Are physicians and clinical pharmacists aware and knowledgeable enough about inappropriate prescribing for elderly patients? Findings from Malaysia

Objectives To assess the knowledge of physicians and clinical pharmacists about inappropriate prescribing for elderly patients, their confidence in prescribing for elderly patients, and their perceptions of barriers to appropriate prescribing in this population. Methods A cross-sectional study using a validated 20-item questionnaire was conducted among physicians (n=78) and clinical pharmacists (n=45) working in the medical wards of two tertiary hospitals in Malaysia. Knowledge was assessed by six clinical vignettes which were developed based on Beers criteria and the STOPP/START criteria. Other domains of the study were investigated using a four-point or five-point Likert scale. Results Of the 82 participants who completed the questionnaire, 65% were physicians, 90.2% had never received training in geriatric medicine, and 70.8% estimated that 25% or more of their patients were elderly. Only six participants (7.3%) had ever used STOPP/START or Beers criteria when prescribing for elderly patients, and 60% of the respondents had never heard of either one of those criteria. The mean score (SD) for the knowledge part was 3.65 (1.46) points, and only 27 participants (22.9%) scored more than four out of a possible six points. Overall, 34% of the participants rated themselves as confident in prescribing for elderly patients, and this was significantly associated with their knowledge score (P=0.02). The mean number (SD) of barriers cited per participant was 6.88 (2.84), with polypharmacy being the most cited barrier. Conclusions The majority of the participants had inadequate knowledge and low confidence regarding recommending medications for elderly patients. Continuing education on geriatric pharmacotherapy may be of value for the hospital physicians and pharmacists

Evaluation of the prescribing of proton pump inhibitors as stress ulcer prophylaxis for non-ICU patients in a Malaysian tertiary hospital

Background Proton pump inhibitors (PPIs) are widely prescribed in hospital settings. Several reports have highlighted concerns about the inappropriate use of PPIs as stress ulcer prophylaxis (SUP) in patients outside the intensive care unit (ICU) setting. Little is known about this phenomenon in Malaysian hospitals. Aims and objectives This study aimed to evaluate the appropriateness of PPI prescribing as SUP for patients admitted to the general medical wards of a Malaysian tertiary hospital and to determine the rate of unnecessary prescription of PPI for discharged patients. Methods This was a retrospective cross-sectional study conducted in a tertiary hospital in Pahang, Malaysia. We reviewed the information held on electronic databases for patients admitted to the general medical wards from January to September 2019. Appropriateness of PPI prescribing was assessed using the criteria for SUP from predefined clinical guidelines. Results Of 660 screened patients admitted to the general medical wards, 200 were prescribed PPIs as SUP. Oral pantoprazole was the most frequently prescribed PPI (51.5%). Only 61 (30.5%) PPIs were prescribed according to current recommendations for the use of PPI for SUP. Sex, age, number of medications, length of hospital stay, and receiving PPI at discharge were not significantly associated with appropriateness of PPI prescribing. Half of the patients continued receiving PPIs at discharge without a documented indication. Conclusion Our findings indicated a high prevalence of inappropriate prescribing of PPIs as SUP for non-ICU patients. Interventions to reduce the unnecessary use of PPIs in Malaysian hospital settings are desperately required. The need for national criteria that address the proper indications and dosing regimens for PPIs as SUP in ICU and non-ICU patients is high. This is a preview of subscription content, log in to check access

Self-medication practices among Malaysian older adults during the COVID-19 pandemic

Objective. To assess the prevalence, patterns, and associated factors of self-medication among Malaysian older adults, and to investigate the impact of COVID-19 pandemic on self-medication. Methods: Between January and June 2021, Malaysian older adults aged ≥60 years were invited to participate in this cross-sectional study. A self-administered questionnaire was used to assess self-medication knowledge, perceptions, and practices before and during the pandemic. Results: Of 170 participants, 122 (71.8%) reported self medication. Common reasons for self-medication were a perception that the condition was minor and previous experience with the same problem. The main symptoms managed by self-medication were sore throat (56.9%), fever (56%), and headache (53.2%). The most commonly used medications were paracetamol (79.8%), analgesic patches (52.3%), and cough medications (47.7%). Most participants were unaware of possible drug-drug/drug-food interactions involving their medications. 33.6% of participants changed their self-medication practices during the pandemic; 65% of them consumed more vitamins and supplements to boost their health. Conclusion: Self-medication for minor ailments is prevalent among Malaysian older adults. Analgesics were the most commonly used medication. 33.6% of participants modified their self-medication practices during the COVID-19 pandemic; 65% of them consumed more vitamins and supplements to boost their health

Influence of hospitalization on potentially inappropriate prescribing among elderly patients in a Malaysian community

Purpose: To compare the prevalence and type of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) on admission and discharge of patients, and to determine the associated predictors. Methods: This was a prospective observational study conducted in the multidisciplinary medical and surgical units of Hospital Tengku Ampuan Afzan (HTAA), Malaysia. The medications of patients who had been admitted to the hospital from community-dwelling settings were reviewed to identify PIMs/PPOs using version 2 of STOPP/START criteria. A logistic regression model was applied to detect the risk factors associated with PIM or PPO at discharge. Results: Among the 300 patients involved in the study, the prevalence of PIMs was 27 % upon admission, which decreased to 22.3 % at discharge (p = 0.014) with PIMs pertaining to increasing the risk of physical falls in elderly people being the most common for pre- and post-hospitalization. The prevalence of PPOs was 47.6 % upon admission, which increased to 48 % at discharge (p = 0.99), with the omission of musculoskeletal medications being the most common PPOs at admission and discharge. Having a PIM at discharge was associated with the number of discharge medications and the history of falls, whereas having a high comorbidity index score or history of falls was associated with having a PPO at discharge. Conclusion: Hospitalization significantly reduces the prevalence of PIMs, but not PPOs or polypharmacy, among elderly patients. The number of discharge medications and the history of falls are predictors of discharge PIM, whilst high comorbidities and the history of falls were the predictors of discharge PPO. Improving the knowledge of hospital practitioners regarding geriatric pharmacotherapy is required to optimize prescribing in elderly patients during hospitalization

Physicians’ perception on prescribing potentially inappropriate medications for older patients: a qualitative study from Malaysia

Introduction: Many quantitative studies reported that potentially inappropriate medication (PIM) is quite prevalent among older adult patients. However, the issue is less explored qualitatively from the perspective of physicians. Objective: To qualitatively explore hospital physicians’ perception regarding PIMs, associated factors and the possible interventions to control this phenomenon. Method: A qualitative study using individual semi-structured and in-depth interview research method was constructed on 15 physicians serving in a Malaysian hospital. The purposive sampling technique was used at the beginning followed by the snowball sampling process. Results: It was found that the physicians have inadequate knowledge about PIM and the published PIM criteria. Several factors were perceived as barriers of appropriate prescribing. Firstly, physicians’ lack of knowledge and training in geriatric medicine as well as lack of time. Secondly, some of the physicians were skeptical about the applicability of PIM criteria in daily practice due to limited alternative medications. Lastly, complexity of the cases due to multimorbidity, polypharmacy and patient’s poor knowledge about their medications. The proposed interventions to optimize prescribing for older patients were education (for patients and physicians), optimization of healthcare workforce and activation of deprescribing. Conclusions: Prescribing for older patients is a complex process that is affected by numerous patient-related and doctor-related factors. Improvement strategies should target the patient, physicians and the work environment activating a joined-up working between the physician and other healthcare providers

Physicians’ Perception on Prescribing Potentially Inappropriate Medications for Older Patients: A Qualitative Study from Malaysia

Introduction: Many quantitative studies reported that potentially inappropriate medication (PIM) is quite prevalent among older adult patients. However, the issue is less explored qualitatively from the perspective of physicians. Objective: To qualitatively explore hospital physicians’ perception regarding PIMs, associated factors and the possible interventions to control this phenomenon. Method: A qualitative study using individual semi-structured and in-depth interview research method was constructed on 15 physicians serving in a Malaysian hospital. The purposive sampling technique was used at the beginning followed by the snowball sampling process. Results: It was found that the physicians have inadequate knowledge about PIM and the published PIM criteria . Several factors were perceived as barriers of appropriate prescribing. Firstly, physicians’ lack of knowledge and training in geriatric medicine as well as lack of time. Secondly, some of the physicians were skeptical about the applicability of PIM criteria in daily practice due to limited alternative medications. Lastly, complexity of the cases due to multimorbidity, polypharmacy and patient’s poor knowledge about their medications. The proposed interventions to optimize prescribing for older patients were education (for patients and physicians), optimization of healthcare workforce and activation of deprescribing. Conclusions: Prescribing for older patients is a complex process that is affected by numerous patient-related and doctor-related factors. Improvement strategies should target the patient, physicians and the work environment activating a joined-up working between the physician and other healthcare providers

Self-medication practice among final year students of a governmental university: a comparison between medical and non-medical students

ntroduction: Self-medication is defined as any usage of the medications without having any proper diagnosis, consultation and prescription from a healthcare practitioner. Objective: This study aimed to determine the prevalence and pattern of selfmedication among undergraduate final year students, and to compare the prevalence and pattern of self-medication between medical and non-medical final year students. Method: A cross-sectional study was conducted among final year students (4 medical programmes and 1 non-medical programme) from International Islamic University Malaysia, Kuantan Campus. A pre-validated questionnaire was distributed to 300 students in October 2016. Chi-square test was used to compare between medical and non-medical students. Results: 225 medical and 63 non-medical students (science programme students) answered the questionnaire. The mean age was 23.23 0.733 years. More than half of the participants (61%) practiced self-medication with no significant difference between medical and nonmedical students (60.9% Vs 61.9%; P = 0.884). The most common reasons of selfmedication in both groups was “a previous experience with similar problem”; with fever being the most self-treated condition followed by flu/cold. The majority of both groups (89.9%; 92.1%) acknowledged the necessity of consulting a certified medical practitioner before taking any medications. However, only 69.3% of the non-medical students believed that selfmedication could be harmful compared with 89.3% of the medical students (P < 0.001). Conclusion: The prevalence of self-medication practice among medical and nonmedical students was high and there was also a lack of awareness about its harm among non-medical students

Cardiovascular outcomes and the use of oral antidiabetic drugs: a review of current evidence from observational studies

Type 2 diabetes mellitus (T2DM) is a major global disease burden that affects millions of people worldwide. The disease is well known to predispose patients to a wide range of macro- and microvascular complications. Cardiovascular complications are common macrovascular consequences among patients with T2DM. The primary goal of T2DM management is to achieve proper glycaemic control that helps to avoid or delay the incidence of disease complications. T2DM management involves the utilisation of oral antidiabetic medications and injectables, including insulin. Hence, we conducted this work to discuss and summarise the cardiovascular outcomes associated with the oral antidiabetic pharmacotherapy prescribed for patients with T2DM. The agents involved were metformin, sulfonylurea, dipeptidyl peptidase-4 inhibitors, thiazolidinediones, alpha-glucosidase inhibitors, and sodium-glucose cotransporter-2 inhibitors. We decided to focus on the findings reported from observational studies published between 2009 to 2019 to provide an updated and more realistic insight on these cardiovascular outcomes associated with the oral antidiabetic drugs in the usual clinical practice

The impact of a multifaceted intervention to reduce potentially inappropriate prescribing among discharged older adults: a before-and-after study

Background Potentially inappropriate prescribing (PIP) is associated with the incidence of adverse drug reactions, drug-related hospitalization and other negative outcomes in older adults. After hospitalization, older adults might be discharged with several types of PIPs. Studies have found that the lack of healthcare professionals’ (HCPs) knowledge regarding PIP is one of the major contributing factors in this issue. The purpose of this study is to investigate the impact of a multifaceted intervention on physicians’ and clinical pharmacists’ behavior regarding potentially inappropriate medication (PIM) and potential prescribing omission (PPO) among hospitalized older adults. Methods This is a before-and-after study that took place in a tertiary Malaysian hospital. Discharge medications of patients ≥65 years old were reviewed to identify PIMs/PPOs using version 2 of the STOPP/START criteria. The prevalence and pattern of PIM/PPO before and after the intervention were compared. The intervention targeted the physicians and clinical pharmacists and it consisted of academic detailing and a newly developed smartphone application (app). Results The study involved 240 patients before (control group) and 240 patients after the intervention. The prevalence of PIM was 22% and 27% before and after the intervention, respectively (P = 0.213). The prevalence of PPO in the intervention group was significantly lower than that in the control group (42% Vs. 53.3%); P = 0.014. This difference remained statistically significant after controlling for other variables (P = 0.015). The intervention was effective in reducing the two most common PPOs; the omission of vitamin D supplements in patients with a history of falls (P = 0.001) and the omission of angiotensin converting enzyme inhibitor in patients with coronary artery disease (P = 0.03). Conclusions The smartphone app coupled with academic detailing was effective in reducing the prevalence of PPO at discharge. However, it did not significantly affect the prevalence or pattern of PIM

Evaluation of medication regimen complexity and its association with medication adherence among Malaysian older adult outpatients in a teaching hospital: a cross-sectional study in Pahang, Malaysia

Introduction: Approximately 60% of Malaysian older adults have poor medication adherence. Nonetheless, the determinants of non-adherence among the Malaysian older adult population are still lacking. This research evaluates medication regimen complexity (MRC) and its association with medication adherence among Malaysian older adults. Methods: A cross-sectional study was conducted in outpatient settings of a teaching hospital in Pahang, Malaysia via in-person interview. Medication Regimen Complexity Index (MRCI) and Malaysia Medication Adherence Assessment Tool (MyMAAT) were used to collect patients’ medical information and medication adherence status. Univariate (χ2 and t-test) and multivariate (logistic regression) analyses using SPSS software were applied. Results: A total of 429 participants were recruited, with the mean of total MRC is 17.38 ± 7.07 and the prevalence of non-adherence is 51.0% (n = 219). While adjusted for co-variables, multivariate logistic regression indicates three significant determinants of non-adherence: (1) Total MRC (adjusted odds ratio/aOR= 1.375, p < 0.001), (2) partially self-man aged medication (aOR = 3.625, p < 0.001) and (3) fully managed medication by the family members/caregivers (aOR = 8.138, p < 0.001). The logistic regression model fit is good based on the Hosmer & Lemeshow test (p = 0.162) and the area under receiver operating characteristic/ROC curve is 0.917. Conclusion: Non-adherence might occur due to high MRC and patient’s inability to manage their medications by themselves. Further studies should increase the generalisability of the Malaysian older adult population from other states in Malaysia, since the study is conducted only in a unicentric based in Pahang, Malaysia