triaging and treatment. The idea of this study is to ascertain the prevalence of MRV, classify them according to the severity and identifying the most common group of drugs implicated to such visits, preventability and outcomes of the same. By doing so we can reduce the incidence of such deleterious event.

Methodology

Design

This was a prospective observational study performed over a span of 4 weeks in a tertiary care centre. Convenient cross-sectional sampling was done by interviewing patients after obtaining informed written consent during a fixed time of 1 h every day (10 AM or 3 PM). The factors contributing to MRV were recorded and the data were analyzed using Hepler and Strand classification.

Setting

We carried out this study in the Adult ED of Christian Medical College and Hospital, a 2900 bedded tertiary care centre in Vellore, Tamil Nadu, South India during August 2018.

Participant

All patients aged above 18 years presenting to triage priority 1 and 2 of ED with MRV during the study period were included in the study. All non-MRV, priority 3 and trauma patients were excluded from the study.

Variables

Patient details were collected by direct patient interview with the patient and/or their relatives, while medication history was collected from prescriptions or through hospital's electronic database. Demographics, examination findings and history of the patients were documented on standard data collection proforma. The variables such as age, gender, presenting complaints, comorbidities, drug history, and physical findings were included in this study.

Triage priority are classified as:

Patients with

Priority-1: Airway, breathing, or circulatory compromise

Priority-2: Stable airway, breathing, and circulation with medical emergencies requiring ED admission.

Severity of MRV was outlined as:[6]

Mild–laboratory derangement/symptoms not warranting intervention

Moderate–laboratory derangement or symptom requiring admission in a hospital/temporary disability

Severe–life-threatening symptoms/Permanent disability.

MRV is grouped based on Hepler and Strand classification into eight categories as:[7]

Untreated indications

Subtherapeutic dosage

Drug use without indication

Drug interactions

Improper drug selection

Failure to receive drugs

Adverse drug reaction

Overdosage.

Outcome variables

Outcome measures were prevalence, severity of MRV, preventability of MRV, and ED outcomes of MRV. Preventability of MRV was assessed by an independent ED consultant.

Bias

Consecutive sampling was not done due to the arduous task of recruiting patients throughout the day in the ED and hence we adopted a convenient cross-sectional sampling technique.

Study size

Based on the research by Zed et al., using a 10.5% prevalence of MRV to ED, with a precision of 5% and 95% confidence, the required sample size calculated was 156.[5]

Statistical analysis

Statistical Package for Social Sciences for Windows (SPSS Inc. Released 2015, version 23.0. Armonk, NY, USA) was used to analyze the data. Continuous variables are described as mean (standard deviation [SD]). Categorical and nominal variables are described as percentages.

Ethical consideration

Institutional Review Board (IRB Min. No. 10524 dated 01/Feb/2017) certified and approved, patient privacy was ensured using unique identifiers and password secured data entry software with regulated users.

Results

Overall, 6372 patients attended the ED during the study period. We screened 443 patients due to convenient cross-sectional sampling method and after the exclusion, 120 visits were deemed MRV and the prevalence was 27.1% [Figure 1]. The mean age was 55 (SD: 15) years with a male preponderance (73 [60.8%]). Triage priority 1 comprised 47 (39.1%) and rest 73 (60.8%) were priority 2. The most common comorbidity was hypertension 66 (55%) followed by diabetes 53 (44.2%), alcohol consumption 22 (18.3%), and smoking 22 (18.3%) [Table 1]. Common presenting complaints included vomiting 30 (25%), breathing difficulty 25 (20.8%), giddiness 24 (20%), seizure 21 (17.5%), and abdomen pain 19 (17.5%) [Table 2]. Most commonly implicated drug was antihypertensives 41 (34.1%) followed by oral hypoglycemics 25 (20.8%) and anticonvulsants 19 (15.8%) [Table 3]. Only half i.e., 52 (43.3%) were compliant to prescribed medication. The most common reasons for MRV were failure to receive drugs 57 (47.5%), subtherapeutic dosage 30 (25%) and adverse drug reaction 20 (16.7%) [Table 4]. Severity of MRV was classified as mild 60 (50%), moderate 46 (38.3%), and severe in 14 (11.7%). Out of these visits, 71/120 (59.2%) were deemed preventable. Three-fourths (73.3%) were discharged stable from the ED [Table 5].

Figure 1

STROBE

Table 1

Baseline characteristics of medication related visit

Characteristics	Number (n=120), n (%)
Mean age (SD) in years	55 (15)
Male sex	73 (60.8)
Triage priority level
Priority I	47 (39.2)
Priority II	73 (60.8)
Comorbidities
Hypertension	66 (55)
Diabetes mellitus	53 (44.2)
Alcohol consumption	22 (18.3)
Smoking	22 (18.3)
Epilepsy	16 (13.3)
Chronic kidney disease	12 (10)
Ischemic heart disease	12 (10)

SD=Standard deviation

Table 2

Chief complaints of patients presenting with medication related visit

Complaints	Number (n=120), n (%)
Vomiting	30 (25)
Dyspnea	25 (20.8)
Giddiness	24 (20)
Seizure	21 (17.5)
Abdominal pain	19 (15.8)
Headache	11 (9.2)
Altered sensorium	8 (6.7)
Cough	5 (4.2)
Altered bowel habits	5 (4.2)
Loss of consciousness	4 (3.3)
Chest pain	4 (3.3)
Fever	4 (3.3)
Drowsiness	3 (2.5)
Palpitation	2 (1.7)
Skin rash	2 (1.7)
Generalized weakness	2 (1.7)

Table 3

Drugs implicated for medication related visit

Drug	Number (n=120), n (%)
Antihypertensive	41 (34.1)
Oral hypoglycaemic agents	25 (20.8)
Anticonvulsants	19 (15.8)
Bronchodilators	8 (6.6)
Antiplatelet	7 (5.8)
Diuretics	7 (5.8)
Insulin	4 (3.3)
Cephalosporin	3 (2.5)
Corticosteroids	3 (2.5)
Antihistamines	3 (2.5)

Table 4

Classification of medication related visit based on Hepler and Strand classification[8]

Category	Number (n=120), n (%)
Failure to receive drugs	57 (47.5)
Sub therapeutic dosage	30 (25)
Adverse drug reaction	20 (16.8)
Over dosage	7 (5.8)
Improper drug selection	3 (4.2)
Untreated indications	2 (1.7)
Drug use without indication	1 (0.8)
Drug interactions	0

Table 5

Severity, preventability and outcomes of medication related visit

Severity	Preventable (n=71), n (%)	Nonpreventable (n=49), n (%)
Mild	39 (54.9)	21 (42.8)
Moderate	24 (33.8)	22 (44.9)
Severe	8 (11.2)	6 (12.2)
Outcome of MRV
Discharged stable	89 (74.2)
Admitted	24 (20)
Lama	7 (5.8)
Death	0

MRV=Medication related visit

Discussion

MRVs are substantial problem and influence to the overall burden of our health care sector. Prospective study design in adult population have shown greater incidence rate than retrospective study design as latter would underestimate the true incidence due to missing data or inaccurate documentation.[1] This study is designed as a prospective observational study to analyze complete medication history captured from routine chart information and brief questionnaire. Thus prospective model, randomization and adequate sample size enhance the probability that our valuations are precise and applicable to general population. Prevalence from earlier prospective studies done in ED visits was consistent with our results.[58910] Arifri et al. conducted a study in Saudi Arabia which showed a lesser prevalence compared to our study and this would reflect our country's position among developing nations.[11] In most studies, MRV is limited to adverse medication reaction stated by the World Health Organization as “any noxious, unintended, or undesired effect of a drug, which occurs at doses used in humans for prophylaxis, diagnosis, or treatment.”[12] Helper and Strand's description of MRV is more complete and reproducible.[7] We have adopted the same for meaningful characterization of MRV to the ED. In our study majority of MRVs were due to failure to receive drugs which is contrary to Pepe et al. where untreated indication and overdosage topped the list.[13] Most patients in our study were noncompliant to drug regimen as seen in the previous international study.[1415] Adequate health education to the patient and/or accompanying relative regarding side effects of medicine and the pros and cons of treatment schedule can minimize noncompliance. Antihypertensives, oral hypoglycemics, and anticonvulsants were the commonly implicated drugs in our study, matching other studies.[1316] This implies medications used for chronic illnesses are to be monitored closely by emphasising regular outpatient department visits, enforced counselling and education are needed for patients receiving chronic drugs. Percentage of preventability of MRV in our study was similar to studies in literature.[171819] In general, the soaring rate of preventability encourages researchers to foresee ideas to confront this issue. On contrary to Singh et al. study, where three fourth MRVs were moderate, our study recorded higher rates of severe outcomes.[20] These ill outcomes can be avoided by patient-centerd care model which includes guided patient care by family physicians and pharmacists. According to existing literature, this is the most efficient way of providing safe and effective therapy.[21] MRVs are directly related to total number of drugs prescribed per patient, as multiple drugs invite the possibility of poor adherence and adverse drug interactions.[22] For that reason, reducing the total number of medicines using fixed-dose combination might help in addressing this issue. It is worthy to investigate the root cause of every such event to allow for suitable mediation in these patients. In conclusion, drug compliance, insight of health provider on prescription medication, monitoring of routine medicine and patient health education are the areas recognized for improvement. Family doctors and pharmacists should work together to fortify care plans and inspect patients at regular intervals to prevent MRVs.

Limitations

A few patients with minor MRVs were excluded due to lower triage priorities as only patients requiring ED admission were recruited. Brief study duration and all data being collected in a single department and hospital are the limitations of our work.

Conclusion

The fact that a quarter of the ED visits are due to MRV and that more than half was preventable is quite alarming. Counteractive, anticipatory and instructive strategies should focus on the most common drug, illness, and particular population. This study encourages the appropriate use of medications to warrant the best result of pharmacological mediation. Further studies with extensive duration focusing on MRVs are needed to prevent this malicious issue.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.