Effect of 2 Models of Care and Factors Predicting Patients' Adherence to Doctor's Appointment Attendance in Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria.

BACKGROUND: Provision of antiretroviral therapy in resource limited settings has put pressure on the available infrastructure. OBJECTIVES: The study examined patients' adherence to Doctor's appointment attendance after an intervention changing the model of care and factors that predicted adherence. METHODS: Observational study was carried out over four years. The model of care was changed in the last year and the effect assessed. SPSS version 15.0 was used for analysis. Predictors of adherence were determined using logistic regression model. RESULTS: Over half 148 (59.7%) of the patients were females, with a mean age of 40.4±8.8 years and baseline CD4 cells of 143.5±92.7cells/microliters. "Adherence" rates were 51.3% in 2007, 35.9% in 2008 and 14.9% in 2009 giving patients' average adherence to Doctor's appointment attendance of 34.03%. Intervention changing the model of care in 2010 recorded an adherence rate of 93.1%. CONCLUSIONS: The change in model of care greatly improved patients' "adherence". Patients' knowledge of management, adherence, and smoking and drinking habits were identified as statistically significant predictors of adherence.

Impact of generic substitution practice on care of diabetic patients.

BACKGROUND: Patients with chronic diseases like type II diabetes mellitus often have their prescriptions substituted with generic medicines in the course of care to save costs of medicines and to improve access. There is need to assess impact of this practice on patient care. OBJECTIVE: To assess patient's knowledge of generic substitution practice and its impact on patient care. SETTING: An outpatient diabetic clinic of a tertiary hospital in Nigeria. METHOD: The study is a cross sectional survey of patients attending a diabetic clinic. A structured questionnaire was used to interview willing patients. A total of 120 patients were enrolled for the study, but only 102 responded (85 % overall response rate). MAIN OUTCOME MEASURES: Patients' knowledge of generic substitution practice, patients' report of abstaining from drug use, experiences of more side effects and patients' confusion. RESULTS: Over half (57.8 %) of surveyed patients (n = 59) had noticed brand switches, out of which, 30.5 % experienced brand switches more than 3 times within a year. More than a third of the respondents (38.6 %) did not know when pharmacists actually substituted their medicines. About one in five (19.6 %) patients did not use their medicines after substitution because they were not sure of the brand supplied but 35.6 % have rejected substitution at one time and insisted on doctors' prescription. Respondents (14.9 %) agreed that brand substitution resulted in confusion while 24 % reported receiving brands that resulted in more side effects. More respondents (58.6 %) indicated that they never had a discussion with their pharmacists about the reasons for generic substitution and switches. CONCLUSION: Generic substitution without adequate information resulted in confusion and subsequent lack of adherence. There is the vital need for appropriate policy and guidelines for generic substitution in Nigeria.

Cost effectiveness of three drugs for the treatment of S. aureus infections in Nigeria.

BACKGROUND: Resistance of microorganisms to existing antimicrobial agents threatens the effective utilization of available resources in sub-Saharan Africa. Cost-effective utilization of antibacterial agents is essential in effective health care delivery in Nigeria. OBJECTIVES: To determine the most cost effective antibacterial agent in the treatment of S. aureus infections in Lagos metropolis. SETTING: The study was carried out in a teaching hospital, a specialist hospital, a referral center and two private hospitals. METHODS: Cost effectiveness analysis of ciprofloxacin, cefuroxime and gentamicin identified to be most effective agent against 463 clinical isolates of S. aureus obtained from the five hospitals was carried out on the basis of societal, health care and third party perspectives using 'decision table" as an analytical model. Criteria considered in the model included degree of efficacy of the agents, adherence tendencies and tolerability. Both direct (cost of drugs, diagnosis/monitoring, personnel and transportation) and indirect (loss of productivity) costs were evaluated. MAIN OUTCOME MEASURES: These include economic outcome as total therapy cost, clinical outcomes as extent of antibacterial effectiveness obtained from degree of antibacterial efficacy, a proxy measurement of cure rates, and adherence tendency. Humanistic outcome was also measured as tolerability prorated from literature reported degree of adverse drug reactions events, risk of infection and pains from drug administration. RESULTS: Ciprofloxacin tablet is a dominant option and much more cost-effective than either cefuroxime or gentamicin in the treatment of S. aureus in Lagos. Regardless of the perspective of analysis, ciprofloxacin has the least cost effectiveness ratio of NGN4214.66 ($28.09), NGN2392.63 ($16.00) and NGN2048.66 ($13.65) from societal, health care and third party payer perspectives, respectively. Sensitivity analysis by increasing the effectiveness index of gentamicin injection-the least cost effective option to the value for the most cost effective option did not change the results. CONCLUSION: Ciprofloxacin should be used as first-line-treatment of S aureus in Lagos as it will lead to significant cost savings in the treatment of S. aureus infections.

Formulation of quinine suppository for initiation of early treatment of malaria - a preliminary study.

Background: In the management of malaria, there is the need for early initiation of treatment. An antimalarial drug for home use must be easy to administer, safe, effective and affordable. Parenteral quinine is the gold standard for treatment of severe malaria. A rectal formulation of quinine will therefore serve the purpose of early initiation of care in patients that lack easy access to medical centers. The main objective of this preliminary work was to develop a quinine suppository with adequate release properties that also meets the dual conditions of affordability and ease of administration. Materials and Methods: Cocoa butter and Fattibase™ were used in the preparation of suppositories containing 200 mg quinine bisulphate. The release profiles of formulations with varying concentrations of polysorbate 80 (0 - 5%) were evaluated by in vitro dissolution in pH 8 buffer medium. Results: The addition of polysorbate 80 improved the release of quinine significantly at 2 and 5%. Cocoa butter suppository with 1% polysorbate 80 released 73.6 mg quinine bisulphate in 1 hr while release from suppositories with 2% and 5% surfactant was higher. Fattibase™ suppositories had better release profiles than cocoa butter formulations. The formulation with 5% polysorbate 80 released 170 mg quinine in 1 hr. Formulations with the two bases released quinine in adequate quantities for the management of malaria. Conclusions: The particle size of quinine is an important factor affecting the physical appearance and drug release from the suppository. The Fattibase™ suppositories were more stable but cost five times the price of the cocoa butter formulations. The cocoa butter formulations, however, still released quinine in sufficient quantities for the management of malaria. Cocoa butter formulations will be more affordable in resource-limited malaria-endemic regions of the world.

Frequency, types and severity of medication use-related problems among medical outpatients in Nigeria.

OBJECTIVES: To determine the frequency, types and severity of medications use-related problems among medical outpatients in a tertiary care setting in southwestern Nigeria. SETTING: Medical outpatient clinics of a 900-bed Teaching Hospital located in Ibadan, Southwestern Nigeria. METHODS: A prospective cross-sectional medication use review was conducted by ten pharmacists for 400 randomly selected medical outpatients over a 4 week period at a 900-bed premier teaching hospital located in Ibadan, Nigeria. Severity assessment of medication use-related problems was done by 3 independent assessors with a modified severity index. MAIN OUTCOME MEASURE: Frequency, types and severity of medication use-related problems identified through pharmacist-initiated medication use review. RESULTS: Of the 400 randomly selected patients, 324 (81.0%) consented and were interviewed. One hundred and sixty-three (50.3%) of the cohort were males and 161 (49.7%) were females; with mean ages 51.5 ± 17.6 and 52.1 ± 17.4 years respectively. Median no. of drugs prescribed per patient per day was 4 (Minimum-Maximum, 1-7). About 27.5% were self medicating with orthodox (prescription-only and over-the-counter) and/or herbal medicines; and only 14.6% claimed disclosure to their physicians. The proportion of patients self medicating with orthodox medicines was significantly higher (P < 0.0001). Two hundred and twenty-six medication use-related problems were identified from 58.6% of patients, but the highest number (5) was identified among 2.6% of patients. The frequency of medication use-related problems appear strongly related to the number of medicines prescribed (r = 0.71, P = 0.006). The majority of medication use-related problems were ranked as potentially harmful [Inter-rater reliability coefficient: Gwet AC1: 0.7214 (P ≤ 0.001)]. Non-adherence (43.8%), problems associated with self medication (39.3%) and adverse drug reactions (15.6%) were the most frequent. Unauthorized drug holidays (46.5%) and stoppage of prescribed prescription-only medications for local herbs (29.3%) were the major consequences of non-adherence. Potentially harmful drug-disease interactions were the most frequent medication use-related problems arising from self medication (40.4%). CONCLUSION: Potentially harmful medication use-related problems are frequently encountered among medical outpatients in Nigeria. The institutionalization of medication use review and the devolution of this task to pharmacists may prove beneficial in optimizing outcomes of medication use in Nigeria.

Pharmacists' participation in the documentation of medication history in a developing setting: An exploratory assessment with new criteria.

OBJECTIVE: To assess the impact of pharmacists' participation on the frequency and depth of medication history information documented in a developing setting like Nigeria. METHOD: The study consisted of two phases. The first phase was a baseline cross-sectional assessment of the frequency and depth of medication history information documented by physicians in case notes of systematic samples of 900 patients that were stratified over 9 Medical outpatients Units at a premier teaching hospital in south western Nigeria. The second phase was an exploratory study involving 10 pharmacists who conducted cross-sectional medication history interview for 324 randomly selected patients. RESULTS: 49.2% of patients, whose medication history were documented at the baseline, by physicians, were males; while 50.3% of patient interviewed by pharmacists were male. Mean age (SD) of males and females whose medication histories were documented by physicians and pharmacists were 43.2 (SD=18.6), 43.1 (SD=17.9) years and 51.5 (SD=17.6), 52.1 (SD=17.4) years respectively. The frequency of medication history information documented by pharmacists was significantly higher for twelve of the thirteen medication history components (P < 0.0001). These include prescription medicines; over the counter medicines; source of medicines; adverse drug reactions; allergy to drugs, allergy to foods, allergy to chemicals; patient adherence; alcohol use; cigarette smoking; dietary restrictions and herbal medicine use. The depth of medication history information acquired and documented by pharmacist was significantly better for all the thirteen medication history components (P<0.0001). CONCLUSION: Pharmacists' participation resulted in significant increase in frequency and depth of medication history information documented in a developing setting like Nigeria. The new medication history evaluation criteria proved useful in assessing the impact of pharmacists' participation.

What probable factors underlie inadequacy of medication history information recorded in patients' case notes by physicians in a Nigerian teaching hospital?

OBJECTIVE: To identify probable factors underlying inadequacy of medication history information recorded in patients' case notes by physicians in an ambulatory tertiary care setting in Nigeria. METHOD: A cross-sectional survey was conducted, with a pre-tested 25-item questionnaire, of 93 physicians at the nine medical units in the Department of Medicine at University College Hospital, Ibadan, Nigeria. KEY FINDINGS: The overall response rate was 79.6% (74/93), and the usable rate was 75% (70/93). A majority of physicians opined that a detailed medication history is an essential component of optimal and patient-specific care; and they were able to identify correctly the key components of a detailed medication history. However, about 60% of physicians opined that the adequacy of medication history documented by them is affected by heavy workload due to the large number of patients to which they attend. The majority (75%) of physicians also considered detailed documentation of patient medical history to be more important than medication history. CONCLUSIONS: Physicians' heavy workload, due to the large number of patients, and their belief that medical history is more important than medication history, appear to be the probable factors underlining the inadequacy of physician-acquired medication history in a developing sub-Saharan tertiary care setting.

Does a physician's specialty influence the recording of medication history in patients' case notes?

AIMS: To determine the impact of a physician's specialty on the frequency and depth of medication history documented in patient medical records. METHODS: A cross-sectional assessment of the frequency and depth of medication history information documented by 123 physicians for 900 randomly selected patients stratified across Cardiology, Chest, Dermatology, Endocrine, Gastroenterology, Haematology, Neurology, Psychiatry and Renal specialties was carried out at a 900-bed teaching hospital located in Ibadan, Nigeria. RESULTS: Four hundred and forty-three (49.2%) of the cohort were males and 457 (50.8%) were females; with mean ages 43.2 +/- 18.6 and 43.1 +/- 17.9 years respectively. Physicians' specialties significantly influenced the depth of documentation of the medication history information across the nine specialties (P < 0.0001). Post hoc pair-wise comparisons with Tukey's HSD test showed that the mean scores for adverse drug reactions and adherence to medicines was highest in the Cardiology specialty; while the Chest specialty had the highest mean scores for allergy to drugs, food, chemicals and cigarette smoking. Mean scores for the use of alcohol; illicit drugs; dietary restrictions was highest for Gastroenterology, Psychiatry and Endocrine specialties respectively. Physicians' specialties also significantly influenced the frequency of documentation of the medication history across the nine specialties (P < 0.0001). CONCLUSIONS: Physicians appear to document more frequently and in greater depth medication history information that may aid the diagnostic tasks in their specific specialty. Researchers and other users of medication history data documented in patients' medical records by physicians may want to take special cognizance of this phenomenon.

Cost implication of irrational prescribing of chloroquine in Lagos State general hospitals.

BACKGROUND: A major share of the hospital budget is spent on drugs. Irrational use of these drugs is a waste of financial and human resources that could have been deployed for another use within the hospital setting especially in cases where such drugs are provided free to patients. Also there is increased morbidity and progression of severity with irrational use. The objective of this study was to determine the irrational use of chloroquine and the subsequent cost implications in Lagos State general hospitals. METHODOLOGY: A retrospective study period of one year (January to December, 2000) was selected. A total of 18,781 prescription forms of "Free Eko Malaria" were sampled for children and adults from all the Lagos State general hospitals. Drug costs in each prescription form were identified. Cost effectiveness analysis of chloroquine tablet and intramuscular injection was undertaken. RESULTS: The average cost of medicine per prescription was 132.071 ($1.03) which should have been 94.22 ($0.73) if prescribed rationally. The total cost of prescriptions for malaria under study was 2,480,425.00 ($19,348.09). About 68% {(1,679,444.00) ($13,100.19)} of the total cost was lost to irrational prescribing. This is a waste of scarce resources. When the prescriptions were differentiated into the different dosage forms prescribed, the prescriptions containing intramuscular injections only had over 90% of the cost lost to irrational prescribing. Cost effectiveness analysis showed that chloroquine tablet was 17 times more cost effective than chloroquine injection (intramuscular) from a health care system perspective while it was 14 times more cost effective from a patient perspective. CONCLUSION: There is waste of scarce resources with irrational dispensing of drugs and these resources could have been deployed to other uses or areas within the hospitals. The tablet chloroquine was more cost effective than injection chloroquine (intramuscular). Increasing the cost of tablets, decreasing effectiveness of tablets, decreasing the cost of injections and increasing the effectiveness of injections did not change the cost effectiveness conclusion.