Prescription analysis and cost of antidepressant drugs in major depressive disorder outpatients at the tertiary care hospital of Pakistan: a prospective approach.

OBJECTIVES: To assess prescribing care indicators, utilization pattern, cost per prescription, cost ratios, and percent cost variation of antidepressants (ADs). METHOD: A prospective cross-sectional study was carried out at the tertiary care hospital of Peshawar, Pakistan among major depressive disorder (MDD) outpatients from July 2019 to February 2020. The ideal standards for World Health Organization (WHO) prescribing care indicators were used. The ePharma Guide was used to calculate the cost in Pakistani rupees (Rs) and United States dollar (USD) 2021 (exchange rate: 1 USD = 154.43 Rs). RESULTS: A total of 296 MDD patients received 846 drugs (average 2.86; range:1-8), of which 366 were ADs (average number ADs/prescription; 1.23). About 23% (n = 68) of patients received more than one AD. Only 21 (5.7%) generic ADs were prescribed, and 346 (94.5%) ADs were prescribed from the hospital formulary list. Selective serotonin reuptake inhibitors (SSRIs) were the most prescribed ADs (67.5%). The average cost of ADs per prescription per month was 700.95 Rs (4.54 USD). Escitalopram (5.69 Rs; 0.04 USD) showed highest cost ratio and maximum percentage cost variation (468.97%). CONCLUSION: This study observed low generic prescribing, a higher prescribing trend of SSRI, wide differences in cost ratio and percentage cost variation among ADs.

Public Knowledge and Practices Regarding Coronavirus Disease 2019: A Cross-Sectional Survey From Pakistan.

Objectives: Effective mitigation of coronavirus diseases (COVID-19) pandemic requires true adoption of precautionary measures by the masses, that primarily depends upon their knowledge and practices behaviors. The current study aimed to assess the knowledge; practices of Pakistani residents regarding COVID-19 and factors associated with adequate knowledge and positive practices. Material and Methods: A cross-sectional online survey was conducted from 15-April 2020 to 20 May 2020 among 689 Pakistanis by using a validated self-administered questionnaire (Cronbach's alpha 0.77). The questionnaire included questions on the assessment of demographics, the source of information, knowledge, and practice of COVID-19 on google forms and shared links with the WhatsApp groups, Facebook pages and other online platforms. Regression analysis was applied to find potential predictors of knowledge and practices. Results: Of 689 participants, 431 (62.6%) were male, 64.3% (n = 443) were aged <30 years, and\328 (47.6%) of participants were married. 48.19% (n = 332) had adequate knowledge; 81% (n = 555) had positive practices regarding COVID-19 and majority (66.62%, n = 459) seek knowledge from social media. Knowledge was significantly higher (OR > 1.00, p < 0.05) among educated and higher income participants. Positive practices were significantly (OR > 1.00, p < 0.05) related to the older age (≥50 years), higher education, higher income and good knowledge regarding COVID-19. Conclusion: The study concluded that Pakistani residents had average knowledge and good practices toward COVID-19 yet there are gaps in specific aspects of knowledge, and practice that should be focused in future awareness and educational campaigns. The study recommends the ministry of health authorities to promote all precautionary and preventive measures of COVID-19-consisting of a better-organized approach to all strata of society: less privileged people, older ones and less educated people, in order to have equilibrium of knowledge about COVID-19; hence effective implementation of precautionary measures.

Predictors of Health-Related Quality-of-Life Status Among Elderly Patients With Cardiovascular Diseases.

OBJECTIVES: Quality of life is an important patient-reported outcome in the care of older patients with chronic diseases owing to aging-associated limited physical activity and poor health status. The current study aimed to evaluate health-related quality of life and its predictors among elderly cardiac outpatients. METHODS: A descriptive, nonexperimental, cross-sectional study was carried out from May 2018 to October 2018 in outpatient departments of a tertiary-care hospital. The population under study were patients aged ≥65 years with at least 1 cardiovascular condition. The EQ-5D-3L (Euro QOL) and Barthel index were used to measure the quality of life and performance of activities of daily living, respectively. Linear regression analysis was performed by using SPSS version 21. RESULTS: Of a total of 386 patients, 198 patients (51.3%) reported impairment in the mobility domain, and 70.5% (n = 272) of patients indicated impairment in the depression domain. Mann-Whitney tests revealed EQ-5D scores, and visual analogue scale scores significantly differed by hospital admissions (P = .001), fall history (P < 0.001), and activities of daily living (P < .001). Kruskal-Wallis analysis revealed that EQ-5D index value and visual analogue scale score were significantly lower among patients who had comorbidities and who were exposed to polypharmacy (5-9 medications) (P < .001). In multivariate linear regression analysis, self-reported health (P = .006) and performance of activities of daily living (P < .001) were reported as influencing factors on health-related quality of life. CONCLUSION: Findings indicated poor quality of life among older patients with cardiovascular diseaese or heart diseases in Pakistan. Measures should be taken to improve patients' perception and to enhance awareness regarding the importance of doing daily living activities as a predictor of good quality of life.

Audit of antibiotic prophylaxis and adherence of surgeons to standard guidelines in common abdominal surgical procedures.

BACKGROUND: Prophylactic use of antibiotics before surgery is evidence-based practice for prevention of surgical site infections (SSIs). AIMS: To investigate adherence to and surgeons' perception of antibiotic prophylaxis guidelines. METHODS: A two-phase, cross-sectional prospective study conducted in two teaching hospitals. Phase 1: 6-month audit of prescriptions to investigate adherence rate to evidence-based guidelines. The important information was collected from medical charts through a predesigned proforma. Phase 2: self-administration questionnaire was used to investigate the surgeons' perception. Descriptive statistics, independent-sample Kruskal-Wallis test and multivariate linear regression analysis were performed using SPSS version 21.0. RESULTS: A total of 866 eligible surgical cases (acute appendectomy; n = 418; 48.2%), laparoscopic cholecystectomy (n = 278; 32.1%) and inguinal hernia (n = 170; 19.7%) were investigated. Surgical antibiotic prophylaxis was prescribed in 97.5% of procedures. Out of these, 9.5% adhered to guidelines with respect to correct choice, 40% for timing, and 100% for dose and route (optimal value 100%). Most patients received ceftriaxone (n = 503; 59.5%) as prophylactic antibiotic. The questionnaire (good internal consistency; α ≥ 0.7) was filled out by 200 surgeons. More than half (69%) of participants thought that antibiotics were overused. Most surgeons perceive that poor adherence to treatment guidelines is due to poor awareness, underestimation of infection, lack of consensus, and disagreement with guidelines recommendations. CONCLUSIONS: Surgeons have positive perception that antibiotics should be used according to guidelines recommendations. However, we found poor treatment adherence to antibiotic prophylaxis guidelines.

Potentially inappropriate medications use and its association with health-related quality of life among elderly cardiac patients.

BACKGROUND: Previous studies identified alarming use of potentially inappropriate medications (PIMs) in Pakistani population but its effect on health-related quality of life (HRQoL) is still largely unknown. OBJECTIVE: This study aimed to determine the association between PIMs use and HRQoL among elderly cardiac outpatients. METHOD: A descriptive, non-experimental, cross-sectional study was carried out from June 2018 to September 2018 in two outpatient departments of tertiary-care hospitals in the Punjab Province of Pakistan. The population under study were patients aged ≥ 65 years with at least one cardiovascular condition taking at ≥ 1 prescribed medication. Patients with PIMs were identified by using Beers criteria. HRQoL was assessed using EuroQoL-5 dimension (EQ-5D) and EuroQoL-visual analogue scale (EQ-VAS). The association of PIMs with HRQoL was analyzed using χ2 tests, independent sample t-test, and one-way ANOVA tests. Multiple linear regression analysis was used to determine how HRQoL varied by PIMs use after adjusting for patient-level covariates. RESULTS: Of 386 elderly cardiac patients, 260 (67.4%) patients were receiving at least one PIM. Mean EQ-5D scores were significantly lower among patients with PIMs (0.51) compared to patients without PIMs (0.65) (P < 0.001). In multiple linear regression analysis, increasing numbers of PIMs were significantly associated with lower EQ-5D scores [ß = - 0.040 (- 0.075, - 0.005), P < 0.001] and VAS scores [ß = - 1.686 (- 2.916, - 0.456), P < 0.05]. CONCLUSION: The present study concluded that exposure to PIM was significantly associated with lower HRQoL. This indicates that guidelines recommendations should be followed to improve patient's quality of life.

Cost analysis of registered brands of oral antidepressant drugs in Pakistan: a descriptive analysis.

Background and objective: Depression is a global public health threat, and its treatment constitutes drugs in psychopharmacology, a domain that is rapidly growing with the addition of newer agents in market that are of high cost. Therefore, the present study aims to investigate the number of registered brands and price variation of oral antidepressants in Pakistan. Methods: A descriptive observational study was carried out to analyze the cost of oral antidepressants in Pakistan. Pharma guide 2019 was used to derive the cost of antidepressants marketed in Pakistan. The details about the number of registered brands and maximum and minimum prices of antidepressant drugs were calculated. Results: Sixteen drugs in 38 formulations were registered in 607 brands in Pakistan. Variations among 38 different formulations range from 0% to 746.39%. Out of these 38 formulations, 31 had variations below 200%, while 7 formulations had price variation above 200%. The highest price (746.39%) variation was observed for citalopram 20 mg (price per tablet PKR 6.79 to PKR 57.47) and no (0%) price variation was for bupropion 75 mg (price per tablet PKR 10). Conclusion: The study revealed wide variations in the number of registered brands and prices of oral tablets of antidepressants in Pakistan. The government needs to devise effective strategies to implement established policies to ensure uniformity in price, quality, and effectiveness with the ultimate goal to reduce treatment cost. Also, measures should be taken to inform prescribers about cost variation of drugs as prerequisite for cost-effective treatments to ultimately reduce treatment cost and financial burden and improve patient's adherence to therapy.

Medication Adherence and Its Association with Health Literacy and Performance in Activities of Daily Livings among Elderly Hypertensive Patients in Islamabad, Pakistan.

Background and Objective: Medication non-adherence is a preventable reason for treatment failure, poor blood pressure control among hypertensive patients and the geriatric population owing to poor physical activity is more vulnerable strata. The objective of this study is to investigate medication adherence and its associated factors among Pakistani geriatric hypertensive patients. Methods: A cross-sectional survey-based study was conducted at the out-patient department of the cardiac center from May 2018 to August 2018. A universal sampling technique was used to approach patients and 262 eligible consented patients were interviewed to collect information about socio-demographics, health, and disease-related characteristics using a structured questionnaire. The Morisky Levine Green test was used for the assessment of medication adherence. The Barthel index and single item literacy screener (SILS) was used to measure performance in activities of daily living and health literacy respectively. Chi-square tests and multivariate binary logistic regression analysis were performed to find factors by using SPSS version 20. Results: Of the total 262 participants, about 38.9% (n = 102) were scored 4 and considered adherent while 61.1% (n = 160) were considered as non-adherent. In logistic regression analysis, self-reported moderate (OR = 3.538, p = 0.009) and good subjective health (OR = 4.249, p = 0.008), adequate health literacy (OR = 3.369, p < 0.001) and independence in performing activities of daily living (OR = 2.968, p = 0.002) were found to be independent predictors of medication adherence among older hypertensive patients. Conclusion: Medication adherence among the older hypertensive population in Pakistan is alarmingly low. This clearly requires patient-centered interventions to overcome barriers and educating them about the importance of adherence.

Non-pharmacological management of hypertension: in the light of current research.

Hypertension is a major risk factor for a number of cardiovascular diseases. Proper management of hypertension may require both pharmacological and non-pharmacological interventions. Non-pharmacological interventions help reduce the daily dose of antihypertensive medication and delay the progression from prehypertension to hypertension stage. Non-pharmacological interventions include lifestyle modifications like dietary modifications, exercise, avoiding stress, and minimizing alcohol consumption. Nutritional requirements of hypertensive individuals can be addressed through adopting either the DASH diet or through traditional Mediterranean diet. These dietary guidelines promote the consumption of fruits, vegetables, grains, dairy products, and food rich in K+, Mg+2, Ca+2, and phosphorus. Restriction of Na+ intake has the greatest role in lowering the blood pressure. The DASH diet alone has the effect equal to that of a single drug therapy. After dietary modifications, exercise and weight loss are the second major intervention for hypertension management. Avoiding stressful lifestyle, depression, and anxiety also help to reduce elevated blood pressure. Minimizing alcohol intake also favors the blood pressure reduction. However, lifestyle modification is a dynamic process and requires continuous adherence. It is a multi-factorial approach targeting more than one intervention. However, 6-12-month lifestyle modifications can be attempted in stage-1 hypertensive patients without any cardiovascular complication, in the hope that they may be sufficiently effective to make it unnecessary to use medicines.