Patient safety in primary health care and polypharmacy: cross-sectional survey among patients with chronic diseases

Araújo, Lorena Ulhôa; Santos, Delba Fonseca; Bodevan, Emerson Cotta; Cruz, Hellen Lilliane da; Souza, Jacqueline de; Silva-Barcellos, Neila Márcia

doi:10.1590/1518-8345.3123.3217

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Revista Latino-Americana de Enfermagem

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Original Article • Rev. Latino-Am. Enfermagem 27 • 2019 • https://doi.org/10.1590/1518-8345.3123.3217 copy

Patient safety in primary health care and polypharmacy: cross-sectional survey among patients with chronic diseases^* * Paper extracted from doctoral dissertation “Avaliação do uso de medicamentos na atenção básica e de aspectos relativos à biofarmácia/bioisenção: uma contribuição à ampliação do acesso aos medicamentos”, presented to Universidade Federal de Ouro Preto, Escola de Farmácia, Ouro Preto, Minas Gerais, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

to characterize and determine the polypharmacy prevalence in patients with chronic diseases and to identify the factors associated, in order to improvement of pharmaceutical care focused on patient safety.

Methods:

cross-sectional study included 558 patients, covered by primary health care, using a household and structured questionnaire. We analyzed the data on polypharmacy and its clinical and socioeconomic factors. Poisson regression analysis with robust variance was applied, with results expressed in prevalence ratio.

Results:

the results showed that polypharmacy (consumption of four or more drugs) was of 37.6%. The prevalence ratio analyses identified independent variables associated with polypharmacy: age (3.05), economic strata (0.33), way of medication acquisition through a combination of out-of-pocket and Brazilian public health system (1.44), diabetes and hypertension (2.11), comorbidities (coronary artery disease 2.26) and hospital admission (1.73). In the analyses, inappropriate medication use of the 278 patients (≥ 65 years) was associated with polypharmacy (prevalence ratio 4.04).

Conclusion:

polypharmacy study becomes an opportunity to guide the strategies for the patient safety to promote the medication without harm in chronic diseases.

Descriptors:
Pharmacoepidemiology; Polypharmacy; Potentially Inappropriate Medication List; Primary Health Care; Patient Safety; Chronic Disease

Variable	%	Polypharmacy		p-value
Variable	%	Yes (n^* * n = number of patients; =210)	No (n^* * n = number of patients; =348)	p-value
Sex				< 0,001^† † Pearson Chi-Square Test;
Female	68,3	79,5	61,5
Male	31,7	20,5	38,5
Age (years)				< 0,001^‡ ‡ Fisher Exact Test; Statistically significant p-value < 0.05;
18-30	1.3	0,0	2,0
31-45	6,6	2,4	9,2
46-60	31,2	26,2	34,2
61-75	42,6	49,0	38,8
≥ 76	18,3	22,4	15,8
Marital status				< 0,001^† † Pearson Chi-Square Test;
Married or cohabiting	58,1	48,1	64,1
Single^§ § Includes unmarried, separated, divorced and widowed;	41,9	51,9	35,9
Economic strata^‖ ‖ Brazil criterion of economic classification				< 0,001^‡ ‡ Fisher Exact Test; Statistically significant p-value < 0.05;
A	0,2	0,5	0,0
B	10,8	5,7	13,8
C	50,3	44,8	53,7
D e E	38,7	49,0	32,5
Education (years)				0,0119^† † Pearson Chi-Square Test;
0-2	31,4	36,2	28,4
3-5	32,9	37,2	30,5
6-8	18,3	15,2	20,1
9-11	9,7	6,2	11,8
≥ 12	7,7	5,2	9,2

Variable	%	Polypharmacy		p-value
Variable	%	Yes (n^* * n = number of patients; =210)	No (n^* * n = number of patients; =348)	p-value
Medication
Way of acquisition				< 0,001^† † Pearson Chi-Square Test; Statistically significant p-value < 0.05;
Out-of-pocket	23,1	21,4	24,1
Out-of-pocket and SUS^‡ ‡ SUS = Brazilian Unified Health System;	10,0	21,9	2,9
SUS^‡ ‡ SUS = Brazilian Unified Health System;	63,8	53,8	69,8
Copayment system^§ § Copayment system - Brazilian Popular Pharmacy;	3,0	2,9	3,2
Self-care				< 0,001^† † Pearson Chi-Square Test; Statistically significant p-value < 0.05;
Yes	90,7	83,3	95,1
No	9,3	16,7	4,9
Diseases				< 0,001^† † Pearson Chi-Square Test; Statistically significant p-value < 0.05;
Hypertension	52,3	34,8	62,9
Diabetes	15,1	9,0	18,7
Diabetes and hypertension	32,6	56,2	18,4
Comorbidities
Stroke				0,0049^† † Pearson Chi-Square Test; Statistically significant p-value < 0.05;
Yes	6,1	10,0	3,7
No	93,9	90,0	96,3
Hypercholesterolemia				0,0026^† † Pearson Chi-Square Test; Statistically significant p-value < 0.05;
Yes	4,1	7,6	2,0
No	95,9	92,4	98,0
Depression				0,0051^† † Pearson Chi-Square Test; Statistically significant p-value < 0.05;
Yes	5,7	9,5	3,4
No	94,3	90,5	96,6
Coronary artery disease				0,0240^‖ ‖ Fisher Exact Test
Yes	2,0	3,8	0,9
No	98,0	96,2	99,1
Acess to medical assistance
Medical consultation (months)				0,0338^† † Pearson Chi-Square Test; Statistically significant p-value < 0.05;
<3	59,3	65,2	55,7
≥3	40,7	34,8	44,3
Hospital admission				< 0,001^† † Pearson Chi-Square Test; Statistically significant p-value < 0.05;
Yes	15,2	26,7	8,3
No	84,8	73,3	91,7
Lifestyle and Health state
Alcohol consumption				< 0,001^† † Pearson Chi-Square Test; Statistically significant p-value < 0.05;
Yes	24,4	15,7	29,6
No	75,6	84,3	70,4
Self-reported health				0,0130^† † Pearson Chi-Square Test; Statistically significant p-value < 0.05;
Good	85,5	80,5	88,5
Poor	14,5	19,5	11,5
Pain / discomfort				< 0,001^† † Pearson Chi-Square Test; Statistically significant p-value < 0.05;
Yes	49,1	58,6	43,4
No	50,9	41,4	56,6

Variable	% of polypharmacy	PR^† † PR = Prevalence ratio;	95%CI^‡ ‡ Confidence interval; Poisson regression, statistically significant p-value < 0.05; Only independent variables with p-value < 0.20 in the univariate analysis were included in the multivariate model;	p-value
Age (years)
18-45	11,4	1,00	-	-
46-60	31,6	2,56	1,25-5,21	< 0,01
61-75	43,3	3,05	1,49-6,24	< 0,01
≥76	46,1	2,73	1,29-5,78	< 0,01
Economic strata^§ § Brazil criterion of economic classification;
A	100,0	1,00	-	-
B	20,0	0,17	0,09-0,31	< 0,001
C	33,5	0,26	0,14-0,49	< 0,001
D and E	47,7	0,33	0,17-0,65	< 0,01
Medication
Way of acquisition
Out-of-pocket	34,9	1,00	-	-
Out-of-pocket and SUS^‖ ‖ SUS = Brazilian Unified Health System	82,1	1,44	1,07-1,94	0,01
Diseases
Hypertension	24,8	1,00	-	-
Diabetes and hypertension	64,8	2,11	1,67-2,66	< 0,001
Comorbidities
Stroke
Yes	61,8	1,64	1,22-2,21	< 0,001
No	36,1	1,00	-	-
Arrhythmia
Yes	58,3	1,56	1,07-2,27	0,02
No	36,7	1,00	-	-
Hypercholesterolemia
Yes	69,6	1,43	1,02-2,01	0,03
No	36,3	1,00	-	-
Coronary artery disease
Yes	72,7	2,26	1,37-3,72	< 0,01
No	36,9	1,00	-	-
Acess to medical assistance
Hospital admission
Yes	65,9	1,73	1,41-2,11	< 0,001
No	32,6	1,00	-	-

Variables	Medication use		PR^† † PR = Prevalence ratio;	95%CI^‡ ‡ Confidence interval; Poisson regression, statistically significant p-value < 0.05	p-value
Variables	Inappropriate (n^* * n = number of patients; = 114)	Appropriate (n^* * n = number of patients; = 164)
Age (years)
65-74	68	100	1,00	-	-
75-84	34	49	1,03	0,80-1,34	0,80
≥85	12	15	1,04	0,68-1,57	0,87
Disease
Hypertension	53	95	1,00	-	-
Diabetes	12	24	0,87	0,61-1,22	0,42
Diabetes and hypertension	49	45	0,91	0,70-1,18	0,49
Comorbidities
Yes	34	25	1,13	0,86-1,47	0,38
No	80	139	1,00	-	-
Polypharmacy
Yes	88	39	4,04	2,76-5,92	< 0,001
No	26	125	1,00	-	-

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[1] Corresponding author: Lorena Ulhôa Araújo. E-mail: loulhoa@yahoo.com.br