|Ahead of print publication
Projecting prescribing issues and patient patterns on the way to therapeutic appropriateness at the community level through elderly hypertensives
Adwait Sodani1, Tomalwar Murari1, VK Sashindran2, Anil S Menon1
1 Department of Medicine, AFMC, Pune, Maharashtra, India
2 Consultant Medicine, Department of Medicine, 7 Air Force Hospital, Kanpur, Uttar Pradesh, India
|Date of Submission||02-Apr-2022|
|Date of Decision||13-Jul-2022|
|Date of Acceptance||25-Jul-2022|
|Date of Web Publication||19-Jan-2023|
Department of Medicine, AFMC, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Despite treatment, up to 50% of older hypertensives have poorly controlled blood pressure in the community. Possibly, the management advice does not reach the intended. Who stands responsible; the prescriber, the system (social dynamics) or the patients themselves? The study aims to showcase various prescribing practices and patient behaviours that influence therapeutic delivery and thus patient care. Appropriate redressals to such practices and behaviours as and when required during health planning/practice could result in the percolation of the best possible care unto all socioeconomic strata within a community. Materials and Methods: Older patients on antihypertensives (n = 143) were interviewed by visits to various urban slums of a district in Western Maharashtra, India, between December 2018 and October 2020 for this cross-sectional, descriptive study. Demographic and clinical data were recorded on a predesigned pro forma with reasons for the patient's behavior concerning disease/treatment. Finally, available prescriptions and the latest blood/urine evaluations were recorded. Prescribing practices were recorded with available tools and data was analysed. Results: The mean age of the study population was 68 ± 7.39 years. Optimal control of the blood pressure was not achieved in 72.03% of patients (P < 0.0001%; 95% confidence interval [CI]: 32.94–53.54%), whereas adverse drug reactions (ADRs) occurred in 35.66% of patients. Physician's prescription was available in 101 patients for prescription quality assessment; however, 12 patients had never been prescribed and 30 lost their prescriptions. Even patients under regular follow-up with a physician failed to achieve the blood pressure targets or prevent an ADR. Finally, the patients' behavior was studied, wherein 41.22% became lost to follow-up and 64.13% of patients had old prescriptions. Forty-two patients could explain such behaviors. Conclusions: Both physicians and patients were responsible for poor blood pressure control. The means of assisting a physician on physician-patient communication would reduce physician workload (thus increasing efficiency) and reduce confusion/misconception (about drug/disease etc) that patient upholds (thus addressing counterproductive patient behaviours).
Keywords: Health behaviors, patient behavior, prescribing practices, prescription quality
|How to cite this URL:|
Sodani A, Murari T, Sashindran V K, Menon AS. Projecting prescribing issues and patient patterns on the way to therapeutic appropriateness at the community level through elderly hypertensives. J Mar Med Soc [Epub ahead of print] [cited 2023 Feb 1]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=368044
| Introduction|| |
Treating hypertension in the elderly (or old) is challenging given its high prevalence (40-80%), the tendency of hypertension to increase with age, and lastly given the fact that 25 - 50% of elderly hypertensives have sub-optimal blood pressure control despite treatment., The reasons for this parlous state of affairs are multifactorial, involving the health-care system, prescribers, and patients. The health-care system is overburdened and the low doctor–patient ratio means that patients do not get sufficient consulting time with their physicians. The lack of adequate geriatricians in the country,(with yearly intake of 42 candidate doctors spread over 08 institutions for a population that long crossed 104 million (the elderly) as per 2011 census of the country) means that these patients are not getting the specialized care that they require., The cultural obsession with super-speciality consultations and eschewal of the role of family physicians/ general practitioners leads to compartmentalized viewing of a patient and a holistic view of overall health remain wanted. Government medicine procurement procedures frequently result in changes in the brands of medicines being procured with the requirement of allowing the lowest price offering firm. The alteration in color, shape, and size of tablets adds to the confusion of patients. Medical practitioners have little guidance in geriatric health in both their undergraduate and postgraduate medical curriculum. Lack of knowledge often leads to prescribing errors (potentially inappropriate medication [PIM]/potential drug–drug interaction [PDDI]). All issues at various levels mentioned apropos get compounded given the heavy clinical workload, and distractions for the physician in the form of academic and administrative duties and research compulsions. Often, the doctors do not find time to explain the treatment plan or the likely adverse effects of the medications to their patients. The pharmacists at the dispensary often fail to fill the lacunae possibly for the similar reason. Thus, even if the doses have been titrated, the patients often continue to take medicines as per old prescriptions. Adverse reactions scare patients and prompt them to stop medications or seek recourse advice from family members and peers. Cultural faith in alternate systems of medicines also leads to the mixing of prescriptions and potentially dangerous drug interactions. Lack of health insurance, social security, and poverty also force patients to miss regular follow-ups and buy selective medicines based on their perceived priorities. Forgetfulness, dementia, confusion, and poor eyesight also contribute to wrong medication and dosing.,,,,, Hence, a study is needed to bring forth seemingly numerous inappropriate prescribing practices and patient behaviors that are plausibly inherent in modern medicine. Both 'inappropriate prescribing practices' and 'odd patient behavious', occur frequently yet are poorly studied in India, less so in the Indian communities, and even more sparsely amongst the more susceptible elderly members' there-in. An assessment of the magnitude of the problem of medication errors related to elderly hypertensives, the contribution of prescribing practices, and patient behavior was thus a perceived imperative. This study aimed to holistically assess prescribing practices and patients' behaviors in elderly hypertensives at a community level.
| Materials and Methods|| |
At the outset, terminologies to be used in the study were clarified and charted (vide [Appendix 1]: Terminologies used and identified by authors in the study). Next, the required sample size was calculated at 143, considering the probability of potentially inappropriate medication (PIM) to be 50% with finite correction at a confidence interval of 95% for this cross-sectional and descriptive study. After institutional ethical committee approval of the protocol, subjects were recruited between December 2018 and October 2020. Consenting elderly (>60 years; here used for older individuals) patients with diagnosed or undiagnosed hypertension and those taking (or defaulting) on at least one antihypertensive medication (complementary and alternative medication [CAM] included) were included in the study. Patients with known secondary causes of hypertension, those on parenteral antihypertensives, or those hospitalized were excluded from the study.
The subjects were recruited by visiting various local communities/health camps/OPDs run by trusts or nongovernment organizations (NGOs). Data on demography, available prescriptions, blood pressure control (controlled only if SBP/DBP: 120-140/70-90 mmHg while both over and under-controlled were considered poorly controlled. Blood pressure was measured as per techniques illustrated by International Society of Hypertension 2020 guideline document) and Adverse Drug Reaction (ADR) was collected. Inquiry on various practices of complementary and alternative medication (CAM, including – Alternative Medicine (AM) or Self Medication (SM)) was made via a performa. A relevant clinical examination was done and lastly their latest prescriptions and laboratory reports were reviewed.
The prescriptions were then scrutinized manually for the applicable components of the Prescription Quality Index. The PIMs were identified using validated scientific modalities, namely, BEER's criterion and the screening tool to alert to right treatment - screening tool of older people's prescriptions (START- STOPP) criterion, whereas Epocrates Plus was applied for capturing the PDDI.
The data were grouped by age and gender, whereas various prescribing practices were segregated into the following groups:
- Allopathic or CAM (+ allopathic drugs) generated standard prescriptions – Which were evaluated further for prescription quality.
- Written and lost (including others) – Meaning thereby that these patients who were prescribed once upon a time and have now lost their prescriptions and are now taking medications over-the-counter (OTC) by showing bills/drug wrappers or by asking for medicines from memory.
- Never prescribed – They were never given a written prescription but are taking medication by OTC or on hearsay (from friends/family/advertisements).
Further, the prescription errors noted were grouped under the heads of PIM/PDDI/Potential Prescription Ommision (PPO)/Duplication/Polypharmacy/ADR/Clerical errors (legibility/physician particulars/patient particulars) etc.
While, the patient behavior patterns observed were classified as those adhering to the prescribed management AND those not doing so (i.e. indulging in OTC/SM/mixed/selective drug intake). Patients lost to follow-up were clubbed with the 2nd group (herein telemedicine was also considered a follow-up-equivalent). Lastly, all this data was arranged to decipher correlates of ADR and blood pressure (BP) control. Social issues, if any, were documented to understand the societal cobweb jamming the smooth prescribing process. The data extracted from the pro forma were fed into Microsoft Excel 2007 (Microsoft Inc.), and continuous data (expressed in mean ± 2 standard deviation) were converted to categorical data (where possible) for ease of further analysis and expressed in proportions (%). The difference of proportions was compared with Chi-squared test using MedCalc Statistical Software (MedCalc Software Ltd, Acacialaan 22, 8400 Ostend, Belgium) version 19.2.6 and significance was mentioned. P ≤ 0.05 (at 95% CI) was considered statistically significant.
| Results|| |
The demographic data and clinical profiles of enrolled subjects are shown in [Table 1]. One hundred and forty-five patients were interviewed, of which two withdrew consent when we wanted to photograph their prescriptions. The mean age of the study population (n = 143) was 68 ± 7.39 years (range, 60–91 years), with 79 being males. The mean duration of diagnosed hypertension in the population was 7.62 ± 6.65 years. One hundred (70%) patients did not have optimally controlled blood pressure. Ninety-six patients had comorbidities.
|Table 1: Demographic and clinical profile of the study population (n=143)|
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Polypharmacy (prescription of >4 pills) was noted in 53.14% (n = 76/143) of the prescriptions reviewed. ADRs were seen in 35.66% [Figure 1]. In only 10 (7%) of 143 patients, the pretreatment evaluation was near ideal. In these cases, the investigations included serum electrolytes and real function tests, electrocardiogram, and evaluation for proteinuria.
The Prescription Quality Assessment is tabulated in [Table 2]. It was interesting to note that a physician's prescription was available to most of the patients (70.63%; 101/143), but 12 had never been prescribed and 30 had lost their prescriptions. These patients continued taking medications OTC either by showing old drug wrappers that they had retained or by verbally asking for medicines they remembered or those that had been suggested to them by family/friends/acquaintances/advertisements.
The patients' behavior was approached under four categories: that pertaining to prescription (compliance-related), that pertaining to the patient (self-prescribing), being lost to follow up and using old prescriptions as tabulated in [Table 3]. Out of the total patients who were once prescribed (n = 131), 54 (41.22%) patients became lost to follow-up (LFU), whereas 59 patients (64.13%, P ≤ 0.0001; 95% CI: 16.22–39.15%) were using their old prescriptions to procure medications (including LFU).
Only 42 patients (of the 99 who were LFU, noncompliant, or into CAM) could explain their behavior stating various reasons such as inability to go to the doctor or purchase medication due to financial or distance issues or because they had taken medication for the first time in a medical camp which was never held again or sometimes because they had been displaced/relocated due devastations caused by natural calamities. One even said that the doctor they had faith in had died, while another said that she was too afraid of medical facilities to visit them regularly. The monetary constraint was the most common reason for self-medication (20.2%; 20/99) [Figure 2].
Optimal blood pressure control and adverse drug reaction
Despite medication, optimal control of the blood pressure was not achieved in a significant proportion of patients [72.03% vs. 27.97%, P < 0.0001; 95% CI: 32.94%–53.54%; [Table 1]]. Fifty-two of 76 patients with polypharmacy did not achieve optimal control of BP. On analysis of the impact of follow-up upon the level of blood pressure control, our findings indicated that 54 of 77 patients who were directly under the care of a physician failed to achieve the target blood pressure (i.e., 120–139/70–89). Forty-five of them had a higher blood pressure, while in 9, the blood pressure was lower than optimal. Amongst the patients who were under follow-up, despite they being under the direct supervision of a physician, 50 (64.93%) patients had an ADR [Figure 1].
| Discussion|| |
Our study showed that hypertension in the elderly at the community level is poorly controlled (standing at 72.03%). Similar findings were reported by a recent family-group-based study from South India by Saju et al., report where blood pressure control was achieved only in about 35%. There was no difference in BP control in regards to gender or number of comorbidities, nor was there a bias for a particular age-group as noted in our study too. Saju et al., however, noted a better control in females.
Our study noted a curious finding of "loss of prescription." No studies documenting such behavior could be found on a literature search. This could be due to the lack of electronic medical records and data retrieval systems in our health-care facilities. Our study does not concur with the observation that hypertensives are highly likely to self-medicate as only 36 of 143 patients in total were found to do so.
Typically, patients were devising new ways to access antihypertensive medications (a combination of CAM-SM/OTC) to avoid expensive or time-consuming or deemed wasteful hospital visits/consultations. Studies from around the globe have also noted such so-called "personal treatment strategies" in people who become LFU. They attributed such practices to reasons such as poor advice/counseling by doctors, poor knowledge of chronic diseases among patients, a variable supply of drugs at government dispensaries, or monetary reasons., We also noted such patient behaviors mainly stemmed from monetary issues. The practice of not mentioning follow-up advice or person to contact in an emergency was glaring (mentioned only in about 41%). In India, to minimize costs and reach out to large populations, medical camps and mobile treatment services are promoted.
The downside of this practice is that there is no continuity of care or review and renewal of prescriptions. Holding camps at regular intervals by the same medical teams within the same community along with electronic data recording may be possible solutions.
Total ADRs encountered in the study population were 35.66% and this was not influenced by age or gender. This rate is similar to outpatient ADR rates reported by Mandavi et al. (5%–35% across all age groups). Although more errors could have been detected; if the patients had been appropriately investigated before initiatiation of treatment. Regardless, it is of note that about 65% (50 over 77) of our patients under direct physician surveillance were having an ADR. This was significantly higher than expected and can probably be due to the pressurized health system building a corpus of prescribers (including nonallopathic). As mentioned in the reply by Sodani A to an article by Mudur G, the practitioners of traditional systems of medicine (CAM), without undergoing the rigors of modern medical (allopathic) education are being permitted to prescribe allopathic treatment with minimal training. As a policy measure to ease pressure on the over-burdened healthcare system, it is laudable approach but the price is being borne by unsuspecting patients. Dhikav et al. pointed out that India does not have a mature and robust system of recognizing and reporting ADRs. This along with lack of awareness about PIM, PDDI, and polypharmacy seems to be plausible explanations for our high rate of ADR. Poor doctor–patient communication, paternalistic prescription culture, and lack of a robust follow-up system are other factors.,
The quality of prescriptions was alarming be these from a postgraduate or just a rookie doctor. A significant number of them were handwritten (n = 67) and mostly illegible. In 62% of 101 prescriptions, a complete diagnosis was missing. A study published in the Medical Journal of Armed Forces, India, by Mohan et al. also mentions that diagnosis was not mentioned in 60% of prescriptions while a 13% were illegible. About 81% of them had mentioned brand names of drugs rather than the generic name, which is the norm. This is also seen in the studies published by Dyasanoor and Urooge and Tamuno and Fadare.,
Only 13.8% of the prescriptions carried advice on lifestyle, diet, and exercise. Counterintuitively, patients under the direct care of physicians were noted to have poorer control of blood pressures; possibly because in our study BP control was deemed poor if BP on the day of interview fell on 'either' side of the specified target range of 120-139 over 70-89 mmHg.
Although the schedule of ingestion of medication was mentioned in 93/101 prescriptions, about 14% of patients were confused or had forgotten the instructions. Patients were also noted to combine two prescriptions or were found selectively taking drugs from the one they had (27.72% of 101) or even if taking the drugs, they were not taking as per dosage advised (36.6% of 101). All such errors can be grouped under the heading of "non-compliance." This was also noted in the study by Shalini et al which noted that the prevalence of non-compliance approached 50% in the elderly. There is a clear need for home health visitors to periodically check the prescriptions and medicines available and instruct the patients about the timing and dose of medicines. Pill bottles with labels in large fonts will go a large way in obviating the confusion created by the change of brands.
Polypharmacy was a common occurrence in our study population. As high as 17 drugs were prescribed, with 7.23 ± 2.26 drugs being the average. Ironically, 52 of the 76 patients exposed to polypharmacy had sub-optimal BP control. Polypharmacy was also noted in 87% of the 1050 hypertensives studied by Akunne and Adedapo from Nigeria and they too noted suboptimal BP control. They also observed an increase in blood pressure with the number of drugs in the prescription (χ2 = 33.618, P < 0.001; r = 0.18, P < 0.001).
Shafiq et al. from PGIMER, Chandigarh, studied 521 consecutive patients attending the hypertension clinic and found that 63.9% used complementary or AM with Ayurvedic drugs being used by 56.7% and herbal medicines by 14.4%. The most common reason for doing so was the fear of ADRs of conventional allopathic medicines. Only 5.4% of the patients reported this practice to their physicians. In our study, only 12.59% of the patients reported consuming complementary or AM.
| Conclusion|| |
At the community level, elderly hypertensives have poor BP control. The etiology is multifactorial with lacunae at the level of the health-care system, doctors, and patients. An overburdened system with a poor doctor–patient ratio means that doctors simply do not have enough time to evaluate their patients appropriately, discuss treatment options, or even explain prescriptions to them. Poor prescription writing, polypharmacy, and lack of electronic record-keeping are other factors. Suboptimal BP control, PIMs, and PDDIs are common.
Aversion to visiting crowded clinics or the inability to get to clinics or, lack of funds to seek consultation; result in loss to follow up. Failing memory, confusion, poor vision, and lack of family support also lead to their consuming wrong medicines or medicines in the wrong doses. Availability of drugs OTC and without prescriptions compounds the problem. The study also throws up simple solutions that can remedy many of these shortcomings.
Limitations of the study
- Due to COVID-19, the social dynamics were toppled and so were patient behaviors and prescribing practices. Prudent would have been a comparison of data collected before and during the pandemic. However, on attempting a comparision it was realized that most of the data was already collected in pre-pandemic (by Mar 2020) times and thus a comparison would have had an inherent bias, thus would not be appropriate. Further study is proposed for the same.
- It was a study based in a single district and thus the results tend to have a bias in accordance with the geosocial structure here.
- Although the study was done in a community with random sampling, its findings cannot be simply extrapolated nationwide/internationally, but it does highlight some maladies the health-care system is facing at present.
Key message, implications of the study, and recommendations from the study
- The health-care system is in grave danger and it is not just because of the doctor but the entire system including the patient (playing a major part in their health). The study discovers and/reiterates curious new patient behavior and doctor prescribing patterns to be wary of while conducting future health studies or planning hereafter
- Patient behaviors (with reasons behind them) should be studied in countries like India and harmful ones' of them be remedied for ensuring better health percolation through all stratas of society especially the one with elderly
- Mass counseling sessions for patients on basic lifestyle and precautions for chronic diseases should be encouraged by NGOs akin to AIDS groups or cancer groups. This will reduce the pressure on present physicians and improve patient behaviors
- One-time medical camps should be discouraged to prevent the genesis of patient medication errors, while further studies may be needed to strengthen this association
- Prescription writing needs to be scrutinized by various means, e.g., electronic prescription systems
Medical education cannot be replaced by a quick substitute to fulfill the demand by just bringing in more "doctors to patient;" rather, a system also should be established to bringing more "patients to the doctors."
- Col Vivek Aggarwal, Associate Prof, Dept of Medicine, AFMC, Pune for helping in the recruitment of subjects
- Med Cdt Madhusudhan, AFMC, Pune; 3rd yr UG Student, for helping in data collection
- Prof Ajoy Sodani, for the flow of thought and organization of matter
- Dr. Aparna Sodani, for giving the impetus
- Dr. Priyanka Sodani for all the support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]