Thirteen research domains focused on medication safety and healthcare quality.
SQH, located within Naresuan University's Faculty of Pharmaceutical Sciences, maintains a comprehensive project portfolio focused on medication safety and healthcare quality — organized into thirteen primary research domains.
See Related ResearchMRPs arise from:
We examined the contribution of MRPs to hospital admissions, identified risk factors, and estimated the economic burden to healthcare systems in the UK (Manchester) and lower northern Thailand at different levels — tertiary care, secondary care, primary care, and patients' homes. Around 3–4% of outpatient visits and hospital admissions were considered due to MRPs, of which half were preventable. Misuse, polypharmacy, and comorbidities were independent predictors of severity and mortality, especially for the elderly, and were most commonly associated with cardiovascular and metabolic disease drugs.
We have shown that, across all health care settings, MRPs increase health care costs and risk of harm, particularly for the elderly, with around 40% of incidents being preventable. Health care professionals at all levels need to be vigilant and aware of MRPs and the circumstances that increase their risk. Patient treatments need periodic review, aiming particularly to reduce polypharmacy in the elderly.
ADR frequency, severity, and nature are important considerations for drug therapy. We conducted systematic literature reviews of studies from across the world, in various settings, and pooled the summary data by meta-analysis. 5% of hospital admissions arose from ADRs, especially in the elderly taking cardiovascular drugs. Drug-drug interactions caused ~1% of hospital admissions/visits, where steroidal anti-inflammatories and warfarin were the commonly offending drugs.
Our studies show that ADRs are an important cause of hospital admissions and are particularly high for the elderly. Pharmacists play an important role in minimising ADRs, which is increasingly recognised by the profession and emphasised in undergraduate curricula.
This is a major challenge in chronic diseases, where many treatments are life-long and aim to prevent further deterioration in health (e.g. diabetes and its dependent pathologies) or reduce risk factors for major debilitating events (e.g. vascular disease and obesity). These lifestyle diseases may have no symptoms, so patients feel no improvement that motivates continued drug administration.
Medication non-adherence affects two of five home-dwelling patients, especially those who are elderly. Cardiovascular treatments are most commonly subject to medication non-adherence, and clinicians in primary care should monitor adherence closely in patients at home. We have shown that polypharmacy is an important risk, and pharmacists are positioned to monitor and encourage patients living independently to better adhere to treatments, particularly through pharmacies and carers.
Chronic disease, polypharmacy, and overstretched health care professionals are risks for medication errors. Missing or incorrect medication both have adverse outcomes requiring additional resources, including hospitalisation and burden on carers and their patients. This is a global problem, but how such errors arise depends on local differences in the medication delivery method to patients. Errors can occur at any stage of the medication chain between prescription and administration to the patient.
In district hospitals, we have identified pharmacists as best positioned to intercept and correct such errors after the prescriber, because they are best able to spot discrepancies between the medication in use and the patient's circumstances. We have shown that polypharmacy is an important risk, and pharmacists are positioned to monitor and encourage patients living independently to better adhere to treatments.
Universal health care is common, but few countries have integrated national health databases. However, the UK and Hong Kong have patient health records integrated into single large databases (i.e. "big data"). We have extracted these data sets to perform retrospective correlations between drug use and outcomes from very large cohorts.
We identified 35,000 patients with atrial fibrillation (AF), and a further 49,000 AF patients also prescribed anticoagulants. While 6,000 patients developed dementia over 6 years, this risk was lower with anticoagulants (hazard ratio 0.90; 95% CI 0.85–0.95; p<0.01) or with antiplatelets (HR 0.84; 95% CI 0.79–0.90; p<0.01).
This project demonstrated the value of oral anticoagulants in reducing dementia risk, resolving some of the controversy arising from several small studies in different settings. This, together with the systematic review, adds to the clear conclusion that the benefit of oral anticoagulants is not confined to myocardial infarction.
Pharmacovigilance (PV) is the process that records suspected adverse reactions to drugs after licensing for regular use in humans. It is particularly valuable for detecting drug reactions that are difficult to detect during drug development. National PV systems are commonly operated through the relevant government health ministry. Initially, reporting was through postal lodging of forms describing the details of the patient, drug, and circumstances of the suspected drug reaction; nowadays, reporting is online. Reports are usually made by the doctor, or sometimes the pharmacist. Many national PV databases link to the global WHO Uppsala Monitoring Centre in Sweden. In some countries, reporting is limited due to the time required to provide the necessary information, or ignorance/misunderstanding of the scope of the system. Most government portals restrict access to health professionals and allopathic (synthetic) drugs.
We conducted two surveys of pharmacovigilance:
To our knowledge, the UK "Yellow Card" is the most open system: (a) it encourages consumers who suspect a drug reaction to report online, (b) it provides unfettered public access to all PV summary data for each drug in its database, and (c) the site is easy to find.
Clearly, reporting by consumers of adverse reactions from herbal medicines is poorly catered for in most countries, particularly those regions relying on herbal products for their staple health-care needs. In Thailand, this deficiency in PV reporting has been partly addressed by offering a public reporting system.
We have secured funding to address wider deficiencies in public resources for herbal medicines, recognising that users need more complete information, including about their effectiveness — see here.
This research area is developed in collaboration with our research partners, exploring the genetic factors that influence individual responses to medications and their role in drug-induced adverse reactions.
Chronic pain is one of the most challenging health-care conditions to treat, yet it causes the greatest misery. We conducted a joint survey with a community in Baltimore, USA, of patients aged over 50 years suffering from chronic pain, compared with a township in Thailand. While the cohorts differed, more USA patients suffered from chronic disease, while musculoskeletal pain arising from labouring occupations was dominant among the Thai participants.
Most striking was that none of the 1,500 participants surveyed were prescribed any opioid; instead, most received only NSAIDs for pain relief, consistent with the Thai government's concern about the addiction and misuse of opioids. Despite non-use of opioids, most Thai participants were able to continue independent living despite their disabilities. This appears to reflect greater community and family interaction seen in the semi-urban environment where our cohort lived, and a greater sense of ordained predetermination (Buddhism).
These observations have important implications for pain management in many Western countries, where opioid over-prescribing has created a major health scandal, and point to non-pharmacological solutions for Western sufferers. Further data from this study are under analysis.
A cross-sectional population study using medication record review aimed to examine the prevalence of medication-related problems (MRPs) at a women's correctional institution. Medical records were retrospectively reviewed to identify MRPs according to the guidelines of the Pharmaceutical Care Network Europe (Classification V6.2).
MRPs arose from sub-optimal effects of drug treatment, adverse events likely due to drug-drug interactions, unnecessary drug treatment, and incomplete recording of laboratory tests or medication doses. Most MRPs were caused by inappropriate drug and dose selection, particularly doses that were too low. MRPs were substantial in this correctional-institution setting, particularly relating to the drug-ordering system, incomplete past medical history records, and the limited availability of healthcare providers — leading to unnecessary drug treatment and duplicate or inappropriate drug use.
An improved medication system — including a more robust drug-ordering process, more complete patient medical records, and greater availability of medication experts — is recommended to reduce MRPs in women's correctional institutions. This is one of the few studies to examine medication safety within a correctional-institution setting in Thailand; further analysis of the prevalence data is ongoing.
Thailand has a rich history of traditional medicine, with healers prescribing herbal preparations that are still practiced today. Like traditional Chinese medicine and Ayurveda, these healers apply holistic medicine as written in abundant ancient texts describing the formulations, the conditions for which they are prescribed, and their adverse reactions. The Thai government is promoting their use and commercial exploitation, and aims to incorporate traditional medicine into the national health-care system. Nevertheless, many clinicians who carry ultimate responsibility for their patients remain skeptical about their efficacy and safety.
Evidence-based herbal and alternative medicines. We have conducted systematic reviews on several herbal and alternative medicines. All studies suffered various degrees of weakness in protocol design, conduct, and analysis, as judged by the Cochrane risk-of-bias tool, alongside unclear composition of the medicines and a lack of safety information. Numerous Cochrane reviews of herbal medicines worldwide reach similar conclusions and are not confined to the products we reviewed. It therefore became apparent that classical clinical-trial protocols are an inefficient way of answering key questions about herbal medicines. Furthermore, the government's Department of Traditional Medicine voiced justifiable concern about the high cost of clinical trials.
We increasingly use our own quality-assessment tool, founded on CONSORT reporting requirements, which reveals actual data defects while also applying Cochrane risk-of-bias assessment. Accordingly, our objective and unbiased conclusions find little evidence of either efficacy or safety.
Opinions and experiences of users, community leaders, and health workers in rural eastern Thailand were sought during 2018–19. Information learned from this cohort was that:
Their view about safety therefore appears different from the Western perception that herbal products, being natural, are inherently safe. A short video capturing consumers' own opinions about herbal medicines is also available as part of this work.
These results were somewhat unexpected but nevertheless rational. They prompted us to rethink the objectives of the proposed pharmacovigilance (PV) portal, switching our thinking from the Western view of herbal medicines to the needs around traditional use, about which we have little information.
Data-entry portal. Our consumers were less interested in a PV website — there are already three in Thailand — than in a complete information source about herbal medicines. Given how little is known about herbal use (in what form, how it is used, for what purpose, and what relief is obtained), PV information alone seems insufficient on its own.
Our philosophy for the herbal medicines portal and database is that consumers should feel they are part of a community-wide resource and share in its ownership. Submitting data needs feedback in three forms: (i) a simple text message, (ii) a telephone call from an expert seeking further information, and (iii) an online database query about other users' experiences of the same medicine, or of other medicines.
Smartphones are almost universally available to consumers, and nearly all areas have 3G coverage, with most now having 4G. Web pages for smartphones are highly suited to inputting simple data, while describing symptoms requires more complex dialogue — so balancing enough information to be useful against asking for too much and causing users to drop out is a major concern.
Many potential users aged over 40 have low educational attainment, which makes it challenging to decide the range of information sought, how questions are framed, and the method of data entry. To begin with, we are surveying experts in pharmacovigilance and herbal medicines to build consensus on essential information. We have also surveyed healthcare professionals in Thailand who study, prescribe, or administer herbal medicines, and are preparing to survey international experts.
This research stream focuses on the improvement of healthcare systems and services, and on research into the quality of health care and service delivery.
Media coverage has highlighted our work on improving medication practices among Thai Buddhist monks.
The introduction of new teaching methods in any area of education, including pharmacy, has mainly been based on anecdotal reports. While pharmacoepidemiology teaching is typically classroom-based, we have sought to improve how undergraduates view the importance of pharmacoepidemiology in their professional lives and the role of pharmacy in health care. Accordingly, we introduced a 'practical' class — a hands-on, research-based element — as an educational intervention trial.
(i) Students recruited close relatives with chronic diseases who were taking appropriate pharmaceuticals, and asked them about the difficulties they faced in adhering to their treatments. In class, the data collected by students was correlated, analysed, and summarised as the main outcome. From this, students learned about the process of running a cohort study, while also understanding why patients experience difficulties and lapses in adherence to treatment for chronic diseases.
(ii) The students themselves were participants in the teaching trial, where the primary endpoint was their understanding and knowledge of relevant areas of pharmacoepidemiology, as determined by a classroom-based examination and by student feedback on this teaching approach. Two trials, using different protocols, were run in non-consecutive years, recruiting around 90 students for each trial.
In addition, challenges in pharmacy education prompted us to evaluate our pharmacy curriculum, including a national data collection across all pharmacy schools in Thailand.
We have developed a methodology for quantifying learning, as measured by examinations, that goes beyond anecdotal metrics. Nevertheless, its impact on skills acquisition and professional competence warrants further exploration.
Our research has directly informed national health policy and clinical guidance in Thailand, including the following: