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\title{Drug Therapy Problem and Contributing Factors among Ambulatory Hypertensive Patients in Ambo General Hospital, West Shoa, Ethiopia}
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             \author[1]{Gobezie Temesgen  Tegegne}

             \affil[1]{  Ambo University, Ethiopia}

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\date{\small \em Received: 10 April 2015 Accepted: 2 May 2015 Published: 15 May 2015}

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\begin{abstract}
        


Background: Hypertension is the most serious health problems in the world. Though modern medicine can improve the well-being, its benefit can be compromised by drugrelated problems (DTPs).Objective: The objective of the study is to determine both type and number of drug related problems and factors affecting it in Ambo General Hospital.Methods: A hospital based cross -sectional study was conducted. All patients who had contact time during the data collection were included. Trained data collectors collected the data. Result and conclusion:A total of 151 ambulatory hypertensive patients were found during data collection period in Ambo general Hospital. A maximum of 200 drug therapy problems were found. The mean DTP was 1.32 + 0.47. The most common DTP was indication type problems. The maximum number of DTPs was three. None of the independent variable is associated with both presence and number of Drug Therapy Problem.

\end{abstract}


\keywords{drug therapy problem, hypertension, indication.}

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\let\tabcellsep& 	 	 		 
\section[{I. Introduction}]{I. Introduction}\par
ardiovascular diseases (CVDs) remain the biggest cause of death world wide. WHO report (2011) estimated that 17.1 million people die of CVDs each year representing 30\% of all deaths. By 2030, an estimated 23.6 million people will die from CVDs mainly from heart disease and stroke. These are projected to remain the single leading causes of death \hyperref[b0]{(1)}. According to the WHO, cardiovascular diseases will be the major cause for death and disability in India by 2020 \hyperref[b1]{(2,}\hyperref[b2]{3,}\hyperref[b3]{4)}.\par
Hypertension (HTN) or high blood pressure, sometimes called arterial hypertension, is a chronic medical condition in which the blood pressure in the arteries is elevated. Blood pressure is summarized by two measurements, systolic and diastolic, which depend on whether the heart muscle is contracting (systole) or relaxed between beats (diastole). This equals the blood pressure at rest is within the range of 100-140mmHg systolic (top reading) and 60-90mmHg diastolic (bottom reading). High blood pressure is said to be present if it is often at or above 140/90 mmHg.\par
The Prevalence of hypertension was 19.04\%. Given that the burden of CVD morbidity and mortality is projected to increase in developing countries, therefore it is essential to provide current reliable data on the epidemiology of hypertension.\par
The first lines of treatment for hypertension are preventive lifestyle changes include: dietary changes, physical exercise, and weight loss. These have all been shown to significantly reduce blood pressure in people with hypertension. If hypertension is high enough to justify immediate use of medications, lifestyle changes are still recommended in conjunction with medication. Therefore, more than one anti-hypertensives might be used. The most common class of anti-hypertensives are calcium channel blockers, angiotensin convertase enzyme blockers, diuretics and beta blockers.\par
Although pharmacotherapy in cardiovascular diseases can improve the well-being, its benefit can be compromised by drug-related problems (DTPs). A drugrelated problem is any event or circumstance involving drug treatment that interferes with the outcome of medical care \hyperref[b4]{(5)}. They pose significant risk, leading to significant morbidity and mortality. Here in this study, type and number of drug therapy problems (DTP) and predictors for it will be assessed. 
\section[{a) Statements of the problem}]{a) Statements of the problem}\par
High blood pressure is widely prevalent in Addis Ababa and may represent a silent epidemic in this population. Overweight, obesity and physical inactivity are important determinants of high blood pressure. There is an urgent need for strategies and programs to prevent and control high blood pressure, and promote healthy lifestyle behaviors primarily among the urban populations of Ethiopia.\par
The burden of this disease is high encompassing economic, psychosocial, and, personal loss to self, family, or immediate community. The cost of illness may be reflected in absenteeism, low productivity, high cost for medical care, and low quality life. These resulted in negative outcome on the socioeconomic status of the country in general.\par
Hypertension is a risk factor for all clinical manifestations of atherosclerosis It is also an independent predisposing factor for heart failure, coronary artery disease, stroke, renal disease, and peripheral arterial disease. It is the most important risk factor for cardiovascular morbidity and mortality, in the world.\par
Many studies have proven the significance of pharmacists in identifying and resolving potential DTPs through timely interventions. Studies assessing the magnitude of DTPs in hospitalized patients and contributing factors are scarce in Ethiopia. 
\section[{II. Significance of the Study}]{II. Significance of the Study}\par
It would be much better to prevent drug related problems than to correct them, but this is not always possible because of the complexity of pharmacotherapy. A more comprehensive study of DRPs in hospitalized patients should be done to provide valuable insights for the healthcare professionals to reduce the incidence of DRPs and the result can also be used as a base line information to establish, since it is an emerging concept on safe use of medication in the health care management. 
\section[{III. Objectives a) General Objectives}]{III. Objectives a) General Objectives}\par
To determine presence of drug related problems among ambulatory hypertensive patient in Ambo General Hospital from April to May 2014.  
\section[{a) The Study area and period}]{a) The Study area and period}\par
This study was conducted from April to May 2014 in Ambo Hospital. This hospital is found in Ambo town Oromia regional state which is located at 114 km away from the capital city of Ethiopia Addis Abebe to the west. People around ambo zone use this general hospital. It has four major wards (internal medicine, gynecology, surgery, and pediatrics). 
\section[{b) Study design}]{b) Study design}\par
Descriptive Cross-sectional studies were conducted in Ambo General Hospital. 
\section[{c) Study Population}]{c) Study Population}\par
All patients receiving anti-hypertensive drugs were included in the study.\par
i The structured questionnaires were used. It contains socio-demographic characteristics, medical and drug condition. The trained data collectors were used to collect the data from patient card and patient him/herself during data collection period.\par
i. Data Analysis All data were cleaned, coded and entered in SPSS version 20. Descriptive, logistic and leaner regressions were used. P< 0.05 is considered to be significant. 
\section[{f) Ethical consideration}]{f) Ethical consideration}\par
Formal letter was obtained from Research Ethics Committee of Ambo University and submitted to Ambo General Hospital, so the letter was given to the hospitals and they allowed us to do the research. Written consent was taken so that the patient was willing to give his/her medical information. 
\section[{g) Operational definition}]{g) Operational definition}\par
Drug therapy problem: involves indication, safety and effectiveness related problem. 
\section[{V. Results}]{V. Results} 
\section[{a) Socio demographic characteristics}]{a) Socio demographic characteristics}\par
A total of 151 patients were encountered during data collection period. 63 (41.7\%) of them were males. 82(54.3\%) and 41(27.15\%) were treated by double and triple therapy respectively.  From the recommended drugs Hydrchlothiazid (108(71.5\%)), Nifidipne (87(57\%)), and Enalapril (66(43.7\%)) were the commonly used drugs. 
\section[{d) Drug therapy problems}]{d) Drug therapy problems}\par
The mean of drug therapy problems is 1.32 + 0.47 and the total numbers of drug therapy problems were 200. Most patients had one drug therapy problem. The most common DTP was indication related problem.    
\section[{VI. Discussion}]{VI. Discussion}\par
Most hypertensive patients had DTP, which is consistent with the study done on Felege Hiwot referral Hospital. There were 200 numbers of DTPs, on the other hand relatively lesser number of DTPs (105) was found in the study done in Felege Hiwot referral Hospital. \hyperref[b5]{[6,}\hyperref[b8]{9]} The number of DTP per patient was 1.32 + 0.47, while study in Jimma showed it was 1.8 + 0.8, relatively higher. This might be due to the fact that the study in JUSH includes all medical patients. \hyperref[b8]{[9]} The most common DTP was indication problem, which is similar to study done in Felege Hiwot referral Hospital while different from study done in India \hyperref[b6]{[7,}\hyperref[b8]{9,}\hyperref[b9]{10,}\hyperref[b10]{11]}. Of the total type of Drug therapy problems, most frequently found was unnecessary drug therapy (24.5\%) and need for additional (31, 20.53\%). On the other hand the study done in India showed, doserelated problems (35.1\%) followed by need for additional drugs (19.7\%), and unnecessary drugs (16.7\%) were the common DTP. \hyperref[b6]{[7,}\hyperref[b8]{9]} In this study, age (p = 0.231), sex (p= 0.395), and number of medication (p=0.085) were not associated with presence of Drug Therapy Problem. Sex (p=0.232), age (p=0.45), and number of medication (p= 0.724) were not associated with number of DTPs. On the other hand the study done in India showed age and number of DTP had significant association, these might be due to here in this study there were lesser number of patients with co-morbidities. \hyperref[b6]{[7]}  
\section[{VII. Conclusion}]{VII. Conclusion}\par
High proportion of patients in Ambo General Hospital had DTPs. The most common DTP was indication type problems. The maximum number of DTPs was three. Age, sex, and number of medication were not associated with presence of Drug Therapy Problem, as well as sex, age, and number of medication were not associated with number of DTPs. 
\section[{VIII. Recommendation}]{VIII. Recommendation}\par
The following recommendations are forwarded: Ambo general hospital: to develop team work among health care professionals.\par
Ambo general hospital pharmacists: to strengthen pharmaceutical care Ambo general hospital physician: to stick them selves to the current guideline IX.\par
We are very grateful to our college staff members for their constructive suggestions starting from the stage of proposal development. Finally our deepest gratitude goes to Ambo General Hospital staff workers who helped and allowed us in collecting and gathering data from the hospital. Finally we thank all hypertensive patients in Ambo General Hospital. 
\section[{Conflict of interest}]{Conflict of interest}\par
The author(s) declare(s) that there is no conflict of interests regarding the publication of this manuscript.\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}}\end{figure}
  \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.85\textwidth}}
d) Sample size and sampling technique\\
All patients who had visit during the data\\
collection period were included. The sampling technique\\
used was every other patient.\\
i. Study Variable\\
a. Dependent\\
Drug therapy problems\\
b. Independent\\
? Age\\
? Sex\\
? Number of drugs\\
? Co morbidity\\
e) Data collection procedures\end{longtable} \par
 
\caption{\label{tab_0}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.85\textwidth}}
b) Blood pressure measurement\\
The mean systolic and diastolic blood pressure was 134.67 + 18.24 and 85. 56 + 10.75 mm Hg\\
respectively.\end{longtable} \par
 
\caption{\label{tab_1}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.23736122971818957\textwidth}P{0.08928266438941075\textwidth}P{0.0029035012809564475\textwidth}P{0.454397950469684\textwidth}P{0.06605465414175918\textwidth}}
Drug therapy problems\tabcellsep \tabcellsep \tabcellsep Reasons\tabcellsep Number of\\
involved\tabcellsep \tabcellsep \tabcellsep \tabcellsep patient (\%)\\
\tabcellsep \tabcellsep \tabcellsep No medical condition\tabcellsep -\\
\tabcellsep Unnecessary\tabcellsep drug\tabcellsep Duplicate therapy\tabcellsep 37(24.5)\\
Indication\tabcellsep therapy\tabcellsep \tabcellsep Non-drug therapy indicated\tabcellsep -\\
\tabcellsep \tabcellsep \tabcellsep Treating avoidable ADR\tabcellsep -\\
\tabcellsep \tabcellsep \tabcellsep Addictive or Recreational drugs\tabcellsep -\\
\tabcellsep \tabcellsep \tabcellsep Untreated indication\tabcellsep 24(15.89)\\
\tabcellsep \multicolumn{2}{l}{Needs additional drug}\tabcellsep Preventive or prophylactic\tabcellsep -\\
\tabcellsep therapy\tabcellsep \tabcellsep Synergistic or potentiating\tabcellsep -\\
\tabcellsep \tabcellsep \tabcellsep More effective drug available\tabcellsep 7(4.64)\\
\tabcellsep \multicolumn{2}{l}{Needs different drug}\tabcellsep Condition refractory to drugs\tabcellsep -\\
\tabcellsep product\tabcellsep \tabcellsep Dosage form inappropriate\tabcellsep -\\
Effectiveness\tabcellsep \tabcellsep \tabcellsep Not effective for condition\tabcellsep 11(7.23)\\
\tabcellsep \tabcellsep \tabcellsep Wrong dose\tabcellsep -\\
\tabcellsep Dosage too low\tabcellsep \tabcellsep Frequency inappropriate\tabcellsep -\\
\tabcellsep \tabcellsep \tabcellsep Drug interaction\tabcellsep -\\
\tabcellsep \tabcellsep \tabcellsep Duration inappropriate\tabcellsep 24(15.89)\\
\tabcellsep \tabcellsep \tabcellsep Undesirable effect\tabcellsep 15(9.93)\\
\tabcellsep \tabcellsep \tabcellsep Unsafe drug for patient\tabcellsep -\\
\tabcellsep \tabcellsep \tabcellsep Drug interaction\tabcellsep -\\
\tabcellsep \multicolumn{2}{l}{Adverse drug reaction}\tabcellsep Dosage administered or changed too rapidly\tabcellsep -\\
\tabcellsep \tabcellsep \tabcellsep Allergic reactions\tabcellsep -\\
Safety\tabcellsep \tabcellsep \tabcellsep Contraindication present\tabcellsep -\\
\tabcellsep \tabcellsep \tabcellsep Wrong dose\tabcellsep -\\
\tabcellsep \tabcellsep \tabcellsep Frequency inappropriate\tabcellsep -\\
\tabcellsep \tabcellsep \tabcellsep Dose too high\tabcellsep -\\
\tabcellsep Dosage too high\tabcellsep \tabcellsep Duration inappropriate\\
\tabcellsep \tabcellsep \tabcellsep Drug interaction\tabcellsep -\\
\tabcellsep \tabcellsep \tabcellsep Incorrect administration\tabcellsep -\\
\multicolumn{2}{l}{e) Factors Affecting Drug Therapy Problems}\tabcellsep \tabcellsep \\
\multicolumn{4}{l}{Age (p = 0.231), sex (p= 0.395), and number}\\
\multicolumn{4}{l}{of medication (p=0.085) were not associated with}\\
\multicolumn{2}{l}{presence of Drug Therapy Problem.}\tabcellsep \tabcellsep \\
\multicolumn{4}{l}{Sex (p=0.232), age (p=0.45), and number of}\\
\multicolumn{4}{l}{medication (p= 0.724) were not associated with number}\\
of DTPs.\tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_3}Table 2 :}\end{figure}
 		 		\backmatter   			 
\subsection[{Acknowledgement}]{Acknowledgement} 
\subsection[{This page is intentionally left blank}]{This page is intentionally left blank} 
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