Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




Prof. Somashekhar Nimbalkar

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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
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Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2012 | Month : June | Volume : 6 | Issue : 5 | Page : 787 - 790

The Characteristics of Drug Wastage at the Hospital, Tuanku Jaafar Seremban, Malaysia: A Descriptive Study

Mohamed Azmi Hassali, Azuwana Supian, Mohamed Izham Ibrahim, Harith K. Al-Qazaz, Mahmoud Al-Haddad, Fahad Salee, Subish Palaian

1. Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia. 2. Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia. 3. Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia. 4. Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia. 5. Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia. 6. Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains, Malaysia, 11800 Penang, Malaysia. 7. Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains, Malaysia, 11800 Penang, Malaysia.

Correspondence Address :
Dr. Mohamed Azmi Hassali, B.Pharm, M.Pharm (Clinical), PhD
Discipline of Social & Administrative Pharmacy,
School of Pharmaceutical Sciences,
Universiti Sains Malaysia, 11800 Minden, Penang, Malaysia
Phone: +6046533888 ext. 4085, Fax: +604-6570017
E-mail: azmihassali@gmail.com

Abstract

Objective:
To identify the types and the costs of medication wastage.
Methods:
Excessive or extra medicines were collected from visiting hypertensive patients, from their houses. The medications were listed and the cost was calculated by using the cost price from the Integrated Store Hospital, Tuanku Jaafar Seremban, Malaysia. The returned medicines from the volunteer patients that were collected at the pharmacy counter in the hospital were listed and the cost was calculated by using the cost price. This study was conducted from June to November 2007.
Results:
A total of 20,799 excessive pills were collected, with an average of 202 pills per patient from visited hypertensive patients. The total cost which was lost or wasted was MYR 4,362.28, with the average wastage being MYR 42.35/patient. A total of 131,098 pills were collected from volunteers at the pharmacy counter, with an average of 21,850 pills per month. The total cost which was lost or wasted was MYR 59,566.50, with the average wastage being MYR 9,927.75 per month.
Conclusion:
The data on the patients’ adherence and medicine wastage may provide useful information to the Ministry of Health with regards to the selection of the first-line medication which was recommended, based on the need to maintain a patient on a given treatment. Pharmacists should clearly explain the patients how to use their drugs and guide them through their initial periods of therapeutic inactivity and transient side-effects.

Keywords

Drug wastage, Excessive medicine, Cost loss

INTRODUCTION
Worldwide, hypertension has been found to be the most prevalent health problem among the adult primary care patients, but its treatment has often been sub-optimal. The introduction of newer medicines has increased the total expenditures on the anti-hypertensive therapy, but the non-adherence to the prescribed medicines has costly financial implications (1). Adherence to the anti-hypertensive medication therapy was not adequately achieved because a high percentage of the subjects discontinued the treatment within 12 months of starting it (2),(3),(4). It was associated with patient-related factors such as age, concurrent chronic pharmacologic treatments, previous hospital admissions for cardiovascular disease and the initial prescribed class of anti-hypertensive medicines. In North Wales, a study reported that over ÂŁ1.1 million worth of medicines are returned to pharmacies to be destroyed. In the United Kingdom, it was estimated that more than ÂŁ90 million worth of medicines were returned unused to the pharmacy and that all these returned medicines could never be re-used by the pharmacists (5). The Northamptonshire Teaching Primary Care Trust (PCT) spends more than ÂŁ80 million a year on medicines which have been prescribed, but millions of pounds worth of medicines which have been dispensed to patients are being returned unused to the pharmacies (6). The extent of medication wastage by the Malaysian consumers was first studied by Ibrahim and colleagues in their study in 1996 (7). This household survey study managed to collect 451 types of unused medicines from 101 houses. The findings showed that the trend of medicine usage was more towards wastage, because the consumers were not fully aware of the types of medications which were used or as to how they could be used properly. Patients tend to Original Articlekeep medicines longer than necessary and they have the tendency of re-using and sharing, which can lead to undesirable effects and poisoning. A cohort study was conducted in a Local Health Unit of Ravenna (North Eastern Italy) by Esposti and colleagues to determine the duration for which patients remained on various anti-hypertensive medicines (8). A total of 14,062 subjects were included in the study in which ACE inhibitors were the class of medications which were most commonly prescribed as the first-time therapy (28.0%). Within the group, it was observed that 60.3% of patients discontinued the use of the medications and that 30.9% continued and that 8.8% switched on to the treatment. A study was conducted in Alberta, Canada from May to November 1999 by Morgan in 2001, to assess the occurrence, costs and the reasons for medication wastage in a population of older adults by doing in-home surveys and counts of leftover medicines (9). A total of 73 subjects received in-home pharmacy evaluations and completed the questionnaires. The sum costs of the wasted medication was USD 2011 in the study group (n=66) and a total of 2078 wasted pills were found. The mean annual cost of the wasted medication was USD 30.47 and 31.5 pills wasted per-person. The most frequently wasted medication classes were antibiotics, benzodiazepine and anti-hypertensives. The most frequent reasons for the wastage of medication were conditions which were resolved (n=44), perceived ineffectiveness (n=14), prescription change (n=14) and adverse effects (n=8).

Material and Methods

This research was divided into 2 parts; part 1 was medicine wastage in the patients’ house and part 2 was medicine wastage by the volunteers at the pharmacy counter. In part 1, a prospective,randomized, community based trial was used in this research. The selected hypertensive patients were briefed about the research and were given a consent form to sign. In this research, all the excessive medications at the patients’ houses were collected during the home visits. The excessive medicines in this research meant, the extra stock of the previous medications which were supplied to the patients’ houses, which resulted from accumulation of the supplied medication or non-adherence to the medication. Only the previous excessive stocks of medicines were taken and the current medicines which were supplied were left behind. All the excessive medications would be collected in order to work out the costing component by using the cost price from the Integrated Store Hospital, Tuanku Jaafar Seremban, for the year 2007. In part 2, the wasted medicines were collected from the volunteer patients or consumers who sent back the unwanted medicines to the pharmacy counter in the Hospital Tuanku Jaafar Seremban. A box was placed at the counter to collect and count the medicines from June to November 2007. The medicines were listed and the cost was calculated by using the cost price from the Integrated Store Hospital Tuanku Jaafar Seremban for the year 2007. This study was approved by the Ministry of Health Ethical Committee (MREC).

Results

One hundred and twenty-one patients met the enrolment criteria and they agreed to participate in this research, but throughout the eight months (April to November 2007), a total of 103 patients (85.12 %) were visited. A total of 20,799 excessive pills were collected with an average of 202 pills per patient from the hypertensive patients’ houses. The total cost which was lost or wasted was MYR 4,362.28, with an average wastage of MYR 42.35/patient. A total of 131,098 pills were collected from volunteers at the pharmacy counter, with an average of 21,850 pills per month. The total cost which was lost or wasted was MYR 59,566.50, with an average wastage of MYR 9,927.75 per month. The medicines that were listed as the top six quantities of excessive medicines from the patients’ houses were metformin, potassium chloride, frusemide, captoril, isosorbide dinitrate and lovastatin (Table/Fig 1). The medicines that were listed in the top six quantities of returned medicine were isosorbide dinitrate, metformin, lovastatin, frusemide, trimetazidine and potassium chloride. The medicines that were listed as having the top six highest costs of drug wastage from the patients’ houses during the study period were gabapentin, insulin (Mixtard®), amlodipine, ticlopidine, captopril and isosorbide dinitrate; and the list which had the highest costs of returned medicine at the pharmacy counter consisted of donepezil hydrochloride, rivastigmine, atorvastatin, isosorbide dinitrate and lansoprazole (Table/Fig 2).

Discussion

The total cost of the collected excessive medicines from the patients’ houses during home visits by the researchers was MYR 4,362.28, with an average of MYR 42.35 for each patient (n=103). A total of 20,799 pills were found and an average of 202 pills was wasted by each patient. It was quite a small amount, but when it was multiplied with the number of patients who were seen in the Medical Outpatients Department in the Hospital Tuanku Jaafar Seremban in the year 2007 (36,176 patients, Annual Report 2007 Hospital Tuanku Jaafar, Seremban), it was found to cost the government about MYR 1,532,053.60. A similar study was done by Thomas M. Morgan, who found that the sum which was wasted in terms of the cost of the medication was USD 2,011.00 and there were 2078 pills in the study group (n=66) (9). The mean annual cost of the wasted medication was USD 30.47 and 31.5 pills were wasted per-person. It also revealed that an average medication waste of USD 30.00 per-person-year represented a conservative estimate, and that the total national cost due to medication wastage would not be less than USD 1 billion per year. In this research, the average medication wastage or excessive supply was found to be MYR 42.35 per person and the total loss of government money throughout Malaysia would exceed a few millions. The total cost of the medications which were returned within the time frame of the research was MYR 59,566.50, with an average of about MYR 9,927.75 each month; and the expected total cost of the wastage from the returned medications for the year 2007 at the pharmacy in Hospital Tuanku Jaafar Seremban was MYR 119,133.00. This finding was consistent with that of a study which was done by Oboh (2006), who reported that 6 to 10% of the total prescribing costs were lost from wasted medications and that up to 50% of those with long-term conditions failed to take their medicines correctly. The economic consequences of the The total cost of the collected excessive medicines from the patients’ houses during home visits by the researchers was MYR 4,362.28, with an average of MYR 42.35 for each patient (n=103). A total of 20,799 pills were found and an average of 202 pills was wasted by each patient. It was quite a small amount, but when it was multiplied with the number of patients who were seen in the Medical Outpatients Department in the Hospital Tuanku Jaafar Seremban in the year 2007 (36,176 patients, Annual Report 2007 Hospital Tuanku Jaafar, Seremban), it was found to cost the government about MYR 1,532,053.60. A similar study was done by Thomas M. Morgan, who found that the sum which was wasted in terms of the cost of the medication was USD 2,011.00 and there were 2078 pills in the study group (n=66) (9). The mean annual cost of the wasted medication was USD 30.47 and 31.5 pills were wasted per-person. It also revealed that an average medication waste of USD 30.00 per-person-year represented a conservative estimate, and that the total national cost due to medication wastage would not be less than USD 1 billion per year. In this research, the average medication wastage or excessive supply was found to be MYR 42.35 per person and the total loss of government money throughout Malaysia would exceed a few millions. The total cost of the medications which were returned within the time frame of the research was MYR 59,566.50, with an average of about MYR 9,927.75 each month; and the expected total cost of the wastage from the returned medications for the year 2007 at the pharmacy in Hospital Tuanku Jaafar Seremban was MYR 119,133.00. This finding was consistent with that of a study which was done by Oboh (2006), who reported that 6 to 10% of the total prescribing costs were lost from wasted medications and that up to 50% of those with long-term conditions failed to take their medicines correctly. The economic consequences of the non-adherence increased when about half of the patients did not take their prescribed medications seriously. In the United States, hypertension was found to affect more than 60 million people at a cost which exceeded USD 8 billion (10). The medicines which were listed as the top six quantities of excessive medicines from the patients’ houses were metformin, potassium chloride, frusemide, captoril, isosorbide dinitrate and lovastatin. A similar pattern was found for the returned medicines at the pharmacy counter. The medicines that were listed in the top six quantities of returned medicine were isosorbide dinitrate, metformin, lovastatin, frusemide, trimetazidine and potassium chloride. From the list, it was found that each medicine had a tendency due to which the patients could not adhere to it. The frequency of the maintenance medicine intake for isosorbide dinitrate, metformin and captopril was three times daily. The number of medicines which were prescribed and the frequency of their doses could influence the patients’ adherence. The same results were shown by Paes and colleagues, where the adherence rates of the diabetic patients who took oral hypoglycaemic agents was 74.8% for once-a-day doses and it was 38% for thrice daily doses (11). Therefore, the most effective strategy for improving the patient adherence by using anti-hypertensive medication was to simplify the dosing regimen to a once daily dosage (12) as long as the increased cost did not cause a barrier to the adherence. Lovastatin was suggested to be taken at night when patients tended to forget it and frusemide which has an inconvenient side-effect especially the urged for urination (diuresis). Patients discontinue the chronic medications frequently because of their side-effects, perceived ineffectiveness and personal considerations which are related to their use and the need for the treatment (13). Diuretics are usually prescribed for most of the patients with uncomplicated hypertension, either alone or combined with drugs from other classes (JNC7). Most of the patients who were interviewed, complained of this inconvenient side-effect, which led them to omit this medication when they wanted to travel or were away from their houses. Pharmacists should clearly explain to the patients as to how to use their drugs and guide them through the initial periods of the therapeutic inactivity and transient of possibly avoidable side-effects. By counselling and educating patients, pharmacists can help the patients by giving them ideas or solutions on how to overcome this problem. The high cost of the medicines will increase the cost of their wastage even though their quantity is small. The highest cost of the drug wastage from the patients’ houses during the study period included Gabapentin (MYR 836.00), followed by mixtard insulin (MYR 450.00) and amlodipine (MYR 436.80) and the highest cost of the returned medicine at the pharmacy counter involved the acetylcholinesterase inhibitor group which was used in the treatment of Alzheimer’s disease (dementia). The total cost of the donepezil hydrochloride tablet (Aricept ®) was MYR 6,129.50 and that of the rivastigmine tablet (Exelon ®) was MYR 3,465.00. Even though the quantity was small (23 boxes of 30 tablets of donepezil hydrochloride and only 9 boxes of 60 tablets of rivastigmine tablet), the high cost of each medicine would increase the total cost of the returned medication. A study which was conducted by Thomas M. Morgan claimed that there were four main causes for the wastage (9); the diagnosis of the disease condition for which the medication was prescribed (37.4%), patient-perceived ineffectiveness (22.6%), prescription changes by the physician (15.8%) and patient-perceived adverse effects (14.4%). But sometimes, the waste cannot be helped. Two of the main causes were the change of treatment by the physician and the returning of the medicines following the death of a patient. The discontinuation of the anti-hypertensive medication treatment has also some important economic implications. Patients who discontinue the therapy may provide useful information to the health ministry, in that they can help in the selection of the first-line medication based on the need to maintain a patient on the treatment as well as on therapeutic efficacy. Improving the adherence with the treatment should be pursued in the short term for a more appropriate use of the pharmacologic resources, and in the long term, to reduce the cardiovascular risk and the high costs which are associated with the specialist hospital treatment. The former Health Minister of Malaysia, Datuk Dr. Chua Soi Lek, in a press statement (NST, April 16, 2005), said that the ministry could not afford the current practices anymore because of the increasing cost of the subsidizing expenditure for the medicines (14). Datuk Dr. Chua Soi Lek also dictated that the prescription of medicines for the patients in a government hospital should have to be reviewed, to prevent their abuse and wastage. The researchers also found that the patients tended to collect as many possible medication supplies as they could, even though they still had enough stock left for a few months, because they thought that it was free and subsidized by the government. Just like plastics, paper and glass, medicines should also be managed in an environmentally responsible manner. The recycling of medicines is generally illegal, because the medicines no longer have the assurance or guarantee of strength, quality, purity or storage condition and these unwanted medicines are regularly returned to the pharmacy for disposal (15). A campaign can be held to raise public awareness on the health and environmental risk which is associated with the storage and the disposal of the unwanted and out-of-date medicines. The Royal Pharmaceutical Society of Great Britain (RPSGB) (1998) suggested that any audit of medication wastage must involve the prescribers, since they are the ones who are able to make most of the changes. It may be helpful to gain the support of the health authorities. The RPSGB produced the data collection sheet of the medication wastage (Appendix K), which could be used by the pharmacists to start with the audit of medication wastage. Medicine wastage should be prevented wherever possible, through trial prescription programs, dispensing of smaller quantities, and by educating the patients, prescribers, the government and the pharmaceutical industry on the cost of waste (National Association of Pharmacy Regulatory Authorities Canada (NAPRA), 1997). All these reasons give an impact of the patients’ adherence to their treatment and medication. This is where pharmacists could play their role as counsellors to counsel and educate the patients regarding the treatment and medicines. The Pharmacist Homecare Service is one of the strategies that can be implemented where the pharmacists can visit the patients’ homes to discuss together with their family. Pharmacists are in an ideal position to assess and act on the individual patient’s reasons for returning the medication and to assist in the safe disposal of the unwanted medicines. As poor adherence was related to the presence of an increased number of medicines in homes, it might be improved by reviewing back the medication regimen through the choice of the medication and its dose and frequency (16).

Conclusion

The data on the patients’ adherence and medicine wastage may provide useful information to the Ministry of Health in the selection of first-line medication which has been recommended, based on the need to maintain a patient on a given treatment. The type of the medicines which have been prescribed and the frequency of their doses can influence the patient adherence and consequently, the medication wastage. Pharmacists should clearly explain to the patients as to how to use their drugs and guide them through the initial periods of therapeutic inactivity and transient side-effects. Through patient education and counselling, a pharmacist can help by giving ideas or solutions on how to improve the adherence to the medication.

References

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Financial OR OTHER COMPETING INTERESTS:
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Date of Submission: Dec 08, 2011
Date of Peer Review: Feb 07, 2012
Date of Acceptance: Feb 22, 2012
Date of Publishing: Jun 22, 2012

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