Quality-of-Life Assessment in Musculoskeletal Disorder Patients, Lahore, Pakistan

Introduction

Musculoskeletal disorders comprise over 150 diseases that affect human muscles, joints, and bones. Many factors such as age, occupation, lifestyle, and family history can add to the risk of musculoskeletal disorders. Therefore, early diagnosis and therapy monitoring by healthcare professionals can improve long-term health outcomes. According to World Health Organization (WHO), 1.71 billion people worldwide have musculoskeletal disorders. The prevalence differs with diagnosis and age; 369 million people are affected in South Asia. The cases of Musculoskeletal Disorders (MSDs) in developing countries will increase by 2030  [1].

The prevalence of Musculoskeletal Disorders (MSDs) in poverty-stricken patients in Pakistan is 70% more than that of developed countries. Musculoskeletal disorders increase the incumbent on hospitals and affect the patients’ Quality of life (QOL). Rheumatoid arthritis affects 0.142% of people in South Pakistan [2]. Osteoarthritis affects 80 % of old females and 20 % of old males in Pakistan [3]. Gout affects men four times more than those women in the age group 35-70 [4]. The work-related MSD also contributes 40% of Pakistan's direct and indirect costs [5].

It was observed that medication therapy patterns require improvement in community pharmacy practice. In 2003, the WHO presented guidelines for prescribing analgesic medications to musculoskeletal disorder patients. It is a three-step approach; firstly, prescribe paracetamol, if pain persists, prescribe Non-steroidal Anti-inflammatory Drugs (NSAIDs), and lastly, prescribe an opioid analgesic for severe pain management [6, 7].

Medication non-adherence is a determinant factor for therapy failure in arthritis. Medication refilling, dispensing, and counseling at community pharmacies can influence patient medication adherence [8].

Insufficient knowledge and poor practice of community pharmacists cause ineffective patient counseling. Community pharmacists should attend patient education training programs. They should consult with clinicians to discuss the patient cases to make better patient health outcomes.  There is no study conducted in Pakistan to highlight this issue [9].

In the past, community pharmacy services expanded from providing a traditional dispensing service to patient-focused services. The previous literature supported that community pharmacists had done effective interventions to promote patient health outcomes [10]. In developed countries such as the UK, 89% of the public can access community pharmacies within 20 minutes. While in the emergency, 100% of the patient can influx the pharmacies for pharmaceutical services [11]. The extended pharmaceutical services (EPS) concept is well established in higher-income countries. In Pakistan, the Extended Pharmaceutical Services (EPS) concept is completely new and undefined. The public considers pharmacies as medical stores due to the provision of traditional pharmaceutical services. Counseling services are available in the community pharmacies of big cities [12].

Studies showed the frequency of rheumatic symptoms was distributed evenly between rural and urban communities in northern Pakistan. The metropolitan cities have a 0.5% prevalence rate. The occurrence of Rheumatoid Arthritis (RA) is significantly observed in the representative population of Pakistan. Osteoarthritis (OA) was frequently seen in women, with a 4:1 female-to-male ratio [13]. It was reported that 7.9% of patients with family history, and 90.2% were chronic sufferers of rheumatoid arthritis patients [14]. The drugs most commonly used in these musculoskeletal disorders are Non-steroidal +Anti-inflammatory Drugs (NSAIDs).

This study focuses on rheumatoid arthritis, osteoarthritis, gouty arthritis, and musculoskeletal pain. The main reason to focus on these disorders is the high prevalence rate with negligible pharmacotherapy. Our study targeted multiple community pharmacies in Lahore compared to other countries [15].

Our study aims 1) To analyze the association of patient Quality of Life (QOL) with contributing factors of musculoskeletal disorders. 2)To assess the health outcomes improved by a community pharmacist's knowledge about Musculoskeletal Disorders (MSDs).

Materials and Methods

Study design

A cross-sectional, observational study was performed to evaluate community pharmacists' health outcomes and the medication use pattern in MSD patients from October 2021 to December 2021.

Study setting

A total of 30 Community Pharmacies of Lahore were visited to conduct this study, of which ten pharmacies participated in our research.

Participant inclusion criteria

The study inclusion criteria were patients of different ages, visiting the community pharmacy could be new or chronic illness, having co-morbidities (Hypertension, Diabetes, Cardiovascular, and Mental Problems), and suffering from rheumatoid arthritis, osteoarthritis, gout, and overall body pain.

The population sample size for the study calculated was 227 given by the formula,

whereas Z=Z statistic for a level of confidence = expected prevalence and d = precision with a 10% margin of error, 90% confidence interval, and 70% prevalence rate of musculoskeletal disorders [16].

Data collection

The questionnaire survey forms were distributed among pharmacies. On each visit, the patients were asked to fill out the survey form entirely and accurately without any assistance from the pharmacist. The data form comprised of four parts: I) Patient's demographics, II) Disease information related to MSD, medicines, and any other treatment, III) Patient health-related quality of life, and IV) Community pharmacy practice from the patient's point of view. The study comprised open and close-ended questions. In the disease information section, Q1, Q2, and Q6 were nominal and close-ended questions. The Q3, Q4, and Q5 were nominal and open-ended questions. In the quality-of-life section, Q1 to Q5 were ordinal and close-ended questions. In the Assessment of community pharmacy practice, Q1 and Q5 were open-ended questions while Q2, Q3, and Q4 were nominal and open-ended questions.

Data analysis

Statistical analysis was executed using Statistical Package for the Social Sciences (SPSS) version 26. Descriptive statistics and a chi-square test of independence were used. The study presumed a 90% confidence interval, and a p-value of less than 0.1 was considered significant in statistical analyses.

Results and Discussion

Four hundred patients were communicated, and 281 patients responded with a 70.25% response rate. Patient demographics are presented in Table 1. Table 2 highlights the medication used for rheumatoid arthritis, osteoarthritis, gouty arthritis, and body pain. Patients with various musculoskeletal conditions tended to use more Non-steroidal Anti-inflammatory Drugs (NSAIDs) 15.7% and few anti-gout drugs (0.4%) compared to any other medicines used. Significant differences were observed for single medicine use. Table 3 presents the data on the patient's quality of life assessed using a questionnaire survey, and various outcomes experienced by patients were analyzed.

During The Assessment of Community Pharmacy Practice in 281 patients, 189 (67.3%) patients got the same brand of medicine as prescribed. On the other hand, 92 (32.7%) patients received the medication with alternate brands of lower costs. Only 54 (19.2%) reported the side effects or ADR from the dispensed medicine. Identification of drug therapy problems and treatment changes in musculoskeletal disorders by the community pharmacist is presented in Figure 1. 39 (13.9%) patients responded that pharmacists identified the drug therapy problems in their prescriptions. Out of 281 patients, 67 patients (23.8%) answered that community pharmacists had changed the treatment plan in consultation with their physicians. The 56 patients (19.9%) specified the treatment changes done by the pharmacists. In comparison, no treatment changes were done in the plan of 214 (76.2%) patients. A total of 165 patients (58.7%) pharmacist has done counseling to them. At the same time, no counseling was done to 116 patients (41.3%).

Table 4 displays the association between quality-of-life scoring with different parameters such as population demographics and counseling given by community pharmacists. The males have a relatively poor quality of life (51.2%), moderate quality of life (27.1%), and good quality of life (21.7%) whereas the females have a good quality of life (34.2%), moderate quality of life (39.5%) and poor quality of life (26.3%). The counseling given at community pharmacy (complete counseling about medicine, lifestyle changes, diet changes, refer to other healthcare professionals, no counseling) presents a significant association with quality of life (p<0.05) while age has no significant association with quality of life.

Table 1 shows the Population demographics and Prevalence of the four Musculoskeletal Disorders in males and females. N= number and %= Percentage

Table 2 shows the frequency of medication usage patterns in the four musculoskeletal disorders prescribed by the physician. N= Number of patients, %= Percentage

Table 3 explains the frequency of five Quality of life parameters including Walking ability, Joint/ Muscle Pain, Sleep Pattern, Social Activities, and Daily Routine of the studied population

Figure 1 shows the community pharmacy assessment practice by the Musculoskeletal Disorder patients comprising the identification of drug therapy problems (Yes= 242, No= 39) and treatment changes done by the community pharmacists (Yes=214, No=67) in their prescriptions

Table 4 describes the musculoskeletal disorder population data with three Quality of life Scoring (Poor, Moderate, Good). *p-value based on Chi-square test of independence with gender, education status, employment, marital status, co-morbid conditions, and counseling given at community pharmacies as significant association with quality of life.