Abdelbary et al. BMC Geriatrics
(2023) 23:377
https://doi.org/10.1186/s12877-023-04062-2
BMC Geriatrics
Open Access
RESEARCH
Implications of the medication regimen
complexity index score on hospital
readmissions in elderly patients with heart
failure: a retrospective cohort study
Asmaa Abdelbary1, Rasha Kaddoura2, Sara Al Balushi2, Shiema Ahmed3, Richard Galvez2, Afif Ahmed4,
Abdulqadir J. Nashwan5*, Shaikha Alnaimi4, Moza Al Hail4 and Salah Elbdri6
Abstract
Background The likelihood of elderly patients with heart failure (HF) being readmitted to the hospital is higher if
they have a higher medication regimen complexity index (MRCI) compared to those with a lower MRCI. The objective
of this study was to investigate whether there is a correlation between the MRCI score and the frequency of hospital
readmissions (30-day, 90-day, and 1-year) among elderly patients with HF.
Methods In this single-center retrospective cohort study, MRCI scores were calculated using a well-established
tool. Patients were categorized into high (≥ 15) or low (< 15) MRCI score groups. The primary outcome examined
the association between MRCI scores and 30-day hospital readmission rates. Secondary outcomes included the
relationships between MRCI scores and 90-day readmission, one-year readmission, and mortality rates. Multivariate
logistic regression was employed to assess the 30- and 90-day readmission rates, while Kaplan-Meier analysis was
utilized to plot mortality.
Results A total of 150 patients were included. The mean MRCI score for all patients was 33.43. 90% of patients had
a high score. There was no link between a high MCRI score and a high 30-day readmission rate (OR 1.02; 95% CI
0.99–1.05; p < 0.13). A high MCRI score was associated with an initial significant increase in the 90-day readmission
rate (odd ratio, 1.03; 95% CI, 1.00-1.07; p < 0.022), but not after adjusting for independent factors (odd ratio, 0.99; 95%
CI, 0.95–1.03; p < 0.487). There was no significant difference between high and low MRCI scores in their one-year
readmission rate.
Conclusion The study’s results indicate that there is no correlation between a higher MRCI score and the rates of
hospital readmission or mortality among elderly patients with HF. Therefore, it can be concluded that the medication
regimen complexity index does not appear to be a significant predictor of hospital readmission or mortality in this
population.
Keywords Elderly, Heart failure, Medication regimen complexity, Polypharmacy
*Correspondence:
Abdulqadir J. Nashwan
anashwan@hamad.qa
Full list of author information is available at the end of the article
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,
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in this article, unless otherwise stated in a credit line to the data.
Abdelbary et al. BMC Geriatrics
(2023) 23:377
Introduction
Early readmissions are common among patients hospitalized with heart failure (HF), with majority of readmissions are due to causes other than HF [1]. After an index
hospitalization with HF, 30- and 90-day readmissions for
HF and all-cause mortality had increased [2]. The rates
of HF rehospitalization were estimated as 18% and 40%
and the rates of cumulative mortalitywere 13% and 20%
at 3 and 12 months, respectively, in seven Middle Eastern
countries including Qatar [3]. Risk factors for HF readmissions are multifactorial; with some deemed modifiable [4, 5]. Medications-related problems such as number
of medications, are one of those risk factors which are
associated with unplanned hospital readmissions in
elderly HF patients [6, 7]. Polypharmacy, defined as taking five or more medications, is only one element of medication regimen complexity [8]. Other elements that can
contribute to regimen complexity include the multiple
characteristics of the prescribed regimen and its other
related factors such as medication administration, number of different dosage forms, dosing frequencies, and
special instructions for medication use. Consequently,
patient’s adherence to medication intake can negatively
be affected [9, 10]. The validated tool known as Medication Regimen Complexity Index (MRCI) comprises 65
items that evaluate the dosage forms, dosing frequencies, and supplementary instructions for each medication
administered [11]. Several studies have suggested that the
complexity of medication regimens and accompanying
instructions can result in medication errors and unfavorable clinical outcomes. As a result, some researchers have
proposed that MRCI may be a useful tool for predicting
adverse clinical outcomes, surpassing the simple medication count [12]. The validity of the MRCI tool is deemed
satisfactory, and its reliability in evaluating medication
regimen complexity has been established in both heart
failure (HF) and chronic obstructive pulmonary disease
(COPD) [13, 14]. The current evidence on the impact of
MRCI use on patients’ clinical outcomes is inconclusive
and had shown inconsistent results [15]. Some studies
had confirmed an association between MRCI and hospital readmissions [16–20], while other studies had failed
to prove the same finding [21, 22]. In the State of Qatar,
31.4% of the population are elderly (i.e., age above 65
years old) as per the 2018 published statistics [23], suggesting higher risk of cardiovascular diseases occurring
among Qatari older population [24]. Thus, the management of cardiac conditions, such as HF, can be more
challenging to the health care system due to multiple
co-morbidities, frailty, and polypharmacy [25–27]. The
prevalence of polypharmacy and potentially inappropriate medications among Qatari elderly patients is high [28,
29]. A study that investigated the prevalence of polypharmacy in elderly patients with cardiovascular diseases,
Page 2 of 8
found that its prevalence rates ranged from 17.2 to 88.6%
in Qatar and the Middle East and North Africa region
[30]and it is negatively affecting our elderly population
[32]. The aim of the present study is to determine the
association between the MRCI scores and hospital readmission and mortality rates in elderly patients with HF.
Methods
This is a single-center retrospective cohort study conducted at the Heart Hospital, a tertiary hospital affiliated
with Hamad Medical Corporation in Qatar. The study
site is an ambulatory advanced HF clinic, established in
2015, that provides specialized multidisciplinary care
and follow-up for patients with HF. The protocol was
approved by the corporation’s Medical Research Center (MRC-01-20-025) in September 2020. The patients’
data review and collection began in October 2020 and
lasted for three months. Patients were identified and
randomly selected from the clinic’s electronic database
between January 1 and December 31, 2018, and were followed for up to 12 months. Patients were eligible if they
were 65 years or older and were referred to the clinic
after being discharged from the hospital with a diagnosis of decompensated or acute HF exacerbation. Exclusion criteria included emergency visits, admission not
related to decompensated HF, discharge against medical advice, and when the medication list was inaccessible. The index discharge date, defined as the date of
hospital discharge before the first visit to the HF clinic,
was the starting point for the screening of the discharge
medication list from electronic medical records. The
MRCI score was manually calculated by independent
investigators for the eligible patients using a validated
tool which was published by George et al. in 2004 [11].
Every third patient was selected from the electronic database, until reaching the planned number of 150 patients.
The tool has three sections (A, B and C). In Section A,
higher weights are assigned to medications with inconvenient dosage forms or more difficult to administer
(e.g., an oral tablet receives 1 point while a metered-dose
inhaler receives 4 points). In Section B, medications that
are administered more frequently or at more strict time
intervals receive more points (e.g., “twice daily” receives
2 points, while “every 12 h” receives 2.5 points). Finally,
in Section C, further points are assigned if the medication regimen indicates any additional instructions such as
“break/crush tablet” (1 point) or “taper dose as directed”
(2 points) [11]. Patients were stratified into patients with
low (< 15) or high (≥ 15) MRCI score. The cut-off score of
15 was reported to be linked to hospital readmission [15,
16]. The primary outcome of this study is to determine
the association between the MRCI score, and the hospital readmission rates in elderly HF patients. The 30-day
readmission rate was counted from the index discharge
Abdelbary et al. BMC Geriatrics
(2023) 23:377
date until hospital readmission. The secondary outcomes
included MRCI association with 90-day readmission rate,
number of readmissions and one-year mortality rate.
Statistical analysis
A sample size of 150 patients was calculated based on a
previous study in which the odds of having MRCI score
of ≥ 15 was higher by 62% among patients who were readmitted to hospital within 30 days of discharge [18]. A cutpoint of 15 for MRCI was used to dichotomize the score.
Baseline characteristics of the participants were tabulated
using proportions (percentages) for categorical variables
and mean for continuous variables. The variables including etiology of HF, ejection fraction, diabetes mellitus,
chronic kidney disease, Charlson score, and total number
of medications were considered clinically important as
per the literature review. Readmission rates (30-day and
90-day) were evaluated by purposeful model building of
a multivariate logistic regression to adjust for the independent variables. The model was validated by correctly
assessing classified predictions, ROC curve andHosmerLemeshow and Pearson Chi-square goodness of fit tests.
The number of readmissions was evaluated by Poisson
regression to adjust for the independent variables. Mortality was analyzed by chi-square test of independence.
All tests were two-sided, with B set at 80% and a P‐value
of < 0.05 to be considered significant. All statistical analysis was performed using Stata/SE 14.2. An online software calculator was used to determine the sample size
with margin of error of 5% (significance level = 0.5) [32].
Results
A total of 150 patients were included in this study. The
mean age was 74.4 (standard deviation (SD) 6.29) years
old, and 82 (54.67%) of the patients were males, 81 (54%)
were Qatari and 69 (46%) were of other nationalities. The
mean MRCI score of all patients was 33.43 (SD 15.47).
Most of the patients (90%) had high MRCI (≥ 15) scores
and 88% were using ≥ 10 medications. The baseline characteristics are described in Table 1. The 30- and 90-day
re-admission rates in the high MRCI group were 14%
(P = 0.120) and 15% (P = 0.109), respectively, as compared with no re-admissions in the low MRCI group at
both follow-up periods. Mortality was not significantly
higher among patients with high MRCI score (30% versus 13%, P = 0.182) (Table 2). The univariate analysis did
not show a significant association between MRCI score
and the 30-day re-admission rate (odds ratio, 1.02; 95%
CI 0.99–1.05; P = 0.13) even after adjusting for all the
independent factors (Table 3). Although the univariate analysis showed a significantly slight increase in the
90-day re-admission rate with high MRCI score (odds
ratio, 1.03; 95% CI, 1.00–1.07; P = 0.022), there was no
significant association after adjusting for the independent
Page 3 of 8
factors (Table 4). The number of re-admissions, using
Poisson regression, was significantly higher in those with
high MRCI score (odds ratio, 1.011; 95% CI, 1.001–1.018;
P = 0.001), but not after adjusting for other factors (odds
ratio, 1.006; 95% CI, 0.999–1.014; P = 0.093) (Table 5).
Deaths during the follow-up period are plotted for both
patients with low and high MRCI scores using KaplanMeier time-to-event curve in Supplementary Fig. 1. An
exploratory analysis was conducted using MRCI score
of 30.5 (the median) as the cut-off point to dichotomize
the groups to low (N = 72) and high (N = 78) MRCI scores.
Results were comparable with no significant differences
between the exploratory cohorts.
Discussion
This study did not show an association between the
MRCI score and hospital readmissions, total number of
admissions or mortality. High MRCI scores in patients
with chronic kidney disease and dialysis were initially
associated with 90 days readmission using univariate
analysis, but after using multivariate logistic regression,
there was no significant association. The total number of
readmissions within 12 months was initially significantly
higher in those with high MRCI and elevated Charlson
comorbidity index and polypharmacy compared to those
with low MRCI, and it was more predominant among the
Qatari population compared to other nationalities, but
again this was non-significant after adjusting other variables. In our study, although the mortality rate was not
statistically significantly higher in the high MRCI group,
it may be of clinical significance, which may confirm the
results of the previously published study that concluded
higher survival rate in elderly patients with simplified
regimen compared to those with complex regimen [33].
The previously published studies investigating MRCI had
focused on elderly patients with multiple co-morbidities, polypharmacy, and subsequently higher medication regimen complexity [34, 35]. This was demonstrated
in our population of this study and in similar studies
done before, indicating that polypharmacy is prevalent
in elderly population in Qatar [30, 31]. While hospital
readmission was one of the most common health care
outcomes studied in association with the MRCI score,
data showed mixed results. Our finding is opposing
the predictive association that was confirmed by some
studies [16–20], but consistent with the results of other
studies [21, 22]. For example, Yam and his colleagues
concluded that medication modification upon hospital
discharge for elderly HF patients usually results in subsequent increase in mean MRCI by 50% and it is harmless [22]. The lack of association between high MRCI
scores and hospital re-admissions may indicate that even
elderly population with relatively simple medication regimens, still need to be supported with their medication
Abdelbary et al. BMC Geriatrics
(2023) 23:377
Page 4 of 8
Table 1 Baseline characteristics of patients
Characteristic
Overall
Low MRCI score
N = 15
Age, mean (SD)
Male, no. (%)
Qatari nationality, no. (%)
Marital status, no. (%)
Married
Divorced
Widowed
Unknown
Smoking status, no. (%)
Smoker
Ex-smoker
Never
Unknown
MRCI score, mean (SD)
74.4 (6.3)
82 (54.7)
81(54)
73.2 (4.5)
9 (60)
4 (26.7)
High
MRCI
score
N = 135
74.5 (6.5)
73 (54)
77 (57)
131 (87.3)
1 (0.7)
7 (4.7)
11 (7.3)
12 (80)
0 (0)
1 (6. 7)
2 (13.3)
119 (88.2)
1 (0.7)
6 (4.4)
9 (6.7)
9 (6)
23 (15.3)
55 (36. 7)
63 (42)
33.43 (15.5)
2 (13.3)
1 (6. 7)
5 (33.3)
7 (46.7)
11.9 (2.5)
7 (5.2)
22 (16.3)
50 (37)
56 (41.5)
35.81
(14.4)
108 (72)
10 (66.7)
98 (72.6)
11 (7.3)
52 (34.7)
87 (58)
1 (6.7)
4 (26.7)
10 (66.7)
10 (7.4)
48 (35.6)
77 (57)
124 (82.7)
139 (92.7)
56 (37.3)
80 (53.3)
7 (4.7)
7 (4.7)
18 (12)
14 (9.3)
1 (0. 7)
25 (16. 7)
7.95 (2.4)
10 (66.7)
14 (93. 3)
1 (6.7)
7 (46.7)
1 (6.7)
0 (0)
3 (20)
2 (13.3)
0 (0)
0 (0)
6.8 (1.9)
114 (84.4)
125 (92.6)
55 (40.7)
73 (54.1)
6 (4.4)
7 (5.2)
15 (11.1)
12 (8.9)
1 (0.7)
25 (18.5)
8.1(2.5)
4 (2.7)
14 (9.3)
132 (88)
4 (26. 7)
8 (53.3)
3 (20)
0 (0)
6 (4.4)
129 (95.6)
HF etiology, no. (%)
ICM
HF, no. (%)
HFmEF
HFpEF
HFrEF
Co-morbidities, no. (%)
Diabetes mellitus
Hypertension
Respiratory disease
CKD or any kidney disease
On dialysis
Chronic liver disease
Cancer
Solid tumor
Leukemia
Cerebrovascular disease
Charlson Score, mean (SD)
Total number of medications, no. (%)
≥5
≥7
≥ 10
CKD: Chronic kidney disease, HF: Heart failure, HFmEF: Heart failure with mid-range ejection fraction, HFpEF: Heart failure with preserved ejection fraction, HFrEF:
Heart failure with reduced ejection fraction, ICM: Ischemic cardiomyopathy, MRCI: Medical regimen complexity index, SD: Standard deviation
Table 2 Outcomes according to MRCI score
Outcome, no. (%)
30-Day readmission
90-Day readmission
Mortality
MRCI: Medical regimen index
Low MRCI
(n = 15)
0 (0%)
0 (0%)
2 (13%)
High MRCI
(n = 135)
19 (14%)
20 (15%)
40 (30%)
P value
P = 0.120
P = 0.109
P = 0.182
management. Of note, there are some factors that could
have contributed to our findings but were not addressed
by the MRCI score itself. Those may include socioeconomic and environmental factors. For instance, factors
like having a competent care giver which can be either a
vigilant family member or a licensed nurse practitioner
who usually has adequate health literacy [37]. Nonetheless, it is unclear whether this applies to our study population since the majority of our patient are Qatari who are
eligible to receive support from the government which
often includes licensed nurses. Additionally, the setting
Abdelbary et al. BMC Geriatrics
(2023) 23:377
Page 5 of 8
Table 3 Univariate and multivariate analyses of 30-day re-admission
Characteristic
Unadjusted OR (95% CI)
P value
Adjusted OR (95% CI)
MRCI score
HF etiology
ICM
NICM
HF
HFmEF
HFpEF
HFrEF
Diabetes mellitus
CKD or any kidney disease
Charlson score
1.02 (0.99–1.05)
0.13
1.01 (0.98–1.05)
P
value
0.430
Ref
1.22 (0.08–0.24)
0.71
0.92 (0.3–2.90)
0.882
Ref
1.21 (0.23–6.42)
0.33 (0.06–1.9)
1.9 (0.41 − 0.35)
1.24 (0.47–3.27)
1.09 (0.9–1.32)
0.825
0.216
0.409
0.670
0.370
1.03(0.17–6.17)
0.26 (0.043–1.57)
1.28 (0.24–6.93)
0.823 (0.22–3.08)
1.13 (0.87–1.48)
0.942
0.142
0.744
0.773
0.361
CI: confidence interval, CKD: Chronic kidney disease, HF: Heart failure, HFmEF: Heart failure with mid-range ejection fraction, HFpEF: Heart failure with preserved
ejection fraction, HFrEF: Heart failure with reduced ejection fraction, ICM: Ischemic cardiomyopathy, NICM: Non ischemic cardiomyopathy, MRCI: Medical regimen
complexity index, OR: odds ratio, SD: Standard deviation
Table 4 Univariate and multivariate analyses of 90-day re-admission
Characteristic
Unadjusted OR (95% CI)
P value
Adjusted OR (95% CI)
MRCI score
HF etiology
ICM
NICM
HF
HFmEF
HFpEF
HFrEF
Diabetes mellitus
CKD or Any kidney disease
On dialysis
Charlson score
1.03 (1.00–1.07)
0.022
1.03 (0.99–1.06)
P
value
0.103
Ref
1.88 (0.71–5.00)
0.204
2.24 (0.72–6.96)
0.162
Ref
1.56 (0.17–14.10)
1.6 (0.19–13.65)
2.04 (0.44–9.38)
3 (1.03–8.74)
10.58 (2.17–51.62)
1.18 (0.98–1.43)
0.825
0.667
0.361
0.044
0.004
0.081
0.58 (0.05–6.46)
1.13 (0.122–10.41)
0.78 (0.14–4.38)
2.71 (0.69–10.63)
4.49 (0.55–36.87)
1.05 (0.75–1.46)
0.659
0.915
0.777
0.153
0.162
0.778
CI: confidence interval, CKD: Chronic kidney disease, HF: Heart failure, HFmEF: Heart failure with mid-range ejection fraction, HFpEF: Heart failure with preserved
ejection fraction, HFrEF: Heart failure with reduced ejection fraction, ICM: Ischemic cardiomyopathy, MRCI: Medical regimen complexity index, NICM: Non ischemic
cardiomyopathy, OR: odds ratio, SD: Standard Deviation
in which the study was done may have contributed to
the results as well. In Qatar, the elderly population with
multiple comorbidities are serviced by the Home Health
Care (HHC) service which provides multidisciplinary
care in the community. Additionally, in our population,
clinical pharmacy services are prominent upon discharge
delivering the education needed to ensure safe and effective medications use. The number of co-morbidities that
elderly HF patients usually have is another factor that
was not addressed by MRCI tool and can directly impact
clinical outcomes. Finally, the high-risk medications, as
it was found that some medications are highly associated
with hospital re-admissions in elderly population compared to other medications [38].
Strengths
To the best of our knowledge, this is the first study in
Qatar and the Middle East that investigated the relationship between MRCI score and important clinical
outcomes in elderly patients with HF. We had used a validated tool, i.e., MRCI, calculated the sample size based
on earlier and previously published research, and manually retrieved data from electronic health records by four
experienced pharmacists to reduce likelihood of errors.
Limitations
The study’s limitations include its retrospective design
and observational nature, which precluded the examination of crucial factors influencing rehospitalization and
medication adherence, such as patient cognition, dependence levels, caregiver availability, caregiver burden, and
other geriatric syndromes. The patient recruitment from
an advanced HF clinic, known for high-quality care,
and the exclusion of emergency department visits may
have positively influenced the clinical outcomes. Potential biases, such as information bias from manual MRCI
score calculation and lack of interrater reliability testing, as well as performance bias from differential care or
Abdelbary et al. BMC Geriatrics
(2023) 23:377
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Table 5 Univariate and multivariate analyses for number of re-admissions
Characteristic
Unadjusted IRR (95% CI)
P value
Adjusted IRR (95% CI)
Age
Male
Nationality
Non-Qatari
Qatari
MRCI score
HF etiology
ICM
NICM
HF
HFmEF
HFpEF
HFrEF
Diabetes mellitus
CKD or any kidney disease
Charlson score
Total number of medications
≥5
≥7
≥ 10
0.99 (0.98–1.07)
0.72 (0.581–0.91)
0.778
0.004
0.96 (0.87–1.06)
0.734 (0.586–0.918)
P
value
0.391
0.007
Ref
2.909 (0.999–8.472)
1.011 (1.001–1.018)
0.050
0.001
3.56 (0.95–13.40)
1.006 (0.999–1.014)
0.060
0.093
Ref
0.929 (0.732–1.779)
0.541
0.849 (0.654–1.102)
0.219
Ref
2.294 (1.726–3.051)
1.838 (1.455–2.323)
1.463 (1.141–1.876)
1.126 (0.892–1.421)
1.045 (1.003–1.089)
0.001
0.001
0.003
0.318
0.037
2.11 (1.504–2.972)
1.748 (1.333–2.292)
1.229 (0.980–1.541)
1.008 (0.753–1.349)
1.020 (0.964–1.079)
0.001
0.001
0.075
0.957
0.500
0.001
0.003
0.797 (0.443–1.434)
0.792 (0.538–1.166)
0.450
0.237
0.521 (0.363–0.747)
0.625 (0.457–0.854)
Ref
CKD: Chronic kidney disease, HF: Heart failure, HFmEF: Heart failure with mid-range ejection fraction, HFpEF: Heart failure with preserved ejection fraction, HFrEF:
Heart failure with reduced ejection fraction, ICM: Ischemic cardiomyopathy, IRR: Incidence rate ratio, MRCI: Medical regimen complexity index, SD: Standard
deviation
treatment, could impact rehospitalization or other outcomes. Moreover, the sample size might be insufficient
for multivariate analysis in observational studies.
Future research should investigate the effects of dedicated homecare health services for the elderly upon discharge on hospitalization and readmission rates, as well
as the role of various socioeconomic factors in elderly
care.
Conclusion
Polypharmacy and complex medication regimens are frequently observed in elderly heart failure (HF) patients.
Despite this prevalence, our study found that medication
regimen complexity, as measured by the MRCI, is not
associated with hospital readmissions or mortality. Consequently, relying on MRCI as a predictor for rehospitalization in elderly HF patients may not be advantageous.
It is important to consider other factors that could contribute to readmissions and mortality in this population,
such as patient cognition, caregiver availability, and social
support. By focusing on these factors and addressing the
limitations of our study, future research may yield more
accurate predictors and help improve care for elderly HF
patients.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12877-023-04062-2.
Supplementary Material 1
Acknowledgements
The publication of this article was funded by the Qatar National Library.
Authors’ contributions
Asmaa Abdelbary: Conceptualization, Methodology, Formal AnalysisAsmaa
Abdelbary, Rasha Kaddoura, Sara Al Balushi, Shiema Ahmed, Richard Galvez,
Afif Ahmed, Abdulqadir J. Nashwan, Shaikha Alnaimi, Moza Al Hail, Salah
Elbdri: Data Curation, Manuscript writing (draft and final editing). All authors
read and approved the final manuscript.
Funding
This study is supported by Hamad Medical Corporation Medical Research
Center.
Open Access funding provided by the Qatar National Library.
Data Availability
All data generated during this study are included in this published article.
Declarations
Ethics approval and consent to participate
This study was approved by the institutional review board at the Medical
Research Center of Hamad Medical Corporation (HMC) (MRC-01-20-025). The
study has been conducted in accordance with the ethical standards noted
in the 1964 Declaration of Helsinki and its later amendments or comparable
ethical standards. Informed consent was waived HMC?s institutional review
board due to retrospective nature of the study.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Abdelbary et al. BMC Geriatrics
(2023) 23:377
Author details
1
Pharmacy Department, Community and Home Health Services, Hamad
Medical Corporation, Doha, Qatar
2
Pharmacy Department, Heart Hospital, Hamad Medical Corporation,
Doha, Qatar
3
Pharmacy Department, Communicable Disease Center, Hamad Medical
Corporation, Doha, Qatar
4
Corporate Pharmacy Department, Hamad Medical Corporation, Doha,
Qatar
5
Nursing Department, Hamad Medical Corporation, P.O. Box 3050, Doha,
Qatar
6
Cardiology Department, Heart Hospital, Hamad Medical Corporation,
Doha, Qatar
Received: 27 February 2023 / Accepted: 23 May 2023
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