Cardiovascular Medication Saving Activity during Dispensing Process at Specialist Clinic Pharmacy in Malaysia

Saiful Nizam M V Mohamed Koya

Pharmacy Department, Hospital Bentong, Pahang, Jalan Padang, 28700 Bentong, Malaysia

Corresponding Author’s Email: saiful.nizam@moh.gov.my

Abstract

Background: Medication saving activity via reduction of medication supply due to medication ref usal by patients during dispensing process is a vital activity that can be led by the pharmacists. However, there is a lack of evidence on how to conduct this activity especially at specialist or outpatient pharmacy for those patients diagnosed with cardiovascular disease (CVD). Thus, this study aimed to determine prevalence, f actors and cost associated with patients’ ref usal to the CVD medication supply during dispensing process by pharmacist at specialist clinic pharmacy. Methods: Patients prescribed with CVD medications were invited to participate in this cross-sectional survey af ter medication dispensing process was completed. This process involved assessing participants’ ref usal to the dispensed CVD medication and issues related to their treatment. Data regarding cost was obtained f rom Pharmacy Inf ormation System (PhIS) at the current f acility. Results: A total of 270 patients participated in this survey. Prevalence of participants ref using medication prescribed was 33.7%. Participants receiving care f rom primary and secondary healthcare simultaneously, experiencing side ef f ects and self - modified treatment were 4.88 (P = 0.027), 5.01 (P < 0.05) and 2.98 (P = 0.018) times more likely to ref use medications dispensed. Those who participated in ‘Medication Therapy Adherence and Counselling’ (MTAC) program however were 0.43 times less likely to ref use medication during dispensing process, (P = 0.012). A saving of 4.8% was achieved f rom this activity. Conclusion: Cost- saved achieved during this study was minimal and f actors associated with medication ref usal was rather concerning.

Keywords: Adherence; Healthcare System; Medication Saving; Specialist Pharmacy

Introduction

Dispensing is the process of preparing, packing, and giving prescribed medication to patients. In order to ensure saf e and ef f ective pharmacological intervention during the dispensing process, pharmacists will provide necessary inf ormation regarding the medications prescribed, such as indications, dosing, and possible side ef f ects of those medications, to the patients (Ferreira et al., 2016). Other activities include assessment of both medications’ side ef f ects and adherence (Payne et al., 2019), and medication-saving activities such as discussion regarding the quantities of medications needed by the patients (Bekker et al., 2018). Patients are an ideal target for medication-saving activity since interventions are highest during interactions between pharmacists and patients compared to interactions between pharmacists and doctors, which are reported to be around 86.65% and 11.80%, respectively (Payne et al., 2019). The practice of discussing the medication needed by patients during the dispensing process might prevent the accumulation of excess medication at home and, in turn, af f ect the patient’s health, the economy, and the environment (Azad et al., 2016), especially for those experiencing adverse ef f ects or receiving the same medications f rom multiple pharmacies. The United States Food and Drug Administration (US FDA) has also advised that patients are allowed to partially f ill their prescriptions so that waste will not occur due to overstocking of medication (Makki et al., 2019).

A reduction in the quantity of medications supplied to patients during the dispensing process is a key element of medication-saving activity (Oh et al., 2022; Lim et al., 2021; Van Herpen-Meeuwissen et al., 2019). The advantage of reducing the amount of medication supplies has been reported in inpatient and outpatient settings internationally and locally via programs such as the use of ‘patient’s own medicines’ (POMs). to educate patients about good pharmacology, to follow up in a structured manner, to identif y clinical recurrence in patients with heart f ailure, and to create medicines in advance of acute exacerbations (Amalia, Said & Nambiar, 2024). However, those studies focused mainly on the cost- saving aspect of POMs, while f actors associated with the excessiveness of POMs were rarely reported (Oh et al., 2022; Lim et al., 2021; Van Herpen-Meeuwissen et al., 2019; Nugraha et al., 2023). On the other hand, reductions in medication supply in outpatient or specialist pharmacy settings are rarely practiced by pharmacists (Bekker et al., 2018). Hence, there is a lack of evidence regarding the f actors and benef its supporting medication-saving activities in outpatient or specialist pharmacy settings obtained via reduction of medication supply during the dispensing process. The types of medications suitable for medication-saving activities might also vary depending on the type of f acility. The current f acility is a secondary healthcare provider and cater treatment for various disorders for patients under specialists’ care, such as cardiologists and nephrologists, and the majority of the medications served revolve around cardiovascular disease (CVD) medicines.

In 2020, CVD medicines constituted 19.65% and 20.21%, respectively, in terms of the number and cost of medicines issued to the specialist dispensary f rom the current f acility’s pharmacy’s medical store. Nationally, 5 out of 10 most commonly used therapeutic groups during 2016 were f rom the CVD group, namely calcium channel blockers (CCB), renin-angiotensin agents (RAS), lipid-modifying agents, and diuretics such as amlodipine, perindopril, simvastatin, atorvastatin, acetyl salicylic acid, and hydrochlorothiazide (Chok & Ahmad Shanizza, 2020). Due to their f requent use, CVD medicines contributed 17.7% of the spending costs between 2010 and 2014, ranking third among 14 other anatomical therapeutic chemicals (ATC) (Hamzah et al., 2020). However, they also ranked f irst at 32.5% in terms of quantity returned to the outpatient pharmacy in Malaysia in 2021 (Jamalud-din et al., 2022), risking medication wastage since excess medications returned to the pharmacy in Malaysia were inevitably disposed of instead of being reused (Yang et al., 2018). Considering the large impact CVD has on our economy coupled with its high medication wastage potential, medication saving activities between pharmacists and patients during the CVD medicine dispensing process are necessary.

Recently, research conducted in Malaysia’s tertiary public hospital found that CVD medicines ranked second in terms of cost savings af ter the implementation of POM for patients discharged f rom the wards (Oh et al., 2022). However, for outpatient settings, previously reported studies have only investigated cost savings obtained f rom reduction of medication supplied during the dispensing process for non- CVD medications such as analgesics, antihypertensive, and benzodiazepines due to medication ref usal by patients during dispensing process (Koya et al, 2021; MV Mohamed Koya et al., 2022). Medication ref usal ref ers to the act of patients ref using the dispensed medication by the pharmacists during dispensing process af ter discussion with the pharmacists (Koya et al., 2021; MV Mohamed Koya et al., 2022). However, to our knowledge, there is no study regarding the reduction of CVD medications between pharmacists and patients during the dispensing process. Determining f actors associated with patients’ ref usal to the dispensed medication that leads to the reduction on the number of medications supplied is vital in order to ensure patients’ saf ety so that medication reduction can be conducted ef f ectively and saf ely. Thus, current study aimed to determine 1) the prevalence of patients prescribed with CVD medications ref using the dispensed medications and 2) f actors and costs-saving associated with a ref usal to the dispensed CVD medication during the dispensing process.

Methodology

Research Population

This study was conducted during the dispensing process using the convenience sampling method at the Specialist Pharmacy Department of Jerantut Hospital f rom October 1st to December 31st, 2020, involving patients prescribed medications for cardiovascular disorders (CVDs). Sample size of 377 participants were required using Raosof t software calculator with margin error of 5% and a conf idence interval of 95%.

Data Collection

The dispensing process was conducted according to the current f acility standard operating procedure. At the end of the dispensing process, patients were invited to participate in the survey. After signing the consent form, participants’ demographic and medication details were entered into the data collection form.

After that, participants were asked if there were any medications they wished to ref use. Participants were also asked questions regarding medication side ef f ects, forgetfulness, belief in medication ef f ectiveness that includes use of traditional medicines, overconf idence that includes belief that their illness is under control, self -modification of the treatment and f ear of medication shortage. These are ‘household f actors’ that lead to medication wastage. For ‘health system cause’ that leads to medication wastage, participants were asked if they are attending multiple medical appointments at other f acilities for the same treatment (repeat treatment prescribing). Insuf f icient prof essional support for proper medicine uses such as participation in medication therapy and adherence counselling (MTAC) were determined f rom the PhIS record. In cases where medication ref usals were due to side ef f ects, participants were advised to seek their doctors.

Medications ref used and returned to the pharmacist by the participants were grouped accordingly for data analysis. CVD medications ref erred to combinations of any type of antihypertensive, anti-anginal drugs such as glyceryl trinitrate, trimetazidine, and isosorbide dinitrate, as well as antiplatelet and anti- hypercholesterolemia drugs (Koya et al., 2021). The total cost f or every prescription and price for every item ref used were extracted f rom the PhIS that stored patients’ medication details and price for each medication. Inclusion criteria for this study were: all patients collecting CVD drugs at the specialist’s pharmacy of Jerantut Hospital and adults aged more than 18 years old who collected medication by themselves. Those newly started on CVD medicines on the day of the data collection were excluded.

Data analysis

Statistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS) version 21.0. Categorical variables were described as f requencies and percentages (%), while continuous variables were reported as mean and standard deviation (SD). Binary logistic regression was used to determine possible independent variables associated with a reduction in the amount of CVD medication supplied. Numerical variables were analysed using the T-Test. Independent variables with a P-value of less than 0.05 were considered signif icant.

Ethical Consideration

This study was approved by Medical Research and Ethics Committee (MREC), Malaysia with registration number: NMRR-20-1068-55189(IIR) on June 29th, 2020.

Results

Overall, 325 individuals were approached to participate in the study. However, 16 ref used to participate due to language barrier, 39 were excluded since they were collecting on behalf of the patients. Overall, 270 patients participated in the survey. Mean age of the participants was 56.2 ± 12.2 The majority of the participants were male (69.6%, n = 188) and of Malay race (83.0%, n = 224). The prevalence of patients who ref used their medication and having unused medicines at home was 33.7% (n = 91) and 85.1% (n = 232), respectively. Around 14.4% (n = 39) of the participants reported extra follow-ups at primary health clinics, and 8.9% (n = 24) received treatment for the same condition f rom other f acilities (or 24/39 = 61.5%). Side ef f ects and self -dose modification were reported by 13% (n = 35) and 10.0% (n = 27) of the participants, respectively. Forgetf ulness to take medicines, believe that illness was under control and consuming traditional medicines were common, (49.3%, n = 133) followed by 13% (n = 35) and 10% (n = 27) respectively. About 30.4% (n = 82) were f rom the MTAC program at the current f acility. The data are shown in Table 1.

Table 1: Participant Characteristics

*Data are presented as n(%) except where indicated

**Data are expressed as mean± standard deviation (SD)

The total number of items dispensed throughout the study period was 1726, accounting for a total of Ringgit Malaysia (RM) 24987.38. Total items ref used and returned to the pharmacy were 116, equivalent to 6.7% of total items dispensed. The cost of items ref used and returned to the pharmacy was RM 1189.20, or equivalent to 4.8% of the total cost prescribed for overall prescriptions. Anticholesterols were the most commonly ref used CVD drugs by participants, (26.7%, n = 31), followed by calcium channel blockers (21.6%, n = 25), sublingual GTN (16.4%, n = 19), angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin II receptor blockers (ARBs) (11.2%, n = 13), beta blockers (9.5%, n = 11), acetylsalicylic acid (6%, n = 7), antianginal (5.2%, n = 6), diuretics (2.6%, n = 3), and alpha blockers (0.9%, n = 1). Overall, 14 types of side ef f ects were reported, with dizziness being the commonest (48.7%, n = 18), followed by hypotension (13.5%, n = 5). The data are shown in Table 2.

Table 2: Details of Medications Reduced and Side Effects Associated with Treatment

Four categorical variables were found to be signif icantly associated with ref usal to medication supply during the dispensing process: receiving treatment f rom primary health clinics, experiencing side ef f ects, self -dose modification, and MTAC program recruits. The odds for patients who received simultaneous treatment f rom both a hospital and a primary health clinic to ref use medications were 4.88 times higher compared to those receiving treatment f rom a single f acility alone (P = 0.027, 95% CI = 1.190 – 18.616). Those experiencing side ef f ects were 5.01 times more likely to ref use the medication during the dispensing process compared to those who did not experience medication side ef f ects (P < 0.05, 95% CI = 2.213 – 11.660). Those who admitted to self -dose modification were 2.98 times more likely to ref use medication compared to those who maintained taking the prescribed dose (P = 0.018, 95% CI =1.211 – 7.334). MTAC recruits were 0.43 times less likely than non-MTAC patients to ref use the medication (P = 0.012, 95% CI = 0.222 – 0.831). The data are shown in Table 3.

Table 3: Binomial Regression for Predictors Associated with Medication Reduction

*Exp (B) (exponentiated coefficient) = Odd ratio

**CI=Confidence interval

Overall, in terms of cost, a saving of RM 13.22 ± 11.79 per patient was produced among those who ref used medication supplied compared to RM 0.05 ± 0.67, P < 0.05 in those who did not ref use medication supplied. In terms of saving percentages, those who ref used their medications supplied contributed toward 22.13 ± 22.30% versus 0.06 ± 0.86% in those who did not ref use their medication supply, P < 0.05. The data are shown in Table 4.

Table 4: Numerical Factors Associated with Reduction in Medication Supplied

*Data are expressed as mean± standard deviation (SD)

Discussion

Prevalence

Previous studies reported that 86% of the pharmacists f rom 22 developed countries claimed they were allowed to reduce the amount of medication supplied during the dispensing process and considered this an important activity despite a lack of implementation due to time constraints (Bekker et al., 2018). In addition, the current study provides a new f inding that the prevalence of patients with CVD ref using some of the medications supplied during the dispensing process was 33.7%. This prevalence is similar to the prevalence of patients being late in collecting their CVD medication ref ill in the United States and Finland, which were reported to be 33% and 40%, respectively (Nabi et al., 2008; Bailey et al., 1996). This prevalence was also comparable to the ref usal to take benzodiazepines, which was reported to be 38.7% among those diagnosed with depression or schizophrenia (MV Mohamed Koya et al., 2022). Even though the prevalence of having excess CVD medicines at home in the current study was 85.9%, similar to 84% among the general population with or without chronic diseases in Malaysia (Wang et al., 2021), it was not associated with ref usal to medication supply during the dispensing process.

Receiving Treatment from Multiple Facilities: Medication Oversupply

Patients receiving CVD medicines tend to oscillate between primary and secondary care for various reasons, such as monitoring of blood pressure and glucose control. In the current study, 14.4% of patients receiving CVD medicines reported multiple medical appointments. However, only 9.8% received prescriptions for the same drugs (repeat treatment prescribing) f rom multiple f acilities (inter- f acilities) f rom diff erent doctors, which can lead to medication oversupply. This f igure was similar to 8.9% of hypertensive patients that f loated between clinics and hospitals and reported having excess medications as measured by the medication possession ratio (MPR) (Kim et al., 2017). Medication oversupply also occurred in 13.4% of hospital patients in our neighbouring country, Thailand (Dilokthornsakul et al., 2014), and 8.6% of diabetic patients in Saudi Arabia (Balkhi et al., 2019) who received treatment within the same f acilities. Multiple medical appointments can lead to inappropriate prescribing and repeated dispensing involving both prescribers and pharmacists, respectively, which is considered a health system's or healthcare provider’s f ailure (Makki et al., 2019), consequently resulting in increased healthcare costs such as USD 189,024 in f inancial loss per year due to medication wastage and hospitalization risk (Dilokthornsakul et al., 2014; Kim et al., 2017). However, discussion between pharmacists and patients might reduce the occurrence of these incidents since those with multiple medical appointments were f ive times more likely to agree on reducing the quantities of medication dispensed to them.

Side Effects

The incidence of side ef f ects f rom CVD medicines in the current study was only 13.1%, which was similar to 18.1% reported in a study in Nigeria (Olowof ela & Isah, 2017), but it led to more than half of our patients with side ef f ects ref using their medications during the dispensing process. Side ef f ects of antihypertensive medications have also reduced adherence in 42.3% (Ramli, Ahmad & Paraidathathu, 2012) of hypertensive patients. A current study found that those experiencing medication side ef fects were f ive times more likely to ref use medication supply during the dispensing process. Similarly, hypertensive patients experiencing side ef f ects were 4.84 times more likely to be nonadherent to their medication (Kretchy et al., 2015). Similar to a previous report, the current study found that the commonest side ef f ects of the therapy were dizziness and hypotension (Rossello et al., 2015). Current f indings indicate the importance of medication side ef fects’ assessment during the dispensing process. If it remains unaddressed, it will lead to medication wastage (Wang et al., 2021; Makki et al., 2019), since 2.9% of Malaysians admitted to keeping unused medicines due to the occurrence of side ef f ects.

Self-Dose Modification

Self -dose modification is a common occurrence in those with health disorders to varying degrees. In the current study, 9.6% of our participants with CVD altered their dose, which is much lower compared to the 27% found in the previous study. One of the explanations for this f inding is that the current study focused specifically on CVD medicines, while previous studies focused on those prescribed with either CVD medicines or analgesics. A previous study was also conducted in a primary health care setting where patients were attended by general practitioners (GPs) (Säf holm et al., 2019) compared to this study, where patients received treatment f rom specialists. Another study also reported that 3.8% of those with atrial f ibrillation (AF) admitted to taking smaller doses of medicines in order to reduce costs (Bamgbade et al., 2023). However, dose modification in the current study could not result f rom cost since medications were subsidized by the government or obtained f ree of charge. Thus, even though dose modification can reduce the number of medications supplied, the main concern f rom this f inding is that inappropriate and unmonitored self -dose adjustment can result in the occurrence of various health complications such as end-stage renal f ailure, coronary artery disease, cerebrovascular disease, and mortality.

Medication Therapy Adherence and Counselling (MTAC) Participation

Medication counselling was reported to af f ect medicine-taking behaviour differently. For instance, a previous study reported that patients who received standard medication review and counselling by community pharmacists af ter they were discharged f rom hospitals had signif icantly fewer numbers and quantities of medication dispensed compared to patients who did not receive medication counselling (Hugtenburg et al., 2009). In contrast, the current study showed that participation in MTAC, namely anticoagulation, nephrology, or diabetes mellitus discipline, was not associated with a reduction in the number of medications supplied. This f inding is consistent with another study that reported medication counselling has signif icantly improved several outcomes in patients, such as medication adherence and quality of lif e (Mishra et al., 2017). Main activities in the MTAC program usually involve activities such as regular counselling sessions with patients and education regarding their illnesses on monthly basis. This might result in increased awareness and knowledge related to medication use and the importance of good medication adherence. In current setting, regular medication reviews by pharmacists were done by MTAC pharmacists and attending doctors were notif ied regarding issues f aced by those in our MTAC programs. Due to this, common issues such as occurrence of side ef f ects, unnecessary prescribing and repeat treatment prescribing are less likely to occur thus resulting in less ref usal to the medication prescribed and supplied.

Cost Saving

Overall, reduction in the quantities of CVD medications during the dispensing process in the current study only produced a modest 4.8% direct medication cost saving, similar to the 4.3% produced at an inpatient nephrology ward in Iran during clinical pharmacist interventions (Gharekhani et al., 2014). However, the percentage of cost savings af ter reduction in the quantities of the medications supplied was 22%, slightly low compared to the 38.96% produced in the POM study among diabetic patients conducted in an outpatient setting in Malaysia. One of the explanations for this f inding was that 80.2% of the medicines ref used in the current study were generic medicines, which were always considered cheaper. In contrast, 70% of the top 10 drugs by price used for POMs in the previous study were of original brand (Lim et al., 2021).

Limitations

This study is subject to several considerations that highlight its specif ic context and scope. Participants’ ability to accurately recall whether they have received similar medications f rom other f acilities adds a nuanced layer to the data collection process. The study emphasizes the medication counselling history recorded at the current f acility, providing a targeted and specif ic insight into the services rendered. By including patients who were able to collect their medication personally, the study ensures a focus on individuals actively engaged in their treatment process.

Conclusion

Medication-saving activity perf ormed during the dispensing process between pharmacists and patients via assessment of ref usal to medication prescribed during dispensing process has produced minimal cost savings. However, this activity has revealed several issues involving both the healthcare system and patient f actors. While some aspects of the patient’s treatment might support this activity, the ref usal of medication due to f actors such as self -dose modification and medication side ef f ects needs f urther observation and investigation by pharmacists so that these issues will not compromise the patient’s treatment and ultimately their health.

Conflict of Interest

The authors declare that they have no competing interests.

Acknowledgement

The authors are thankf ul to the institutional authority for completion of the work.

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