Polypharmacy and potentially inappropriate medications among hospitalized older adults with COVID-19 in Malaysian tertiary hospitals

Effects of physician-led medication reconciliation on the outcomes of outpatients utilizing the PharmaCloud system

BACKGROUND

Taiwan introduced PharmaCloud, a system designed to streamline access to comprehensive medication records from various healthcare settings. Despite its potential, the impact of physician-led medication reconciliation (MR) utilizing PharmaCloud on outpatient outcomes remains unclear. This study aims to address this gap by evaluating the effectiveness of PharmaCloud-enabled MR in improving patient outcomes.

METHODS

We collected data from outpatients with major polypharmacy (≥ 10 medications) between May 19, 2019, and April 18, 2020, comparing those who received MR with those who did not. Outcomes including total medical expenditures, ED visits, hospitalizations, mortality rate, and number of medications were compared between the two cohorts over a 12-month follow-up period.

RESULTS

The study enrolled 209 patients with MR and 9,053 patients without MR. Patients who received MR were older, had lower body mass index, took more medications, and had a higher prevalence of hypertension, cerebrovascular disease, chronic kidney disease, and mental disorder. After 12 months of follow-up, patients who received MR had a higher proportion of reduced medications (adjusted odds ratio: 1.4; 95% confidence interval: 1.0 - 2.0), but also had more ED visits in the first 12 months compared to those who did not receive MR. The study did not find any significant differences in total medical expenditures, hospitalizations, and mortality rates between the two cohorts.

CONCLUSIONS

The model reduced medication use. Further research, including prospective designs, pharmacist involvement, and evaluations of reduced complications from fewer medications, is needed to better clarify patient outcomes.

Polypharmacy or potentially inappropriate medications among older adults with COVID-19 in a secondary hospital in China and their association with mortality

Elderly patients with multiple concomitant chronic diseases are the particularly vulnerable during the Coronavirus disease 2019 (COVID-19) epidemic, which accounts for a large number of COVID-19-related deaths. The purpose of the study was to investigate the impact of polypharmacy and potentially inappropriate medications (PIMs) on in-hospital mortality in a secondary hospital in China. A cross-sectional, retrospective study was conducted using electronic medical data collected from Shanghai Gonghui Hospital from April 2022 to June 2022. Two types of PIMs were adopted, involving the evaluation of the PIM status of older patients with COVID-19 (age ≥ 60 years) identified by AGS/Beers Criteria (PIM-Beers) and the PIM related to Covid-19 antiviral NMV/r (Nirmatrelvir/ritonavir) (PIM-NMV/r). Multivariate logistic regression was used to identify the risk factors associated with PIM use and in-hospital mortality. A total of 617 older COVID-19 inpatients were included in the study. The prevalence of polypharmacy and excessive polypharmacy were 24.6% and 19.1%, respectively. The prevalence of PIMs, PIM-Beers, and PIM-NMV/r were 25.8%, 22.5%, and 60.8%, respectively. Multivariate regression demonstrated that male (OR: 0.57 [95% CI: 0.33-0.98], p = 0.044), diabetes (OR: 2.05 [95% CI: 1.11-3.80], p = 0.023), the more number of medications (OR: 1.44 [95% CI: 1.20-1.72], p < 0.001) and given NMV/r (OR: 3.67 [95% CI: 1.48-9.10], p = 0.005) were influencing factors associated with PIM use. A multivariate logistic regression demonstrated that severe COVID-19 (OR: 6.56 [95% CI: 1.13-38.03], p = 0.036), polypharmacy (OR: 15.43 [95% CI: 3.20-74.29], p = 0.001), excessive polypharmacy (OR: 51.09 [95% CI: 5.23-499.52], p = 0.001), and long-term hospitalization (OR: 0.08 [95% CI: 0.02-0.32], p < 0.001) were influencing factors associated with in-hospital mortality in older COVID-19 inpatients. The polypharmacy and drug-drug interactions of NMV/r were observed in many older COVID-19 inpatients. Older patients with severe COVID-19, a higher number of medications and long-term hospitalization had a higher in-hospital mortality. This result highlights the importance of conducting clinical pharmacists-led medication reviews to identify PIMs of NMV/r and collaboratively working with the physicians to ensure medication appropriateness.

Prevalence of Potential Drug Interactions With Direct-Acting Antivirals for COVID-19 Among Hospitalized Patients

PURPOSE

Clinicians consider polypharmacy, comorbidities, and other factors including the potential for drug-drug interactions (DDIs) when evaluating therapeutic options for specific clinical diagnoses. Contemporary treatment for coronavirus disease 2019 (COVID-19) includes direct-acting antivirals (DAAs). We sought to characterize patients' characteristics, comorbidities, and medications received during their hospitalization for COVID-19 and quantify potential DDIs that clinicians consider in selecting appropriate DAAs.

METHODS

Patients hospitalized with a primary diagnosis of COVID-19 between May 2020 and December 2022 from the PINC AI Healthcare Database were identified. Medications administered during the hospitalization with the potential to cause DDIs with nirmatrelvir/ritonavir, remdesivir, or molnupiravir (per the Emergency Use Authorization factsheet or package insert) were assessed. For DDIs with nirmatrelvir/ritonavir, medications are categorized as "Contraindicated," "Avoid Concomitant Use," or "Other DDIs" (includes recommendation for dose modification or clinical and laboratory monitoring). For remdesivir, coadministration with chloroquine phosphate and hydroxychloroquine sulfate was not recommended. For molnupiravir, no drugs are listed as having potential DDIs. In a subset of patients, a multivariable logistic regression model was used to examine the association between documented patient/hospital characteristics and the likelihood of being "Contraindicated" to receive nirmatrelvir/ritonavir.

FINDINGS

Of the 788,238 patients hospitalized for COVID-19 in 920 hospitals, 53% were ≥ 65 years old, and 31% had Charlson Comorbidity Index (CCI) ≥ 3. During the study period, about half of the patients received medications categorized as "Contraindicated" (11%) and/or "Avoid Concomitant Use" (41%) with nirmatrelvir/ritonavir. The frequency of administered drugs was higher in those aged ≥ 65 years (68%), CCI ≥ 3 (78%), with high-risk underlying conditions (55%). About 1% of patients received medications that were not recommended to be coadmistered with remdesivir. Among a subset of patients hospitalized for COVID-19 in 2022, those who were older, had higher CCI, high-risk underlying conditions, severe hepatic impairment, Medicare insurance, and hospitalized in larger hospitals were significantly more likely to be categorized as "Contraindicated" when considering nirmatrelvir/ritonavir as a therapeutic option to manage COVID-19.

IMPLICATIONS

A significant proportion of patients hospitalized for COVID-19 receive medications for other conditions that have the potential to result in DDIs with DAAs; most predominantly with nirmatrelvir/ritonavir, a strong CYP3A enzyme inhibitor, fewer with remdesivir, and none with molnupiravir. Higher age and comorbidity burden were significantly associated with a higher likelihood of receiving medications that are "Contraindicated" with nirmatrelvir/ritonavir. In the evolving COVID-19 era, these findings provide insights into patients hospitalized for COVID-19, and the polypharmacy evaluations that clinicians may encounter when selecting among DAAs to manage COVID-19.

Factors influencing healthcare providers' behaviours in deprescribing: a cross-sectional study

Introduction

Deprescribing serves as a pivotal measure to mitigate the drug-related problem due to polypharmacy. This study aimed to map the factors influencing healthcare providers' deprescribing decision using the Behaviour Change Wheel framework and develop an innovative conceptual model to support deprescribing practice.

Methods

A cross-sectional online survey targeting doctors and pharmacists was conducted to assess the influence of various factors on healthcare providers' comfort in recommending deprescribing. The conceptual model was formulated, based on the existing deprescribing framework and the Behaviour Change Wheel. The model's robustness was scrutinised through Partial Least Squares Structural Equation Modeling (PLS-SEM), and model-fitting indices were employed to obtain the best-fit model.

Results

A total of 736 responses were analysed with the final best-fit model consisting of 24 items in 5 constructs (R 2: 0.163; SRMR: 0.064; rho_c: 0.750-0.862; AVE: 0.509-0.627) and three independent factors. Based on the results, we proposed that deprescribing could be promoted through strategies aimed at enhancing healthcare providers internal capabilities such as knowledge levels, when patients' condition deteriorated and previous experiences with adverse events of drugs. Organisational support in providing such educational opportunities is important, with the empowerment of patient and healthcare providers through policy enhancements, guideline development, and effective communication.

Conclusion

The deprescribing behaviours of healthcare professionals are influenced by an intricate interplay of patient, prescriber, and system factors. Enhancing deprescribing practices necessitates a comprehensive strategy that encompasses providers and patients' education, the development of structured deprescribing guidelines, the implementation of deprescribing support tools, and the enhancement of communication between healthcare providers.

Healthcare professionals' understanding and perception of drug-related issues linked to off-label pharmacological medications used for COVID-19

BACKGROUND

To evaluate the opinions of healthcare workers regarding drug therapy problems linked to anti-infective medicines used for the treatment of COVID-19 infection in Pakistan.

RESEARCH METHODOLOGY

This cross-sectional study was conducted from January to October 2022 using a self-administered questionnaire developed by the authors, having three sections: demographics, knowledge, and perception. The study was validated by research experts and pilot-tested on 30 subjects. The study included medical doctors, nurses, pharmacists from Punjab's government and private medical institutes.

RESULTS

In this study, 382 of 400 participants replied. The mean knowledge score was 9.52 (SD 2.97), showing that participants had adequate knowledge of COVID-19 pharmacological interventions. The knowledge scores were significantly higher of those who treated COVID-19 patients and were from Lahore. Many doctors considered that elderly patients and those with blood disorders were at greater risk of experiencing drug-related problems. Most pharmacists support electronic prescription systems. Many doctors thought the lack of unified treatment guidelines, multiple prescribers, and self-medication were key obstacles in managing COVID-19 patients.

CONCLUSION

Most respondents had adequate knowledge. Older patients with comorbidities are at risk of adverse effects. Self-medication, polypharmacy, and multiple prescriptions can lead to misdiagnosis and complications. Electric prescriptions, team effort, and training programs can decrease these issues.

Medication use problems and factors affecting older adults in primary healthcare

BACKGROUND

As the largest demographic group utilizing primary healthcare facilities, older adults often face the challenge of managing multiple chronic illnesses, leading to numerous medications.

OBJECTIVE

The present study aims to assess medication use problems among older adults and explore the factors affecting them in primary healthcare settings.

METHODS

A mixed-method study was conducted to establish a baseline understanding of the perspectives and challenges faced by older adults, with regards to medication use. Translated Medication Use Questionnaire (MedUseQ), a patient-centered tool, was distributed to older adults above 60 in primary healthcare settings to assess their frequency of problems related to medication use. Fifteen semi-structured interviews were conducted to explore this topic in depth. Descriptive and inferential analyses were conducted with quantitative data. Interviews were transcribed verbatim, and thematic analysis was conducted. Quantitative and qualitative findings data were triangulated.

RESULTS

The study involved 393 participants. The most common problems with regards to medication use were polypharmacy (55.4%), administration difficulties (48.4%), limited awareness about adverse drug events (47.3%), issues with adherence (46.5%), and accessibility to primary healthcare (42.7%). Approximately 55% were satisfied with the older adult-centered medication use services by pharmacist and doctors. The qualitative findings showed that major factors affecting medication use were forgetfulness, language barriers, lack of awareness, transportation problems, long waiting times, and multiple visits to healthcare facilities.

CONCLUSION

The findings of this study reveal that a significant proportion, around 50%, of the older adult population face challenges with medication use in Penang. These difficulties mainly stem from medication administration, adherence, accessibility, polypharmacy, and inadequate medication knowledge. The qualitative analysis further highlighted several factors that contribute to such medication-related problems. Given the rapidly aging Association of Southeast Asian Nations (ASEAN) population, it is essential to devise effective solutions and strategies to tackle medication use-related issues among older adults.

Polypharmacy, potentially inappropriate medications, and drug-drug interactions in older COVID-19 inpatients

OBJECTIVES

The purpose of this study was to assess the impact of polypharmacy, potentially inappropriate medications, and drug-drug interactions on in-hospital mortality in older COVID-19 inpatients.

METHODS

A cross-sectional study was conducted using electronic medical data from a tertiary hospital in Chengdu from December 2022 to January 2023. The 2019 AGS/Beers criteria was used to evaluate the potentially inappropriate mediation (PIM) status of older COVID-19 inpatients (age ≥ 65 years), the drug-drug interactions were evaluated on Medscape, and multivariate logistic regression was used to identify the risk factors associated with in-hospital mortality.

RESULTS

A total of 206 older COVID-19 inpatients were included in the study. The mean number of drugs per day was 13.04. The prevalence of PIM use based on the 2019 AGS Beers Criteria was 66.99%. The prevalence of drug-drug interactions was 61.65%. Logistic regression demonstrated that age ≥ 80 (OR: 10.321, 95% CI: 1.649, 64.579, P = 0.013), renal insufficiency (OR: 4.740, 95% CI: 1.366, 16.447, P = 0.014), long-term hospitalization (OR: 6.637, 95% CI: 1.030, 42.779, P = 0.046), severe pneumonia (OR: 50.230, 95% CI: 5.180, 487.041, P = 0.001) were influencing factors associated with in-hospital mortality in older COVID-19 inpatients.

CONCLUSIONS

The polypharmacy, potentially inappropriate medications, and drug-drug interactions were seen in many older COVID-19 inpatients.

Medication management of COVID-19 patients during transition to virtual models of care: a qualitative study

INTRODUCTION

Expansion of hospital service models was one of the strategies implemented to manage the COVID-19 pandemic through virtual models of care. COVID-19 patients were hospital inpatients transferred to virtual wards and managed outside the hospital. Pharmacists had to provide distance medication management and support services. Virtual care patient support incorporated telehealth consultations by doctors, pharmacists and nurses. This study explored hospital clinicians' experiences and perspectives on medication management and safety issues of the COVID-19 patients transferred from inpatient units (IPUs) to virtual models of care at the time of transfer.

METHODS

Semi-structured qualitative interviews were conducted with purposively selected doctors, pharmacists and nurses involved in the management of COVID-19 patients in a virtual model of care (home or hotel). Clinicians were interviewed face-to-face or via MS Teams between March and May 2022. An interview schedule included 13 questions and prompts to explore perceptions of medication management and safety aspects.

RESULTS

Twenty clinicians were interviewed: six doctors, seven pharmacists, and seven nurses. The average interview time was 26 min (SD: 4.7; range 21-39). Four major medication management and safety themes emerged from the data: (1) complexities involved in efficient handover between IPU and virtual models of care; (2) lack of clarity on roles and responsibilities between hospital and primary care clinicians; (3) communication challenges when pharmacists work remotely; and (4) proactive management of specific medication safety risks. A common thread throughout the themes was concerns for potential impact on patient safety.

CONCLUSION

Overall, clinicians were supportive of the virtual models although patient safety issues were raised that need to be addressed in the development of future services. The results from this study may inform improvements in medication safety implementation of future virtual models of care.

Development of a Malaysian potentially inappropriate prescribing screening tool in older adults (MALPIP): a Delphi study

INTRODUCTION

Polypharmacy and potentially inappropriate medications (PIM) are common among older adults. To guide appropriate prescribing, healthcare professionals often rely on explicit criteria to identify and deprescribe inappropriate medications, or to start medications due to prescribing omission. However, most explicit PIM criteria were developed with inadequate guidance from quality metrics or integrating real-world data, which are rich and valuable data source.

AIM

To develop a list of medications to facilitate appropriate prescribing among older adults.

METHODS

A preliminary list of PIM and potential prescribing omission (PPO) were generated from systematic review, supplemented with local pharmacovigilance data of adverse reaction incidents among older people. Twenty-one experts from nine specialties participated in two Delphi to determine the list of PIM and PPO in February and March 2023. Items that did not reach consensus after the second Delphi round were adjudicated by six geriatricians.

RESULTS

The preliminary list included 406 potential candidates, categorised into three sections: PIM independent of diseases, disease dependent PIM and omitted drugs that could be restarted. At the end of Delphi, 92 items were decided as PIM, including medication classes, such as antacids, laxatives, antithrombotics, antihypertensives, hormones, analgesics, antipsychotics, antidepressants, and antihistamines. Forty-two disease-specific PIM criteria were included, covering circulatory system, nervous system, gastrointestinal system, genitourinary system, and respiratory system. Consensus to start potentially omitted treatment was achieved in 35 statements across nine domains.

CONCLUSIONS

The newly developed PIM criteria can serve as a useful tool to guide clinicians and pharmacists in identifying PIMs and PPOs during medication review and facilitating informed decision-making for appropriate prescribing.

Impact of deprescribing intervention on potentially inappropriate medications and clinical outcomes among hospitalized older adults in Malaysia: a randomized controlled trial (REVMED RCT) protocol

BACKGROUND

Polypharmacy and the use of potentially inappropriate medications (PIMs) are prevalent among older patients admitted to hospitals, posing a heightened risk of adverse drug events. This trial aims to evaluate the effectiveness of a pharmacist-led deprescribing intervention in reducing medications, PIM and improving clinical outcomes, using the locally developed Malaysian Potentially Inappropriate Prescribing Screening tool in Older Adults (MALPIP).

METHODS

This is an 18-month cluster-randomized, open-label, parallel-arm controlled trial conducted at 14 public hospitals in the Perak state of Malaysia. Patients aged 60 and above, who have at least one medication and one comorbidity are eligible. A stratified-cluster randomization design is employed, with 7 hospitals assigned to the control arm and 7 hospitals assigned to the intervention arm. The MALPIP screening tool will be used in the intervention group to review the medications. If PIM is detected, the pharmacists will discuss with doctors and decide whether to stop or reduce the dose. The primary outcomes of this trial are the total number of medications and number of PIM. The secondary outcomes include fall, emergency department visits, readmissions, quality of life and mortality. Outcomes will be measured during enrolment, discharge, 6, 12, and 18 months.

DISCUSSION

This REVMED trial aims to test the hypothesis that a pharmacist-led deprescribing intervention initiated in the hospital will reduce the total number of medications and PIM 18 months after hospital discharge, reducing fall, emergency department visits, readmissions, mortality and lead to improvement in quality of life. Trial findings will quantify the clinical outcomes associated with reducing medications and PIM for hospitalized older adults with polypharmacy.

TRIAL REGISTRATION NUMBER

This trial was prospectively registered at clinicaltrials.gov (NCT05875623) on the 25th of May 2023. NCT05875623 Clinicaltrials.gov URL: NCT05875623 registered on 25th July 2023.

Drug Utilisation Review among Geriatric Patients with Noncommunicable Diseases in a Primary Care Setting in Malaysia

A prospective cross-sectional study was conducted to analyse the drugs prescribed to the elderly population with noncommunicable diseases and to determine the polypharmacy at a primary care clinic in Negeri Sembilan, Malaysia. The study was conducted for 6 months at the primary care clinic of Gemas. Geriatric patients above the age of 65 and diagnosed with noncommunicable diseases were included upon providing written informed consent. The majority of the geriatric patients were between 65 and 69 years (mean: 69.72 ± 2.85) and prescribed 4 or more medications (mean: 5.18 ± 0.64, p = 0.007). More than 95% (n = 295) of the geriatrics were found to have multimorbidity, in which around 45% (n = 139) had type-2 diabetes together with hypertension and dyslipidaemia. Combination therapy was prescribed to more than 97% (n = 302) of the elderly, whereas cardiovascular and endocrine medications were the most commonly prescribed. Ten prescriptions were found to have drug-related problems, prescribing cascade (80%), lack of medicine optimisation (10%), and inappropriate prescription (10%). In this study, the majority of the elderly had multimorbidity; polypharmacy was commonly seen among geriatric patients. Polypharmacy is the biggest threat to the elderly population, as it increases the chances of falls and fall-related injuries. Medicine optimisation and deprescribing will reduce the chances of drug-related problems and morbidity and mortality associated with polypharmacy and over-consumption of medications. Hence, the study recommends the health fraternity look for medication optimisation and deprescribing to reduce the future complications associated with polypharmacy.