An Assessment of the Current Level of Implementation of the Core Elements of Antimicrobial Stewardship Programs in Public Hospitals in Ghana.

Introduction: Antimicrobial resistance (AMR) is becoming a threat to global public health. Antimicrobial stewardship (AMS) program (ASP) is one of the 5 strategic areas in the Ghana National Action Plan to fight this menace. Assessment of the core elements of ASP in a hospital setting has been identified as a pragmatic way of identifying the barriers and facilitators for its effective implementation. Method: The World Health Organization's toolkit for assessment of the 7 core elements of ASP in hospitals in low and middle income countries was used for this situational analysis of public hospitals in 2 regions of Ghana. The core elements included leadership commitment, accountability and responsibility, pharmacy expertize, AMS actions and interventions, education and training, and periodic monitoring and surveillance. Data collected using a checklist were imported into STATA version 14 for descriptive and bivariate analyses. Results: 15 public hospitals were assessed with the toolkit. Most of them were primary health care facilities (n = 12, 80.0%), had bed capacities between 100 and 199 beds, less than 50 medical doctors (n = 12, 80.0%), less than 5 pharmacists (n = 10, 66.7%), and between 100 and 199 nurses. Performances in 4 out of the 7 core elements were most deficient and they included leadership commitment, pharmacy expertize, AMS actions (interventions) implemented, monitoring and surveillance of antibiotic use, and bacteria resistance rates. Pharmacist-led ASPs were also found to be associated with their formal training on AMS. Key barriers identified included lack of skilled human resources, lack of available time for AMS-related duties and poor laboratory infrastructure. Conclusion: There was sub-optimal performance for almost all the core elements of ASP in the public hospitals in Ghana hampered mostly by lack of skilled human and financial resources. Pharmacists must be empowered through formal training and certificate programs in infectious disease management and AMS principles and strategies to enhance their contribution toward ASPs in hospitals. The results from this study should encourage nationwide assessment of ASPs across hospital settings in Ghana to better evaluate the level of their implementation and address potential barriers to guide AMS policies and ASP strategy development toward the fight against AMR.

Trends in the utilization of medicines sold in the private sector post- registration in South Africa and the implications for similar countries.

BACKGROUND: Regulatory authorities register medicines for patients to access them within a reasonable period of time. There is a paucity of available data regarding the extent to which registered medicines reach the public after market authorisation is granted by the South African Health Products Regulatory Authority (SAHPRA). This is important since time spent by SAHPRA assessing medicines that are subsequently not launched onto the South African market means time wasted, which could be spent on assessing new medicines that address an unmet need in the country. Consequently, we initially analysed the time taken for registered medicines to reach patients and the relationship between medicines registered at SAHPRA and those subsequently dispensed in private pharmacies. The extent of registration of multiple sourced versus new patented medicines was also explored. METHODS: A retrospective, descriptive and quantitative investigation was conducted for medicines registered between 2014 and 2019. Registered and dispensed medicines were compared to establish accessibility post registration. Data sources included SAHPRA and IQVIA datasets. Microsoft Excel and SAS were used for data storage, analysis, and computation of descriptive statistical analysis. RESULTS: Of (N = 2175) registered medicines, only 358 (16.5%; 95% CI 15.0%-18.1%) were dispensed to patients, and out of 1735 medicines registered between 2015 and 2019, only 57 (3.3%; 95% CI 2.5%-4.2%) were dispensed during the study period. Medicines acting on the central nervous system were registered and dispensed the most at 21.0% and 18.0%, respectively, whereas antineoplastic and immunomodulation agents were registered and dispensed only 11% and 5%, respectively. A concern was that only 13.0% of registered medicines were originators, with most either as generics, including branded generics, or pseudo-generics. CONCLUSION: Regulatory measures should be implemented to ensure increased medicine access post-registration for new originators, especially for priority disease areas that benefit patients. Mental health diseases and improved access to oncology medicines require special attention and further investigation in South Africa.

Low influenza vaccine uptake by healthcare workers caring for the elderly in South African old age homes and primary healthcare facilities.

BACKGROUND: The elderly bear the highest burden of South Africa's estimated annual > 10 million influenza cases and > 11,000 influenza-related deaths. Unvaccinated healthcare workers (HCWs) are at high occupational risk of contracting influenza, and may transmit influenza to elderly patients in their care. Thus, the South African National Department of Health recommends that HCWs receive annual influenza vaccination. This study aimed to determine influenza vaccination coverage among HCWs; identify reasons for their vaccination status; and investigate if HCWs recommend vaccination to their elderly patients. METHODS: A descriptive study was conducted in 18 community health centres and 44 private sector and non-governmental organisation managed old age homes across South Africa, using a self-administered structured questionnaire, which was distributed to 360 HCWs present on the day of data collection. Data were captured using Microsoft Excel® and imported to Epi Info™ 7 (Centers for Disease Control and Prevention, USA) for descriptive statistical analysis. Ethics approval (SMUREC/P/36/2018: PG) and permission to conduct the study at the facilities were obtained. All participants provided informed consent. RESULTS: The response rate was 76.7% (276/360). Most participants were female (90.9% [251/276]), nursing professionals (81.2% [224/276]) with a mean age of 41.1 ± 11.7 years. Although 62.7% of participants indicated having ever received at least one dose of the influenza vaccine, influenza vaccine uptake for 2017 and 2018 was 24.36% (41/276) and 33.3% (92/276) respectively. The main reasons given for never being vaccinated against influenza were related to the unavailability of the vaccine (70.9%) and vaccine hesitancy (27.2%). Most participants (67.8% [187/276]) recommended vaccines to elderly patients in their care. CONCLUSION: The main reasons behind low influenza vaccine uptake by HCWs in South Africa who care for the elderly were related to unavailability of the vaccine and vaccine hesitancy. Strategies to educate HCWs on the importance of influenza vaccination, while concurrently increasing sustained and easy access to the vaccine by HCWs are needed to preserve public health.

Estimated indirect costs of haemodialysis versus peritoneal dialysis from a patients' perspective at an Academic Hospital in Pretoria, South Africa.

In South Africa (SA), patients with kidney failure can be on either haemodialysis (HD), which is performed by a healthcare professional in a hospital thrice weekly; or peritoneal dialysis (PD), which can performed daily at home. There needs to be more studies within the South African healthcare sector on the cost of kidney failure and especially the indirect costs associated with patients being on dialysis to provide future guidance. This study aimed to determine and compare the indirect costs associated with HD and PD from the patients' perspective at an Academic Hospital in Pretoria. The study used a cross-sectional prospective quantitative study design. The researcher used face-to-face interviews to collect data and the human capital approach to calculate productivity losses. The study population included all patients over 18 receiving HD or PD for over three months; 54 patients participated (28 on HD and 26 on PD). The study lasted seven months, from September 2020 to March 2021. Haemodialysis patients incurred greater productivity losses per annum ($8127.55) compared to PD (R$3365.34); the difference was statistically significant with a P-value of p < 0.001. More HD (96.4%) patients were unemployed than (76.9%) PD patients.

Airport-based pharmacies: Products, services and challenges essential for patients in a global travel landscape.

The role of airport pharmacies has grown in recent years to provide a range of services to travelers, including over-the-counter and prescription medicines, as well as advice on prevention of infectious and other diseases. Prevention, including protective equipment, is especially important during pandemics, as seen with the recent coronavirus disease-2019 (COVID-19) pandemic. In addition, offering vaccinations where appropriate. However, this is not universal, and there are currently no acknowledged guidelines for pharmacists operating within airports. In addition, research into their role as well as potential ways to improve this is lacking. This is a concern with community pharmacists playing a valuable role during the COVID-19 pandemic. Potential ways forward include greater research into their activities to enhance their role and address challenges. These include issues of brand names and language, as well as encouraging travel pharmacy in future university curricula. In addition, producing guidelines for their activities and monitoring their implementation. This can help build a greater role for their services, benefiting airport staff and travelers in the future.

Using Culture Sensitivity Reports to Optimize Antimicrobial Therapy: Findings and Implications of Antimicrobial Stewardship Activity in a Hospital in Pakistan.

Background: There are concerns with inappropriate prescribing of antibiotics in hospitals especially broad spectrum in Pakistan and the subsequent impact on antimicrobial resistance rates. One recognized way to reduce inappropriate prescribing is for empiric therapy to be adjusted according to the result of culture sensitivity reports. Objective: Using culture sensitivity reports to optimize antibiotic prescribing in a teaching hospital in Pakistan. Methods: A retrospective observational study was undertaken in Ghurki Trust Teaching Hospital. A total of 465 positive cultures were taken from patients during the study period (May 2018 and December 2018). The results of pathogen identification and susceptibility testing from patient-infected sites were assessed. Additional data was collected from the patient's medical file. This included demographic data, sample type, causative microbe, antimicrobial treatment, and whether empiric or definitive treatment as well as medicine costs. Antimicrobial data was assessed using World Health Organization's Defined Daily Dose methodology. Results: A total of 497 isolates were detected from the 465 patient samples as 32 patients had polymicrobes, which included 309 g-negative rods and 188 g-positive cocci. Out of 497 isolates, the most common Gram-positive pathogen isolated was Staphylococcus aureus (Methicillin-sensitive Staphylococcus aureus) (125) (25.1%) and the most common Gram-negative pathogen was Escherichia coli (140) (28.1%). Most of the gram-negative isolates were found to be resistant to ampicillin and co-amoxiclav. Most of the Acinetobacter baumannii isolates were resistant to carbapenems. Gram-positive bacteria showed the maximum sensitivity to linezolid and vancomycin. The most widely used antibiotics for empiric therapy were cefoperazone plus sulbactam, ceftriaxone, amikacin, vancomycin, and metronidazole whereas high use of linezolid, clindamycin, meropenem, and piperacillin + tazobactam was seen in definitive treatment. Empiric therapy was adjusted in 220 (71.1%) cases of Gram-negative infections and 134 (71.2%) cases of Gram-positive infections. Compared with empiric therapy, there was a 13.8% reduction in the number of antibiotics in definitive treatment. The average cost of antibiotics in definitive treatment was less than seen with empiric treatment (8.2%) and the length of hospitalization also decreased. Conclusions: Culture sensitivity reports helped reduced antibiotic utilization and costs as well as helped select the most appropriate treatment. We also found an urgent need for implementing antimicrobial stewardship programs in hospitals and the development of hospital antibiotic guidelines to reduce unnecessary prescribing of broad-spectrum antibiotics.

A Narrative Review of Recent Antibiotic Prescribing Practices in Ambulatory Care in Tanzania: Findings and Implications.

Background and objectives: There are concerns with the current prescribing practices of antibiotics in ambulatory care in Tanzania, including both the public and private sectors. These concerns need to be addressed as part of the national action plan (NAP) of Tanzania to reduce rising antimicrobial resistance (AMR) rates. Issues and concerns include high rates of prescribing of antibiotics for essentially self-limiting conditions. Consequently, there is a need to address this. As a result, the aims of this narrative review were to comprehensively summarize antibiotic utilization patterns particularly in ambulatory care and their rationale in Tanzania and to suggest ways forward to improve future prescribing practices. Materials and Methods: We undertook a narrative review of recently published studies and subsequently documented potential activities to improve future prescribing practices. Potential activities included instigating quality indicators and antimicrobial stewardship programs (ASPs). Results: Published studies have shown that antibiotics are being excessively prescribed in ambulatory care in Tanzania, in up to 95% to 96.3% of presenting cases depending on the sector. This is despite concerns with their appropriateness. High rates of antibiotic prescribing are not helped by variable adherence to current treatment guidelines. There have also been concerns with extensive prescribing of 'Watch' antibiotics in the private sector. Overall, the majority of antibiotics prescribed across the sectors, albeit inappropriately, were typically from the 'Access' group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than 'Watch' antibiotics to limit AMR. The inappropriate prescribing of antibiotics in ambulatory care is linked to current knowledge regarding antibiotics, AMR, and ASPs among both prescribers and patients. Recommended activities for the future include improved education for all groups, the instigation of updated quality indicators, and the regular monitoring of prescribing practices against agreed-upon guidelines and indicators. Education for healthcare professionals on ASPs should start at undergraduate level and continue post qualification. Community advocacy on the rational use of antibiotics should also include social media activities to dispel misinformation. Conclusion: The quality of current prescribing practices of antibiotics in ambulatory care is sub-optimal in Tanzania. This needs to be urgently addressed.

Antibiotic Susceptibility Surveillance in the Punjab Province of Pakistan: Findings and Implications.

Background and Objectives: The increase in antimicrobial resistance (AMR) across countries has seriously impacted the effective management of infectious diseases, with subsequent impact on morbidity, mortality and costs. This includes Pakistan. Antimicrobial surveillance activities should be mandatory to continually assess the extent of multidrug-resistant bacteria and the implications for future empiric prescribing. The objective of this retrospective observational study was to monitor the susceptibility pattern of microbes in Pakistan. Materials and Methods: Clinical samples from seven laboratories in Punjab, Pakistan were collected between January 2018 and April 2019, with Punjab being the most populous province in Pakistan. The isolates were identified and their antimicrobial susceptibility was tested using the Kirby-Bauer disc diffusion assay and micro broth dilution methods. The antibiotics assessed were those typically prescribed in Pakistan. Results: In total, 2523 bacterial cultural reports were studied. The most frequently isolated pathogens were Staphylococcus aureus (866, 34.3%), followed by Escherichia coli (814, 32.2%), Pseudomonas aeruginosa (454, 18.0%) and Klebsiella pneumoniae (269, 10.7%). Most pathogens were isolated from pus (1464, 58.0%), followed by urine (718, 28.5%), blood (164, 6.5%) and sputum (81, 3.2%). Conclusions: The findings suggest that current antimicrobial options are severally restricted in Pakistan due to the emergence of multidrug-resistant pathogens. This calls for urgent actions including initiating antimicrobial stewardship programs to enhance prudent prescribing of antibiotics. This includes agreeing on appropriate empiric therapy as part of agreed guidelines, in line with the WHO EML and AWaRe book, whilst awaiting culture reports. This is alongside other measures to reduce inappropriate antimicrobial prescribing and reverse the threat of rising AMR.

Emicizumab prophylaxis for people with hemophilia A: Waste estimation and the Brazilian perspective.

Costs of hemophilia A treatment are increasing. Waste of clotting products should be avoided. To estimate the first-year waste of emicizumab prophylaxis for people with hemophilia A and inhibitors (PwHAi) who failed immune tolerance induction (ITI), in Brazil. We evaluated the manufacturer and the Brazilian Ministry of Health (MoH) protocol-recommended regimens in a budget impact model. The loading dose consisted of 3.0 mg/kg/Q1W for 4 weeks, for both recommendations. The manufacturer maintenance regimens comprised 1.5 mg/kg/Q1W, 3.0 mg/kg/Q2W, and 6.0 mg/kg/Q4W. The MoH protocol maintenance regimen encompassed a hybrid Q1W/Q2W administration, depending on the body weight. The Q4W regimen was not recommended by the MoH protocol. Analyses were performed to estimate waste given its expense based on the World Health Organization body weight range (percentiles [P] 15, 50, and 85). The first-year emicizumab waste was estimated individually and for the disclosed PwHAi who failed ITI (n = 114). The highest emicizumab waste was estimated for the lowest body weights and the Q1W regimen. The Q4W regimen resulted in the lowest emicizumab waste, followed by the MoH protocol regimen. The total reconstituted costs estimated for the PwHAi who failed ITI according to the hybrid MoH protocol ranged from US$32,858,777 (P15) to US$47,186,858 (P85), with emicizumab waste ranging from 7.9 % (US$2,594,515) to 3.7 % (US$1,738,750), respectively. Lost resources due to current protocols for emicizumab prophylaxis for PwHAi who failed ITI in Brazil are considerable. Waste was more pronounced due to lower body weight and shorter administration intervals.

Adherence to WHO Criteria on Drug Promotion Literature: An Exploratory Study From a Tertiary Healthcare Facility in South-West Nigeria.

Introduction: In many low and middle-income countries (LMIC), drug promotional literature (DPL) remains one of the main sources of drug information for physicians. Studies conducted in many LMICs showed poor compliance to the WHO guidelines for ethical drug promotion especially in the area of information about excipients, adverse drug reactions, drug-drug interactions and contra-indications. These inadequacies in the information provided may mislead the prescriber with potential adverse consequences among patients using the medicines. Nigeria has a big pharmaceutical sector which is poorly regulated and we hypothesize that such unethical drug promotional practices may exist. This study therefore set out to assess compliance to the WHO ethical drug promotion (using DPL) at the Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti, South-West Nigeria. Methodology: This was a descriptive cross-sectional study conducted in several specialist clinics of EKSUTH, Ado-Ekiti. Printed DPLs (brochures and leaflets) were collected from these clinics, collated using a pre-designed data collection form and analyzed using the WHO ethical criteria for medicinal drug promotion. Results:Two hundred seventy-five DPLs were screened A total of out of which 234 DPLs were selected after screening to after removal of duplications. Only 5 (2.1%) DPLs met all the WHO criteria. DPLs promoting antibiotics, cardiovascular drugs, and vitamins/nutritional supplements were in the majority (22.2%, 17.1%, and 11.5% respectively. Most of the DPLs had the generic (223; 95.3%) and brand (234; 100%) names, active ingredients (209; 89.3%), excipients (149; 63.7%), and indications (232; 99.1%). Information about adverse drug reactions (76; 32.5%), contra-indications (73; 31.2%), and drug interactions (46; 19.7%) was less represented. Only 59 (25.2%) DPLs had references. Fixed-dose combination drugs made up 34.6% of drugs being promoted. Conclusion:The DPLs assessed in this study had low adherence to WHO ethical drug promotion criteria especially those related to adverse drug reaction, drug interactions, and contra-indications.

Key characteristics including sex, sexual orientation and internet use associated with worse mental health among university students in Brazil and implications.

BACKGROUND: The symptoms of anxiety and depression disorders are multifactorial and can trigger a series of problems especially among university students. The aim of this study was to assess the prevalence and associated factors with anxiety and depression symptoms among first-semester university students at a Federal University in Brazil given the paucity of such data and the first semester is the most stressfultime. METHODS: Cross-sectional study with first-semester university students. The questionnaire included socio-demographic variables, lifestyles, health conditions and the Depression Anxiety Stress Scales. Descriptive analysis was performed, followed by bivariate analysis and Poisson regression analysis. RESULTS: Three hundred and fifty-six students (65.2%) across a range of courses in their first semester participated. The prevalence of anxiety was 42.5% and depression 33.2%. Regarding symptoms of anxiety and depression disorders, a positive association was observed among females, non-heterosexual, non-white skin color, excessive internet use, lack of physical activity, not attending university parties, having psychological counseling, history of anxiety in first- or second-degree relatives, poor self-rated health and use of psychotropic medicines. CONCLUSIONS: Due to the high prevalence of anxiety and depression symptoms, the importance of developing programs to promote mental and physical health of university students is highlighted.

A Cross-Sectional Study of Quality of Life Among Brazilian Adults With Type 1 Diabetes Treated With Insulin Glargine: Findings and Implications.

This article describes a cross-sectional study involving 401 adults with type 1 diabetes treated with insulin glargine in Minas Gerais, Brazil. Health-related quality of life was assessed, and worse scores were found to be associated with a low level of education, self-perceived health reported as poor/very poor, being bedridden and not physically exercised, having seen a doctor more than four times in the past year, and having reported comorbidities and episodes of hypoglycemia.

Sick leave duration as a potential marker of functionality and disease severity in depression.

Objective: To discuss the impact of depression on work and how depression-related sick leave duration could be a potential indicator and outcome for measuring functionality in depression.Methods: Our review was based on a literature search and expert opinion that emerged during a virtual meeting of European psychiatrists that was convened to discuss this topic.Results: Current evidence demonstrates that depression-related sick leave duration is influenced by multiple disease-, patient- and work-related factors, together with societal attitudes towards depression and socioeconomic conditions. A wide variety of pharmacological and non-pharmacological treatments and work-based interventions are effective in reducing depression-related sick leave duration and/or facilitating return to work. Recent real-world evidence showed that patients treated with antidepressant monotherapy appear to recover their working life faster than those receiving combination therapy. Although depression-related sick leave duration was found to correlate with severity of depressive symptoms, it cannot be used alone as a viable marker for disease severity.Conclusions: Given its multifactorial nature, depression-related sick leave duration is not on its own a viable outcome measure of depression severity but could be used as a secondary outcome alongside more formal severity measures and may also represent a useful measure of functionality in depression. Key pointsDepression in the working population and depression-related sick leave have a profound economic impact on societyDepression-related sick leave duration is influenced by multiple disease-, patient- and work-related factors, together with societal attitudes towards depression and socioeconomic conditionsA wide variety of pharmacological and non-pharmacological treatments and work-based interventions have been shown to be effective in reducing depression-related sick leave duration and/or facilitating return to workIn terms of pharmacological intervention, recent real-world evidence has shown that patients treated with antidepressant monotherapy are able to recover their working life faster than those treated with combination therapyAlthough depression-related sick leave duration has been shown to correlate with severity of depressive symptoms, it is not a viable outcome measure of depression severity on its own, but could be used as secondary outcome alongside more formal clinician- and patient-rated severity measuresDepression-related sick leave duration may, however, represent a viable outcome for measuring functionality in depression.

Tenofovir disoproxil fumarate associated nephrotoxicity: a retrospective cohort study at two referral hospitals in Namibia.

INTRODUCTION: The incidence and risk factors of tenofovir disoproxil fumarate (TDF)-related renal impairment (RI) in Namibia are unknown where TDF-containing ART regimens are used as the first line for HIV. METHODOLOGY: A retrospective cohort study among HIV-infected patients at two intermediate hospitals. A decline in estimated glomerular filtration rate (eGFR) was significant if it was ≥25% and included a change to a lower eGFR stage. New-onset RI was defined as an eGFR <50 mL/min/1.73m2 . RESULTS: 10 387 patients were included: 11.4% (n = 1182) experienced the decline in eGFR. Of these, 0.6% (n = 62) migrated to eGFR stages IV and V. The incidence was 4.5 (95% CI: 4.3-4.8) per 100 patient years. RI developed in 400 patients for an incidence rate of 2.4 (95% CI: 2.2-2.6) cases per 100 patient years. Risk factors with effect sizes >2.0, for decline-in-eGFR were baseline eGFR >60 (aHR = 15.6); hyperfiltration (aHR = 5.0); and pregnancy (aHR = 2.4); while for RI, they were hyperfiltration (aHR = 4.1) and pregnancy (aHR = 29). CONCLUSION: The incidence of decline-in-eGFR was higher than in other sub-SSA countries, but not RI. A high baseline eGFR had the greatest risk for the decline, and hyperfiltration for the RI.

Pharmacists' clinical knowledge and practice in the safe use of contraceptives: real knowledge vs. self-perception and the implications.

BACKGROUND: Pharmacists are often the first healthcare professionals that patients contact with their illnesses and requests for medical information, which is enhanced following the recent COVID-19 pandemic. Community pharmacists are expected and required to possess a broad spectrum of knowledge and skills. Self-assessment of these competencies is needed for their self-improvement. PURPOSE OF THE STUDY: To assess pharmacists' clinical knowledge and practice in the safe use of contraceptives, and to compare the scores obtained by external observation with pharmacists' self-assessment of their knowledge as well as investigate the significance of preceptorship experiences. Contraceptives was chosen as the subject area in view of high rates of abortions as a means of contraception in Bosnia and Herzegovina. METHODS: A questionnaire approach was used. The questionnaire included the following: the first domain contained two case scenarios (safe use of contraceptives), which evaluated clinical knowledge, a second domain in which pharmacists self-assessed their knowledge to resolve cases from the first domain and a third domain that measured the demographics of pharmacists (including experience in preceptorship). Dispensing practice was evaluated in the second domain. The questionnaires were distributed to a convenient sample of 100 pharmacists at the Annual Meeting of Bosnia and Herzegovina Pharmacists. The results were presented as counts (%). The groups (preceptors and non-preceptors) were compared using Mann-Whitney U test, paired assessments were analyzed by Wilcoxon signed-rank test and Spearman's correlation was used to assess the correlation between variables. RESULTS: Of the 100 pharmacists invited to participate, 84 completed the questionnaire (84 % response rate). There was no agreement between pharmacists' real knowledge (average score - case 1: 2.71, case 2: 3.3) and their self-assessment (average score - case 1: 3.77, case 2: 3.91). There was no statistically significant difference in the actual knowledge of pharmacists (experienced/non-experienced in precepting), while the difference in the self-assessment was significant between these two groups. CONCLUSION: Pharmacists appear to overrate themselves, which leads to self-enhancement bias, in which the experience in precepting has some influence. Pharmacists' capability in performing an objective self-assessment of their clinical knowledge needs to be carefully studied in the future to fully benefit patients.

Real-world evaluation of the impact of statin intensity on adherence and persistence to therapy: A Scottish population-based study.

AIM: To assess associations between statin intensity and adherence, persistence and discontinuation of statin therapy in Scotland. METHOD: Retrospective cohort study, using linked electronic health records covering a period from January 2009 to December 2016. The study cohort included adult patients (≥18 years) newly initiating statins within Greater Glasgow and Clyde, Scotland. Study outcomes comprised adherence, discontinuation and persistence to treatment, stratified by three exposure groups (high, moderate and low intensity). Discontinuation and persistence were calculated using the refill-gap and anniversary methods, respectively. Proportion of days covered (PDC) was used as a proxy for adherence. Kaplan-Meier survival curves and Cox proportional hazard models were used to evaluate discontinuation, and associations between adherence/persistence and statin intensity were assessed using logistic regression. RESULTS: A total of 73 716 patients with a mean age of 61.4 ± 12.6 years were included; the majority (88.3%) received moderate intensity statins. Discontinuation rates differed between intensity levels, with high-intensity patients less likely to discontinue treatment compared to those on moderate intensity (prior cardiovascular disease [CVD]: HR 0.43 [95% CI 0.34-0.55]; no prior CVD: 0.80 [0.74-0.86]). Persistence declined over time, and high-intensity patients had the highest persistence rates. Overall, 52.6% of patients were adherent to treatment (PDC ≥ 80%), but adherence was considerably higher among high-intensity patients (63.7%). CONCLUSION: High-intensity statins were associated with better persistence and adherence to treatment, but overall long-term persistence and adherence remain a challenge, particularly among patients without prior CVD. This needs addressing.

Statin prescription among patients with type 2 diabetes in Botswana: findings and implications.

BACKGROUND: There is evidence of statin benefit among patients with diabetes regardless of cholesterol levels or prior cardiovascular disease history. Despite the evidence, there is under-prescription of statins in clinical practice. This study aimed to assess statin prescriptions and associated factors among patients with type 2 diabetes in Botswana. METHODS: The study was a secondary data analysis of 500 randomly selected type 2 diabetes patients at a specialised diabetes clinic at Gaborone, Botswana. We assessed the proportion of statin-eligible patients who are prescribed statins and evaluated the adjusted associations between various factors and statin prescriptions. RESULTS: Overall, 477 (95.4%) participants were eligible for a statin prescription. Clinicians prescribed statins in 217 (45.5%) of eligible participants, and only one (4.4%) ineligible participant. The probability of a statin prescription was higher in participants with high baseline low-density lipoprotein cholesterol (risk ratio [RR]: 1.49; 95%CI: 1.17-1.89), increasing duration of diabetes (RR: 1.01; 95%CI 1.00-1.03) and the presence of chronic kidney disease (RR: 1.35; 95%CI: 1.06-1.74). CONCLUSION: A large proportion with type 2 diabetes in Gaborone is not receiving statins. Clinicians did not consider most guideline-recommended indications for statin prescriptions. The findings call for improvement in diabetes quality of care by implementing evidence-based guideline recommendations.

Challenges facing drug utilization research in the Latin American region.

PURPOSE: The International Society of Pharmacoepidemiology (ISPE) in collaboration with the Latin America Drug Utilization Research Group (LatAm DURG), the Medicines Utilization Research in Africa (MURIA) group, and the Uppsala Monitoring Center, is leading an initiative to understand challenges to drug utilization research (DUR) in the Latin American (LatAm) and African regions with the goal of communicating results and proposing solutions to these challenges in four scientific publications. The purpose of this first manuscript is to identify the main challenges associated with DUR in the LatAm region. METHODS: Drug utilization (DU) researchers in the LatAm region voluntarily participated in multiple discussions, contributed with local data and reviewed successive drafts and the final manuscript. Additionally, we carried out a literature review to identify the most relevant publications related to DU studies from the LatAm region. RESULTS: Multiple challenges were identified in the LatAm region for DUR including socioeconomic inequality, access to medical care, complexity of the healthcare system, limited investment in research and development, limited institutional and organization resources, language barriers, limited health education and literacy. Further, there is limited use of local DUR data by decision makers particularly in the identification of emerging health needs coming from social and demographic transitions. CONCLUSIONS: The LatAm region faces challenges to DUR which are inherent in the healthcare and political systems, and potential solutions should target changes to the system.

Proactive risk assessment of vincristine use process in a teaching and referral hospital in Kenya and the implications.

INTRODUCTION: The chemotherapy use process is potentially risky for cancer patients. Vincristine, a "High Alert" medicine, has been associated with fatal but preventable medication errors. Consequently, there is a need to improve the use of vincristine especially in lower- and middle-income countries where there are constraints with resources and often a lack of trained personnel to administer cancer medicines. However, where there is a rising prevalence of cancer cases. These concerns can be addressed by performing proactive risk assessments using Healthcare Failure Mode Effect Analysis (HFMEA) and implementing the findings. METHODS: A multidisciplinary health team driven by pharmacists identified and evaluated potential failure modes based on a vincristine use process flow diagram using a hazard scoring matrix in a leading referral hospital in Kenya. RESULTS: The processes evaluated were: prescribing, preparation and dispensing, transportation and storage, administration and monitoring of the use of vincristine. Seventy-seven failure modes were identified over the three-month study period, of which 25 were classified as high risk. Thirteen were adequately covered by existing control measures while 12 including one combined mode required new strategies. Two of the failure modes were single-point weaknesses. Recommendations were subsequently made for improving the administration of vincristine. CONCLUSIONS: HFMEA is a useful tool to identify improvements to medication safety and reduction of patient harm. The HFMEA process brings together the multidisciplinary team involved in patient care in actively identifying potential failure modes and owning the recommendations made, which are now being actively followed up in this hospital. Pharmacists are a key part of this process.

Medicine shortages and challenges with the procurement process among public sector hospitals in South Africa; findings and implications.

BACKGROUND: Medicine shortages are a complex global challenge affecting all countries. This includes South Africa where ongoing medicine shortages are a concern among public sector hospitals as South Africa strives for universal access to healthcare. The objectives of this research were to highlight challenges in the current pharmaceutical procurement process for public sector hospitals. Subsequently, suggest potential ways forward based on the findings as the authorities in South Africa seek to improve the procurement process. METHOD: Qualitative in-depth interviews were conducted with 10 pharmacy managers in public sector hospitals in the Gauteng Province, South Africa. A thematic content analysis was performed, with transcripts coded by two of the authors. Coding was discussed until consensus was reached. Categories were developed and grouped into themes. RESULTS: The 'Procurement process' emerged from the data as the overarching theme, rooted in three main themes: (i) The buy-out process that was used to procure medicines from suppliers other than the contracted ones; (ii) Suppliers not performing thereby contributing to medicine shortages in the hospitals; and (iii) Challenges such as the inaccuracy of the electronic inventory management system used in the hospitals. CONCLUSIONS: Effective management of contracts of suppliers by the Provincial Department of Health is crucial to ensure accessibility and availability of essential medicines to all citizens of South Africa. Ongoing monitoring and support for the future use of computerised inventory management systems is important to reduce medicine shortages, and this is being followed up.