Patients' Perceptions on Community Pharmacy Services of a Ward (10) of Kathmandu Metropolitan.

Purpose: Community pharmacists' role is shifting from product-oriented function towards patient-centered care. The patient-centered role of pharmacists is undervalued, as the public is unaware of pharmacists' role. This study aims to identify patients' perceptions and satisfaction with pharmaceutical care services and factors affecting their preferences for community pharmacy services. Patients and Methods: A quantitative cross-sectional study was conducted for three months on patients visiting registered community pharmacies in Kathmandu metropolitan ward number 10. Results: Out of 406 participants, 30.5% perceive pharmacists to have a balance between business and health aspects of pharmacy practices; 29.1% view them as drug experts; and 11.8% consider pharmacists to be more concerned with business. 43.8% of participants were found to discuss their drug-related queries with pharmacists, possibly due to low treatment costs. Approximately 77% of respondents had no hesitancy when contacting pharmacists for health-related information because they believed pharmacists were sufficiently qualified to address drug-related questions. Around 88% of respondents agreed that the role of pharmacists is to counsel the patient about the directions for the use of medications. The level of satisfaction indicated that 72.4% are highly satisfied with pharmacy services. In addition, patients feel comfortable discussing their health with pharmacists due to their ability to protect the privacy of their medical records. In contrast, more trust in doctors seems to be the most common barrier for patients visiting pharmacists. Conclusion: Overall, pharmacists were regarded as the most trusted health care personnel to contact. However, to facilitate the expansion of pharmaceutical care services, the public should be aware of their distinctive professional talents. It is recommended for future researchers to understand the subjective perspective of pharmacy staff, managers, and pharmaceutical policy makers.

Health system gaps in cardiovascular disease prevention and management in Nepal.

BACKGROUND: Cardiovascular diseases (CVDs) are the leading cause of deaths and disability in Nepal. Health systems can improve CVD health outcomes even in resource-limited settings by directing efforts to meet critical system gaps. This study aimed to identify Nepal's health systems gaps to prevent and manage CVDs. METHODS: We formed a task force composed of the government and non-government representatives and assessed health system performance across six building blocks: governance, service delivery, human resources, medical products, information system, and financing in terms of equity, access, coverage, efficiency, quality, safety and sustainability. We reviewed 125 national health policies, plans, strategies, guidelines, reports and websites and conducted 52 key informant interviews. We grouped notes from desk review and transcripts' codes into equity, access, coverage, efficiency, quality, safety and sustainability of the health system. RESULTS: National health insurance covers less than 10% of the population; and more than 50% of the health spending is out of pocket. The efficiency of CVDs prevention and management programs in Nepal is affected by the shortage of human resources, weak monitoring and supervision, and inadequate engagement of stakeholders. There are policies and strategies in place to ensure quality of care, however their implementation and supervision is weak. The total budget on health has been increasing over the past five years. However, the funding on CVDs is negligible. CONCLUSION: Governments at the federal, provincial and local levels should prioritize CVDs care and partner with non-government organizations to improve preventive and curative CVDs services.

Anticoagulant Use in Patients With Nonvalvular Atrial Fibrillation: Has Prescribing Improved?

Discordance between international guideline recommendations and anticoagulant prescribing patterns among patients with nonvalvular atrial fibrillation (NVAF) has been frequently reported. This study was designed to compare the anticoagulant utilization pattern to earlier data in the same population and identify predictors of anticoagulant prescribing among patients with NVAF. We reviewed patients with NVAF admitted to Tasmania's 3 major hospitals between January 2011 and June 2012 and compared the anticoagulant utilization pattern to earlier data. Patients were excluded if they had only 1 episode of NVAF that reverted spontaneously or upon cardioversion. Multivariate logistic regression analysis was used to identify predictors of anticoagulant prescribing. Overall, 53.8% of patients received anticoagulant treatment compared to 40.4% 15 years ago. Among eligible patients at high-risk of stroke, 52.5% were receiving anticoagulant therapy (vs 42.1% 15 years ago). Approximately 10% of patients with a CHADS2 score ≥2 were not receiving any antithrombotic treatment, reduced from 18.2% in the earlier cohort, whereas anticoagulant use increased among those at low risk (score 0) to 48.5% from 14.2%. Younger age (odds ratio [OR] 0.99, 95% confidence interval [CI] 0.97-1.0; P = .04); CHADS2 = 1, relative to 0 (OR 1.68, 95% CI 1.07-2.63; P = .02); CHF (OR 1.56, 95% CI 1.12-2.15; P = .008); and embolic disease history (OR 1.77, 95% CI 1.09-2.86; P = .02) were significant predictors of anticoagulant prescribing. While there has been improvement over the past 15 years, suboptimal use of anticoagulant therapy among high-risk patients with NVAF remains common. There is significant potential for improvement in the quality of stroke prophylaxis in patients with NVAF.

Patient Characteristics and Antithrombotic Prescribing Patterns in Patients With Atrial Fibrillation in Tasmania.

Limited data are available on atrial fibrillation (AF) and its clinical management and outcomes from an Australian perspective. This study was designed to examine the patient characteristics and antithrombotic treatment patterns among patients with AF in Tasmania, Australia. This retrospective observational study reviewed and followed patients with AF admitted to Tasmania's 3 major hospitals between January 2011 and June 2012. Patients were excluded if they had only 1 episode of AF that reverted spontaneously or upon cardioversion without any documented recurrences. We reviewed the records of 2502 patients (≥18 years), and1469 were subsequently included in the study. The mean (±standard deviation [SD]) age of the patients was 76 (±12.3) years. The mean (± SD) CHADS2 score was 2.1 (±1.3), and 65.7% had a score ≥2. In total, only 55.6% of patients with CHADS2 score ≥2 were receiving anticoagulation and 9.9% were not receiving any antithrombotic treatment, whereas 85.4% of those at low risk (score 0) were on antithrombotic therapy. Hospitalization was associated with a significant increase in the rate of combination (antiplatelet plus anticoagulant) therapy ( P < .001). Suboptimal use of antithrombotic therapy highlights the need to improve AF management in our jurisdiction.

Potential use of NOACs in developing countries: pros and cons.

PURPOSE: Although vitamin K antagonists (VKAs) are effective for long-term thromboprophylaxis in atrial fibrillation (AF), their limitations have led to widespread underutilisation, especially in the developing world. Novel oral anticoagulants (NOACs) have emerged as promising alternatives to VKAs, although there are some particular considerations and challenges to their introduction in developing countries. This review summarises the current state of antithrombotic management of AF in the developing world, explores the early evidence for the NOACs and describes some of the special considerations that must be taken into account when considering the role of the NOACs within developing countries' health care systems. METHODS: A literature search was conducted via PubMed and Google Scholar to find articles published in English between the years 2000 to 2014. Search terms used were "atrial fibrillation", "oral anticoagulants", "warfarin", "NOACs", "dabigatran", "rivaroxaban", "apixaban", "edoxaban", "time in therapeutic range", "International Normalized Ratio" "cost-effectiveness", "stroke", "adverse-drug reactions" and "drug-drug interactions", together with the individual names of developing countries as listed by the World Bank. We reviewed the results of randomized clinical trials, relevant retrospective and prospective studies, case-studies and review articles. RESULTS: Many developing countries lack or have sporadic data on the quality of AF management, making it difficult to anticipate the potential impact of NOACs in these settings. The utilisation of anticoagulants for AF appears highly variable in developing countries. Given the issues associated with VKA therapy in many developing countries, NOACs offer some potential advantages; however, there is insufficient evidence to advocate the widespread replacement of warfarin at present. VKAs may continue to have a role in selected patients or countries, especially if alternative monitoring strategies can be utilised. CONCLUSION: The evaluation of the introduction of NOACs should consider safety, budget concerns and the quality of oral anticoagulation care achieved by each country. Prospective registries will be important in developing countries to better elucidate the comparative safety, efficacy and cost-effectiveness of NOACs and VKAs as NOACs are introduced into practice.

Impact of educational intervention on the pattern and incidence of potential drug-drug interactions in Nepal / Impacto de una intervención educativa en el esquema e incidencias de interacciones medicamentosas potenciales en Nepal

Objective: To study the impact of educational intervention on the pattern and incidence of potential drug-drug interactions (DDIs). Method: All patients admitted to Internal Medicine wards of Manipal Teaching Hospital during the study period were included. Patient details were collected using a patient profile form and the datum from the filled forms was analyzed using Micromedex electronic database. An intervention was carried out through a presentation during clinical meeting and personal discussion. The target groups for the intervention included doctors and the nurses. Results: Altogether 435 patients during preintervention and 445 during postintervention were studied. The incidence of potential DDIs was 53% (preintervention) and 41% (postintervention) [chi-square =11.27, p=0.001]. The average number of drugs per patient was 8.53 (pre-intervention) and 7.32 (post-intervention) [t=3.493, p=0.001]. Sixty-four percent of the potential DDIs were of "Moderate" type and 58% had a "Delayed" onset in both the phases. Seventy percent of the potential DDIs during the pre-intervention phase and 61% during post-intervention phase had a "Good" documentation status. Pharmacokinetic mechanism accounted for 45% of the potential DDIs during pre-intervention and 36% in the post-intervention phase. Cardiovascular drugs accounted for 36% of the potential DDIs during pre-intervention and 33.2% during post-intervention phase. Furosemide was the high risk drug responsible for DDIs in both phases. The most common potential DDIs observed were between amlodipine and atenolol (4.82%) (preintervention) and frusemide and aspirin (5.20%) (postintervention). Conclusion: There was an association between potential DDIs and age, sex, and polypharmacy (AU)

Objetivo: Estudiar el impacto de una intervención educativa en el esquema y la incidencia de las interacciones medicamentosas potenciales (DDI). Método: Se incluyó a todos los pacientes que visitaron el servicio de medicina interna del Hospital Universitario de Manipal. Los detalles de los pacientes se recogieron utilizando un formulario de perfil de paciente y los datos fueron analizados utilizando la base de datos electrónica Micromedex. Se realizó una intervención mediante una reunión clínica y discusión personal. El grupo diana eran los médicos y los enfermeros. Resultados: Se estudiaron 435 pacientes durante la pre-intervención y 445 durante la post-intervención. Las incidencia de DDI potenciales fue del 53% (pre-intervención) y 41% (post-intervención) [chi cuadrado=11,27, p=0,001]. La media de medicamentos por paciente fue de 8,53 (pre-intervención) y 7,32 (post-intervención) [t=3,493, p=0,001]. El 64% de las DDI potenciales eran de tipo "Moderadas" y el 58% tenía una iniciación "Retrasada" en ambas fases. El 70% de las DDI potenciales durante la fase de pre-intervención y el 61% en la post-intervención tenían un estado de documentación "Bueno". Mecanismos farmacocinéticos contabilizaron el 45% de las DDI potenciales durante la pre-intervención y el 36 en la post-intervención. Los medicamentos cardiovasculares sumaron el 36% de las DDI potenciales durante la pre-intervención y el 33,2% en la post-intervención. La furosemida fue el de mayor riesgo de DDI en las dos fases. La DDI potencial más comúnmente observada en la pre-intervención fue entre amlodipino y atenolol (4,82%), y en la post-intervención fue entre furosemida y aspirina (5,29%). Conclusión: Existía una asociación entre DDI potencial y edad, sexo y polimedicación (AU)

Impact of educational intervention on the pattern and incidence of potential drug-drug interactions in Nepal.

OBJECTIVE: To study the impact of educational intervention on the pattern and incidence of potential drug-drug interactions (DDIs). METHOD: All patients admitted to Internal Medicine wards of Manipal Teaching Hospital during the study period were included. Patient details were collected using a patient profile form and the datum from the filled forms was analyzed using Micromedex electronic database. An intervention was carried out through a presentation during clinical meeting and personal discussion. The target groups for the intervention included doctors and the nurses. RESULTS: Altogether 435 patients during preintervention and 445 during postintervention were studied. The incidence of potential DDIs was 53% (preintervention) and 41% (postintervention) [chi-square =11.27, p=0.001]. The average number of drugs per patient was 8.53 (pre-intervention) and 7.32 (post-intervention) [t=3.493, p=0.001]. Sixty-four percent of the potential DDIs were of 'Moderate' type and 58% had a 'Delayed' onset in both the phases. Seventy percent of the potential DDIs during the pre-intervention phase and 61% during post-intervention phase had a 'Good' documentation status. Pharmacokinetic mechanism accounted for 45% of the potential DDIs during preintervention and 36% in the post-intervention phase. Cardiovascular drugs accounted for 36% of the potential DDIs during pre-intervention and 33.2% during post-intervention phase. Furosemide was the high risk drug responsible for DDIs in both phases. The most common potential DDIs observed were between amlodipine and atenolol (4.82%) (preintervention) and frusemide and aspirin (5.20%) (postintervention). CONCLUSION: There was an association between potential DDIs and age, sex, and polypharmacy.