Patterns of Prescription and Drug Dispensing

Transcription

1 Original Article Patterns of Prescription and Drug Dispensing Sunil Karande, Punam Sankhe and Madhuri Kulkarni Department of Pediatrics, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai, India Abstract. Objective : To analyze the patterns of prescriptions and drug dispensing using World Health Organization core drug use indicators and some additional indices. Methods : Data were collected prospectively by scrutinizing the prescriptions written by pediatric resident doctors and by interviewing parents of 500 outpatient children. Results : The average number of drugs per encounter was 2.9 and 73.4% drugs were prescribed by generic name. Majority of drugs prescribed were in the form of syrups (60.8%). Use of antibiotics (39.6% of encounters) was frequent, but injection use (0.2% of encounters) was very low. A high number of drugs prescribed (90.3%) conformed to a model list of essential drugs and were dispensed (76.9%) by the hospital pharmacy. Certain drugs (5.7%) prescribed as syrups were not dispensed, although they were available in tablet form. Most parents (80.8%) knew the correct dosages, but only 18.5% of drugs were adequately labeled. No copy of an essential drugs list was available. The availability of key drugs was 85%. Conclusion : Interventions to rectify over prescription of antibiotics and syrup formulations, inadequate labeling of drugs and lack of access to an essential drugs list are necessary to further improve rational drug use in our facility. [Indian J Pedlatr 2005; 72 (2) : ] karandesunil@yahoo.com Key words : Drug utilization review; Essential drugs; Liquid drug formulations; Medical audit; Outpatients Essential drugs offer a cost-effective solution to many health problems in a developing country. 1 They should be selected with due regard to disease prevalence, be affordable, with assured quality and be available in the appropriate dosage forms. 1 Prescribers can only treat patients in a rational way if they have access to an essential drugs list and essential drugs are available on a regular basis. 2 To assess the scope for improvement in rational drug use in outpatient practice, the World Health Organization (WHO) has formulated a set of "core drug use indicators" (Table 1). 2 The core prescribing indicators measure the performance of prescribers, the patient care indicators measure what patients experience at health facilities, and the facility indicators measure whether the health personnel can function effectively. 2 Based on these indicators, studies have been carried out in Bangladesh, a Burkina Faso, 4 Cambodia, s Ethiopia, 6 Ghana, 7 Lebanon, s Morocco, 9 Nepal, 1~ Nigeria, ~ Pakistan, ~2 Tanzania, ~3 Zimbabwe, ~4 and in India. ~5-21 Since no such study has been carried out selectively in a pediatric outpatient department, we wanted to measure these indicators in our facility to obtain data for promoting rational drug use. MATERIALS AND METHODS Ours is a major teaching tertiary-level public hospital which primarily serves the lower socioeconomic class of patients. In our outpatient department children aged from Correspondence and Reprint requests : Dr. Sunil Karande, Fiat 24, Joothica, 5th Floor, Opposite Grant Road Post Office, 22A, Naushir Bharucha Road, Mumbai , India. 28 days to 12 years of age avail medical consultation at a very nominal cost of Rupees 10/-, and drugs are dispensed free of cost. The WHO indicators are to be used to focus on the local health problems. 2 Therefore, only children who received treatment for acute gastroenteritis, acute respiratory infections, or malaria (the three commonest illnesses) were prospectively enrolled. The "minimum" recommended sample size for a study carried out in a single health facility is 100 encounters. 2 We decided on a larger sample size of 500 encounters; and that both the "prescribing and patient care indicators" would be measured for the same patients, as this would give a better idea of the total service individual patients were receiving? The interviews were held discretely in the corridor just outside the pediatric outpatient department, where P.S. would record the data on predesigned WHO forms. 2 The data for the "prescribing indicators" was recorded by scrutinizing the prescription immediately after the patient-prescriber encounter. P.S. would then instruct the parent to collect the prescribed drugs from the hospital pharmacy, and to meet her again to record data for the "patient care indicators". Which drugs were dispensed was determined by examining the drug packages/bottles the parent had actually received. It was noted whether they had been adequately labeled, viz. whether the name of the patient, the generic name of the drug and when the drug should be taken was written on them. 2 Lastly, the parent's knowledge of when and in what quantity each drug that was actually dispensed should be taken was evaluated. Failure to know either of these two points would result in parent's knowledge being scored as inadequate. 2 Data Indian Journal of Pediatrics, Volume 72--February,

2 Sunil Karande et al was collected on Mondays and Thursdays, from 10 a.m. to 12 noon, the middle time of the outpatient day, to ensure that the results were not overly influenced by the rush to see patients at the beginning or end of a clinic session, or by freshness or fatigue of the health workers. 2 It took P.S. a period of nine months (April to December 2001) to collect the data. In our outpatient department, children are seen by many residents in a single consultation room and parents often queue within the consultation room itself. Also at the hospital pharmacy counter situated on another floor, patients from all outpatient departments queue to collect their medicines. Thus it was impossible to collect data to calculate the average consultation and dispensing times. Penicillins, other antibacterial agents (including sulfa drugs), anti-infective dermatological drugs, anti-infective ophthalmological agents and antidiarrheal drugs with streptomycin, neomycin, nifuroxazide or combinations were regarded as antibiotics; while antiamoebic, antigiardiasis, antihelminthic, and antimalarial drugs were not regarded as antibiotics. 2 Immunizations were not counted as drugs dispensed. 2 The 1998 WHO model list of essential drugs (tenth list) was used to define the drug names that were counted as "generic". 22 Data pertaining to the "facility indicators" were gathered at the end of the present study. The staff nurse responsible for maintaining equipment was asked whether any essential drugs list existed in the outpatient department during the study period. 2 Fifteen essential drugs formed the checklist to measure the availability of "key drugs", viz. drugs that should always be available for the treatment of common health problems, during the study period (Table 2). 2 This information was obtained from the records of the hospital pharmacy and medical stores. Even if one bottle or a few tablets were available the drug was recorded as being in stock. 2 Additional indices viz. "specific treatment practices" were calculated: (i) the types of drugs (injections, tablets, syrups, etc.) being prescribed, (ii) the percentage of antibiotics of total number of drugs prescribed, (iii) the commonest antibiotics prescribed, (iv) the number of antibiotics per prescription, (v) the percentage of prescriptions wherein all the prescribed drugs were dispensed, (vi) the percentage of drugs not dispensed in the same strength as prescribed, (vii) the drugs that were prescribed, yet not dispensed, and (viii) the errors in dispensing, if any.2 RESULTS The mean age of the patients was 3.5 years (range 3 months-12 years, s.d. _+ 3.3 years). Males were 299 and females 201 (59.8% vs. 40.2%). A total of 1432 individual drugs were prescribed for 500 drug encounters, giving an average of 2.9 (s.d. _ 0.98); and the range of drugs per encounter varied from 1 to 8 (Table 3). There was not a single prescription wherein no drug was prescribed. Generic prescribing dominated (Table 4). Drugs were prescribed in eight different dosage forms. Syrups were most commonly prescribed (60.8%), followed by tablets (20.5%), oral rehydration salts (11.1%), eye/ear/nose drops (3.2%), nebulizations (2.1%), capsules (1.8%), lotions (0.4%), and injections (0.1%). Use of antibiotics was frequent (Table 4). The number of encounters with antibiotics was 198. Antibiotics constituted 14% of the total number of drugs prescribed. A single antibiotic was prescribed in 195 prescriptions, and two antibiotics were prescribed in the remaining three prescriptions. Thirtyfour (24.6%) out of 138 children with acute gastroenteritis, 162 (52.8%) out of 307 children with acute respiratory infections, and 2 (3.6%) out of 55 children with malaria were prescribed antibiotics. Ampicillin, cotrimoxazole, amoxicillin, and erythromycin constituted 87.6% (176/ 201) of the total number of antibiotics prescribed. Every child with acute gastroenteritis was prescribed oral rehydration salts. No antidiarrheal drugs with streptomycin or neomycin were prescribed. Injection use was very low. Only one patient, a three-year-old boy with acute gastroenteritis received an injection of hyoscine butylbromide for his abdominal colic. Most of the drugs prescribed (1293/1432) conformed to the WHO tenth revised model list of essential drugs. Three-fourths (1102/1432) of prescribed drugs were TABLE 1. World Health Organization Core Drug Use Indicators to Investigate Drug Use in Health Facilities Prescribing indicators 1 Average number of drugs per encounter 2 3 Percentage of drugs prescribed by generic name Percentage of encounters with an antibiotic prescribed 4 Percentage of encounters with an injection prescribed 5 Percentage of drugs prescribed from essential drugs list or formulary Patient care indicators 6 Average consultation time + 7 Average dispensing time * 8 Percentage of drugs actually dispensed 9 Percentage of drugs adequately labeled 10 Patient's knowledge of correct dosage Facility indicators 11 Availability of copy of essential drugs list or formulary 12 Availability of key drugs + Not recorded in current study actually dispensed by the hospital pharmacy. In 50% (250/500) of encounters the fuu quota, and in 3% (15/500) none of the prescribed drugs were dispensed. Only 2.2% (31/1432) of dispensed drugs were not in the same strength as prescribed. Certain drugs prescribed as syrups (for example, calcium supplements, iron-folic acid supplements, mebendazole, metronidazole, multivitamins, pheniramine maleate, and salbutamol) were not dispensed although they were available in tablet form. They constituted 5.7% (82/1432) of the total number of drugs prescribed. No patient received a wrong drug or 118 Indian Journal of Pediatrics, Volume 72--February, 2005

3 Patterns of Prescription and Drug Dispensing TABLE 2. World Health Organization Recommended List of Key Drugs for Testing Drug Availability Common health problem Diarrhea Acute respiratory tract infections Malaria Anemia Worm infestations Conjunctivitis Skin disinfection Fungal skin infection Pain Prophylactic drugs Key drug Oral rehydration salts, cotrimoxazole tablets Cotrimoxazole tablets, procaine penicillin injection, pediatric paracetamol tablets, Chloroquine tablets, Ferrous salt + folic acid tablets Mebendazole tablets Tetracycline eye ointment Iodine, gentian violet or local alternative Benzoic acid + salicylic acid ointment Acetylsalicylic acid or paracetamol tablets Retinol (vitamin A), ferrous salt + folic acid tablets TASTE 3. Number of Drugs Prescribed Per Prescription Prescription containing Number of number of drugs prescriptions (%) One 24 (4.8) Two 164 (32.8) Three 204 (40.8) Four 81 (16.2) Five 22 (4.4) Six 3 (0.6) Seven 1 (0.2) Eight 1 (0.2) Total 500 (100) an incorrect dosage. Most drugs (898/1102) were inadequately labeled as the name of the patient and the generic name of the drug were not written. However, all drug packages/bottles had a pictogram drawn on them indicating how the drug should be taken. For example, if a tablet was to be taken three times a day; the pictogram drawn was O O O. Four-fifths (392/485) of parents knew the correct dosage schedule for all the drugs prescribed. No essential drugs list was available. Only two key drugs, procaine penicillin injection and tetracycline eye ointment were not available. DISCUSSION Average number of drugs/injections per encounter is an important index of the scope for educational intervention in prescribing practices. 2 Our figure of 2.9 drugs per encounter is higher than the recommended limit of Similar findings have been reported in other Indian studies (Table 4); and from Burkina Faso, 4 Cambodia, s Ethiopia, 6 GhanaJ Morocco, 9 Nepal, 1~ Nigeria, u Pakistan, 12 Tanzania, 13 and Zimbabwe '4 (2.2 to 4.8 drugs per encounter). Even in USA 23 children receive 2.7 drugs per encounter. However, studies from Bangladesh 3 and Lebanon 8 have reported rational figures of 1.4 and 1.6, respectively. In the present study three or more drugs were prescribed in 62.4% of prescriptions which increase the risk of drug interactions, of dispensing errors and of the parent not knowing the dosage schedules. 2 Increasing generic prescribing would rationalize the use and reduce the cost of drugs. 1 Our figure of 73.4% drugs being prescribed by generic name is higher than those reported in all other Indian studies (Table 4); and those from Ghana, 7 Lebanon, ~ Nepal, ~~ and Pakistan 12 (2.9% to 65.0%). However higher figures (75% to 99.8%) of generic prescribing has been reported from Bangladesh, 3 Cambodia, 5 Ethiopia, 6 and Tanzania23 Appropriate use of antibiotics is necessary to prevent emergence of drug resistant bacteria. Our figure of 39.6% prescriptions having an antibiotic is lower than those reported in most other Indian studies (Table 4); and those from Cambodia, s Ethiopia, 6 Ghana, 7 Morocco, ~ and Nigeria 1~ (47.5% to 100%). However lesser figures of antibiotic prescribing (17.5 % to 35.4%) have been reported from Bangladesh, 3 Lebanon, 8 Nepal, ~~ and Tanzania. ~3 Most acute gastroenteritis cases are viral and need only oral rehydration therapy. 24 Although in the TABLE 4. Comparison of Core Drug Use Indicators Obtained in Current Study with Other Indian Studies Core drug use indicator Current Biswas study et al (20oo) Average number of drugs prescribed % of drugs prescribed by generic names % of encounters with an antibiotic prescribed % of encounters with an injection prescribed % of drugs prescribed from essential drug list Average consultation time (rain) Average dispensing time (rain) % of drugs actually dispensed % of drugs adequately labeled % patients with correct knowledge of dosage Essential Drugs List / formulary available % availability of key drugs Ref Reference, % percentage, - not recorded/mentioned No Hazra Biswas Rehan Maini Rehan Rishi et al et al et al et al et al et al (2000) (2001) (2001) (2002) (2002) (2003) No O Indian Journal of Pediatrics, Volume 72--February,

4 Sunil Karande et al present study 24.6% of children with acute gastroenteritis were prescribed an antibiotic, this is lower than figures reported in other Indian studies (64 and 83%) 25,26; and those from Nigeria, 27 Indonesia, 2s Bangladesh, 29 and Pakistan 3~ (58% to 96%). Similarly most acute respiratory infections are viral and antibiotics need not be prescribed. 31 In the present study 52.8% of children with acute respiratory infections were prescribed an antibiotic, but this is lower than figures reported from Mexico 32 (77%); and from developed countries such as USA a3 (43%) and Canada 3* (74%). An urgent need arises to reduce injection use in developing countries to prevent healthcare associated infections with HW and other blood borne pathogens. 35 In the present study injection use was very low as compared to other Indian studies (Table 4). Inappropriate high injection prescribing (17.1% to 80%) has been reported from Ethiopia, 6 Ghana, / Morocco, 9 Pakistan, 12 Tanzania, 13 and Zimbabwe. 14 Although our pediatric residents had no essential drugs list to refer to, 90.3% of the drugs prescribed were essential drugs, which is higher than figures reported in most other Indian studies (Table 4); and those from Bangladesh, 3 Burkina Faso, 4 Lebanon, s Morocco, 9 Nepal, 1~ and Pakistan 12 (2.9% to 88%). However, higher figures of 99.7% and 97% have been reported from Cambodia s and Ghana, 7 respectively. A locally adapted essential drugs list will help promote rational drug use in our outpatient depa~-tment. 1, 2 In our facility 76.9% of prescribed drugs were dispensed, which is higher than figures reported in other Indian studies (Table 4); but lower than those from Burkina Faso,* Cambodia, s and Ethiopia 6 (82% to 100%). The cost of equivalent dose of drug in syrup form is almost twice that of the drug in tablet form. 36 Hence overdependence on syrup formulations needs to be rectified. Also, if a drug prescribed as syrup is not available; its tablet form should be dispensed. The parent can be explained each time to crush the prescribed tablet and prepare a palatable syrup dose, otherwise the parents would have to use private resources to obtain the syrup formulation, which they often cannot, resulting in noncompliance with the treatment. The level of appropriate labeling (18.5%) needs to be improved. Although not a single dispensed drug was adequately labeled in an Indian, 2~ and Cambodian s study; much higher figures of 56.2% and 87%, respectively, have been reported in another Indian, 16 and Tanzanian ~3 study. At the end of the study, when the dispensers were asked about the inadequate labeling, they stated that given their typical workload they hardly got a few minutes to interact with the parents, which they preferred to utilize to draw the pictogram and explain how the individual drugs should be taken. The use of pictograms has been shown to improve recall of medical information in people with low literacy skiusy However, writing the patient's name and generic name of the drug on the label is necessary. This would also help in reducing the risk of dispensing errors. 3~ Although only 80.8% of parents knew the correct dosage schedule, our figure is higher than those reported in other Indian studies (Table 4); and those from Bangladesh, 3 Burkina Faso 4 and Cambodia 5 (55% to 68.3%). The dispensers after having explained once should request the parents to repeat the drug dosages. This would help identify parents who require to be explained again. The availability of all key drugs should be ensured. A similar figure of 86.6% availability of key drugs has been reported from Cambodia 5, a lower figure of 54% from Bangladesh, 3 and an optimal figure of 100% from Ethiopia. 6 Any drug utilization study based on the WHO core drug use indicators has limitations? Determining the quality of diagnosis and evaluating the adequacy of drug choices is beyond the scope of the prescribing indicators? Also, the patient care indicators do not capture many fundamental issues related to the quality of examination and treatment. 2 However, the present study provides important useful baseline data which will be useful for comparison when in future any pediatric drug utilization study is carried out. Acknowledgement We thank our Dean, Dr. M. E. Yeolekar, for granting us permission to publish this study. REFERENCES 1 Quick JD, Hogerzeil HV, Velasquez G, Rago L. Twenty-five years of essential medicines. 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