Hospital Admissions Associated With Medication-Related Problems in Thai Older Patients: A Multicenter Prospective Observational Study.

OBJECTIVE: The aim of the study was to estimate the prevalence rate and risk factors of medication-related problems (MRPs) leading to hospital admissions in Thai older patients. METHODS: A prospective observational study was carried out in nine hospitals in Lower Northern Thailand. Participants admitted to internal medicine units were screened for suspected MRPs by clinical pharmacists using medical record review and patient interview. Three experts evaluated suspected MRPs independently using the following four criteria: contribution of MRPs to hospital admissions, causality, severity, and preventability. RESULTS: Of 1776 patients admitted during the study period, 56 patients (3.2%) were deemed to have causal MRPs; 24 (42.9%) were judged as preventable. The medication groups most commonly associated with MRPs were those targeting the endocrine system, especially antidiabetic medications, such as metformin and glipizide. Preventable MRPs were usually manifest as hypoglycemia (n = 15, 62.5%). The variables that contributed to hospital admissions associated with MRPs were age (odds ratio = 1.92; 95% confidence interval [CI] = 1.06-3.47), starting a new drug within 1 week (odds ratio = 2.31; 95% CI = 1.08-4.95), or within 1 month (odds ratio = 2.17; 95% CI = 1.05-4.48). CONCLUSIONS: Hospital admissions associated with MRPs in Thai older patients continue to burden the Thai healthcare system of which nearly half were preventable. Further studies should consider analysis of costs and include hepatic and renal function status of participants.

Hospital Outpatient Visits Associated With Medication-Related Problems in Thailand: A Multicenter Prospective Observational Study.

OBJECTIVES: The aims of the study were to investigate the prevalence of hospital visits associated with medication-related problems (MRPs, i.e., adverse drug events [ADEs], adverse drug reactions [ADRs], nonadherence [NA] to medication, and medication error) and to identify the medications involved in hospital visits associated with MRPs in outpatient departments (OPDs). METHODS: A prospective observational study was carried out in OPD of 11 hospitals in the lower northern region of Thailand. Patients visiting OPDs were screened for suspected MRPs by clinical pharmacists using medical record review supplemented by patient interview. Three experts evaluated suspected MRPs using the following 3 criteria: causality, severity, and preventability. RESULTS: Of the 3069 patients who visited the OPDs during the study period, 113 (3.7%) were deemed to have causal MRPs. Nearly half of the causal MRPs (n = 49, 43.4%) were preventable. The following 4 types of causal MRPs were identified: ADEs (n = 112, 3.7%), ADRs (n = 65, 2.1%), NA to medications (n = 48, 1.6%), and medication errors (n = 1, 0.03%). In nonelective patients (n = 764), 35 patients (4.6%) were judged to have causal MRPs. Of the nonelective patients who experienced causal MRPs, 25 (71.4%) were preventable. The medications commonly associated with ADEs and NA to medication were those targeting the cardiovascular system (especially enalapril, amlodipine, and hydrochlorothiazide), whereas the medications involving ADRs involved the cardiovascular and endocrine systems (especially, enalapril, amlodipine, and metformin). CONCLUSIONS: Outpatient department visits associated with MRPs, particularly in nonelective patients, were preventable. Effective strategies are needed for reducing visits to hospital OPD associated with preventable MRPs.

Trends and predictors of high-intensity statin therapy and LDL-C goal achievement among Thai patients with acute coronary syndrome.

BACKGROUND: Previous studies on the use of high-intensity statins and low-density lipoprotein cholesterol (LDL-C) goal achievement were mostly conducted in patients with acute coronary syndrome (ACS) receiving care before 2013. We aimed to determine trends and predictors of high-intensity statin therapy and LDL-C goal achievement in a more recent cohort of Thai ACS patients. METHODS: We analyzed data from electronic databases of ACS patients at a tertiary-care, teaching hospital in Thailand between 2013 and 2017. Trends and predictors of high-intensity statin therapy and LDL-C goal achievement after hospital discharge were determined with logistic regression analysis. RESULTS: Among 1753 ACS patients, 987 (56.3%) received high-intensity statin at discharge. A higher proportion of ACS patients were prescribed high-intensity statins over time (p=0.033 for linear trend), rising from 10% in 2013 to 88% in 2017. Independent predictors of high-intensity statin therapy included age ≤75 years, a diagnosis of myocardial infarction, receiving P2Y12 inhibitors, and beta-blockers. Within 120 days after discharge, 427 (24.4%) patients had follow-up LDL-C measurements. Overall, 185 (43.3%) patients achieved LDL-C goals based on either of the following criteria: LDL-C <70mg/dL or ≥50% reduction in the baseline LDL-C. There was a non-significant trend (p=0.402 for linear trend) in the proportion of patients achieving LDL-C goals over the study period. Independent predictors of achieving LDL-C goal included high-intensity statin therapy after discharge and lower baseline LDL-C on admission. CONCLUSIONS: In a more recent cohort of Thai ACS patients, a higher proportion of patients were prescribed high-intensity statins before discharge over the study period. However, the proportion of patients who achieved LDL-C goal did not increase accordingly. This finding should promote more discussion among health policy makers to improve statin treatment and quality of care for ACS patients.

Prevalence and Predictors of Statin Treatment Among Patients With Chronic Heart Failure at a Tertiary-Care Center in Thailand.

BACKGROUND: Statins play important roles in the prevention of atherosclerotic vascular diseases; however, their beneficial effects in patients with chronic heart failure (CHF) are uncertain. This study aimed to investigate the prevalence and predictors of treatment with statins to better understand their prescribing patterns in CHF patients. METHODS: We conducted a cross-sectional study in patients with first-time diagnoses of CHF receiving care in the outpatient clinics affiliated with a tertiary-care teaching hospital in Thailand. Data were retrieved from electronic claims database. Multivariable logistic regression was used to identify independent predictors of treatment with statins. RESULTS: A total of 3445 patients were included in this study. Among them, 1908 (55.4%) were prescribed statins, with most of them (89.7%) receiving simvastatin 20 mg daily. Factors independently associated with the statin treatment include the following: being male (odds ratio [OR] = 1.21, 95% confidence interval [CI] = 1.02-1.44, P = .03); diagnoses of dyslipidemia (OR = 4.88, 95% CI = 3.88-6.14, P < .001), ischemic heart disease (OR = 2.71, 95% CI = 2.18-3.36, P < .001), diabetes (OR = 1.95, 95% CI = 1.55-2.46, P < .001), or cerebrovascular disease (OR = 1.64, 95% CI = 1.12-2.40, P = .01); and receipt of angiotensin-converting enzyme inhibitors (OR = 3.44, 95% CI = 2.87-4.13, P < .001), aspirin (OR = 2.79, 95% CI = 2.30-3.40, P < .001), non-dihydropyridine calcium channel blockers (OR = 2.35, 95% CI = 1.30-4.24, P = .004), organic nitrates (OR = 2.04, 95% CI = 1.16-3.58, P = .01), beta-blockers (OR = 1.51, 95% CI = 1.23-1.84, P < .001), and digoxin (OR = 0.65, 95% CI = 0.50-0.86, P = .002). CONCLUSIONS: Statins were prescribed to more than half of the newly diagnosed CHF patients. Independent predictors of statin treatments include hypercholesterolemia and comorbidities indicative of high atherosclerotic vascular risk as well as drugs recommended as cardiovascular protective therapy for CHF patients.

Attributable Costs of Postoperative Atrial Fibrillation among Patients Undergoing Cardiac Surgery.

BACKGROUND: Postoperative atrial fibrillation (POAF) is the most common complication among patients undergoing cardiac surgery. However, data on the economic burden and resource utilization associated with POAF in Asian population are limited. The present study aimed at estimating medical costs attributable to POAF after cardiac surgery in Thai population. METHODS: We analysed data from claims database of patients who underwent valve replacement, coronary artery bypass grafting (CABG), or a combination of both procedures at a tertiary-care, academic hospital in Thailand. Multiple linear regressions of log-transformed costs were developed with the occurrence of POAF and preoperative patient characteristics as covariates. After back-transformation to the original scale, costs attributable to POAF were estimated from the mean difference between patients with and without POAF. RESULTS: Of 711 patients undergoing cardiac surgery, 241 (30.94%) developed POAF over a median hospitalization of 10 days. Patients with POAF utilized more resources than those without POAF. POAF was an independent predictor and increased cost by 23% in linear regression model. On average, patients with POAF had higher medical costs than those without POAF (269,000 versus 218,999 Thai Baht (THB)) with a mean difference of 50,000 THB (1,667 USD). The difference was observed in patients undergoing isolated valve surgery (47,761 THB (1,592 USD), 95% CI: 39,809-55,712), CABG (50,865 THB (1,696 USD), 95% CI: 37,233-64,496), and a combination of both procedures (72,287 THB (2,410 USD), 95% CI: 49,910-94,405). CONCLUSIONS: In a single-institution study in Thailand, POAF is associated with increased resource use and medical costs among patients undergoing cardiac surgery. Effective strategies to prevent POAF should be implemented to reduce its economic burden.

Patterns and adherence to guidelines of antithrombotic therapy in Thai patients with nonvalvular atrial fibrillation.

BACKGROUND: Antithrombotic therapy is essential in patients with atrial fibrillation (AF) to prevent systemic thromboembolism, particularly ischemic stroke. Several studies conducted in North America and European countries revealed that AF patients at high risk for thromboembolism did not adequately receive antithrombotic therapy as recommended by relevant guidelines. However such a few studies were reported from Asian countries. OBJECTIVE: To describe patterns and adherence to the guideline of antithrombotic therapy in ambulatory patients with nonvalvular AF in Thailand. MATERIAL AND METHOD: From an electronic medical database, data of all patients that were diagnosed with AF and presented to the ambulatory care clinic between June 1 and September 30, 2008 were retrieved for analysis. The most recently prescribed antithrombotics and associated risk factors for thromboembolism were reviewed for patterns and adherence to guidelines of antithrombotic therapy according to the CHADS2 (congestive heart failure, hypertension, age >75, diabetes and stroke/transient ischemic attack) score. RESULTS: Five hundred thirteen AFpatients were identified, ofthese, 369 patients had no valvular heart diseases or replacement and were recruited into data analysis. Among non-valvularAF patients, 138 (37.4%), 127 (34.4%), and 1l04 (28.2%) patients were classified as high (CHADS2 score > or =2), intermediate (CHAD S2 = I), and low (CHADS2 = 0) risk for ischemic stroke, respectively. Patients who were classified as low and intermediate risk were prescribed warfarin as antithrombotic therapy in 51.0% and 52.8%, respectively. Among high-risk patients, 70.3% were prescribed warfarin while 19.6% received only antiplatelets and 10.1% received no antithrombotic therapy. CONCLUSION: The present study has demonstrated that a proportion of non-valvular AF patients at high-risk for ischemic stroke had not received anticoagulation therapy as recommended by relevant guidelines. Further low-risk patients were over-treated with anticoagulants. The finding should prompt health care policy makers to take action to improve quality of care for these patients.

Rate and predictors of early readmission among Thai patients with heart failure.

BACKGROUND: Readmission to hospital after discharge has been recognized as a significant problem in patients with chronic heart failure (CHF). No studies report rate of early readmission (defined as readmission within 30 days after discharge) and its predictors among Thai patients with CHE. OBJECTIVE: To determine rate and predictors of early readmission among Thai patients with heart failure. MATERIAL AND METHOD: From an electronic medical database of a tertiary care hospital in Thailand, we retrieved data of all patients who were hospitalized with a principal diagnosis of CHF between January 1, 2005 and December 31, 2006. Patients were followed whether they were readmitted within 30 days after discharge. RESULTS: Seven hundred eighteen patients were included for analysis. Studied patients were mostly female (57.52%) with mean age of 64.91 +/- 14.14 (SD) years. The median length of hospital stay (LOS) was five days. One hundred one patients (14.07%) had their first readmission from all causes within 30 days after discharge. An exacerbation of CHF was the most common cause. In a multivariate model, only the LOS >5 days predict higher risk of early readmission (adjusted OR = 1.41, 95% CI = 1.05-1.89, p = 0.023). No significant association between discharge medications and early readmission was found in the present study. CONCLUSION: Early readmission rates appear modest among Thai patients with CHFE The LOS > 5 days was a positive predictor of early readmission while discharge cardiovascular medications were not associated with early readmission.

Validation of electronic medical database in patients with atrial fibrillation in community hospitals.

BACKGROUND: The electronic medical database (EMD) has been increasingly used for clinical research as it reflects a real-world practice with large and heterogeneous samples. However, few studies have reported on the validity of EMD from community hospitals for research purposes. OBJECTIVE: To assess the validity of EMD based on data from patients with atrial fibrillation (AF) receiving care from community hospitals in Phitsanulok Province, Thailand. MATERIAL AND METHOD: The validity of EMD was determined using hand-written out-patient medical records (OPMRs) as a criterion standard. One hundred ninety three records of patient with ICD-10 of AF (148) were retrieved from the EMD of two community hospitals between August 2007 and July 2008. For each patient, data of a randomly selected visit from the EMD was matched to data of the same visit from OPMRs, abstracted by a standardized data collection form. The EMD was cross-validated with OPMRs based on patient's diagnosis of AE co-morbidities (risk factors for stroke) and bleeding events. All data were tabulated in a 2 x 2 format to calculate sensitivity, specificity and the Cohen's Kappa. RESULTS: Out of 193 AF patients retrieved from the EMD, 169 (87.56%) were documented as having a diagnosis of AF in OPMRs. The EMD data on risk factors for stroke showed moderate to high sensitivity (range: 66.67-100%) and high specificity (range: 98.77-100%). The agreement between the two databases was considered good to very good (calculated kappa range: 0.7942-0.9681). The specificity based on major bleeding was 100%; however, sensitivity and the Cohens Kappa could not be determined as the major bleeding diagnosis was found in neither the EMD nor the OPMRs. CONCLUSION: The EMD of AF patients from community hospitals in Phitsanulok was valid and in good agreement with the OPMRs. The EMD from community hospitals appeared suitable for health research in patients with AF

TA205, an anti-talin monoclonal antibody, inhibits integrin-talin interaction.

Talin mediates integrin signaling by binding to integrin cytoplasmic tails through its FERM domain which consists of F1, F2 and F3 subdomains. TA205, an anti-talin monoclonal antibody, disrupts actin stress fibers and focal adhesion when microinjected into fibroblasts. Here, we showed that TA205 caused an allosteric inhibition of integrin alphaIIb beta3 binding to the talin FERM domain and mapped the TA205 epitope to residues 131-150 in talin F1. Furthermore, binding of a talin rod fragment to talin head was partially inhibited by TA205. These findings suggest that talin F1 may be important in regulation of integrin binding and talin head-rod interaction.