Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 6  |  Page : 695-700  

Drug prescription behavior in a Teaching Hospital of Western Maharashtra


Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India

Date of Web Publication16-Nov-2016

Correspondence Address:
Gurpreet Singh
Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.194184

Rights and Permissions
  Abstract 

Context: To identify drug prescription behavior and thus, guide further actions to recommend evidence-based module for learning in postgraduate curriculum. Aims: To determine drug prescribing behavior of postgraduate residents. Settings and Design: Retrospective historical data-based cross-sectional study in a tertiary care, multispecialty teaching hospital. Materials and Methods: Calculation of sample size and sampling procedure was based on standard recommendations of the World Health Organization for investigation of "drug use in health facilities." A sample size of 1200 was selected from a sampling frame of 86,213 prescriptions using systematic random sampling. Statistical Analysis Used: The data were entered in MS Excel and analyzed for determining core drug use prescription indicators, namely, average number of drugs per encounter, percentage of drugs prescribed by generic name, percentage of encounters with an antibiotic prescribed, percentage of encounters with an injection prescribed. Additional indicators suggestive of drug prescribing behavior such as polypharmacy, type of drug prescribed, department wise distribution, percentage of prescription forms with patient identification details, and demographic characteristics of outpatient department attendees were also calculated. Results: A total of 4096 drugs were prescribed in 1200 prescriptions. Thus, an average of 3.41 (±2.07) drugs per encounter was prescribed. Generic name was used for prescribing 2008 (49.02%) drugs. Antibiotics and injectable were prescribed in 222 (18.5%) and 48 (4%) prescriptions, respectively. Polypharmacy was seen in 286 (23.8%) of prescriptions. Conclusions: Such detailed studies can contribute vital inputs for the development of evidence-based training modules for rational drug use even at the institutional level. Availability and accessibility of essential drugs at affordable prices can be achieved with rationale use of drugs.

Keywords: Drug use, health facility, outpatient department, prescription


How to cite this article:
Singh G, Bhatnagar A, Mukherji S, Goel D. Drug prescription behavior in a Teaching Hospital of Western Maharashtra. Med J DY Patil Univ 2016;9:695-700

How to cite this URL:
Singh G, Bhatnagar A, Mukherji S, Goel D. Drug prescription behavior in a Teaching Hospital of Western Maharashtra. Med J DY Patil Univ [serial online] 2016 [cited 2022 Aug 11];9:695-700. Available from: https://www.mjdrdypu.org/text.asp?2016/9/6/695/194184


  Introduction Top


Medicines play a pivotal role in the delivery of health care services. Highest standards of health care delivery can only be achieved through rational drug use because of medical, psychosocial, and financial implications. [1] Medication errors resulting in adverse drug reactions are reduced to minimum and faith in health care delivery system is enhanced with rational use of medicines. However, in developing regions, irrational and often incorrect use of drugs appears to be widespread. [2] An essential prerequisite for achieving universal health coverage in developing countries including India require access to essential medicines at affordable prices. [3] However, various studies carried out in developing countries are suggestive of a lack of satisfactory drug prescribing practices even among professionally trained doctors practicing in higher medical centers. Essential medicines are not available for one out of every three patients globally. These figures escalate up to 65% in India. Further, prescriptions are medicolegal documents often used for as well as against the physician. [4]

Continuous assessment and refinement of drug prescription behavior are required to provide optimum, cost-effective treatment, and to ensure minimal hospitalizations due to adverse side effects. [5] Such an assessment, in a tertiary care teaching institution, also provides vital feedback to postgraduate residents, creates awareness, and facilitates implementation of rational drug use in the clinical setting. However, objective and periodic assessment of prescription practices, even in higher hospitals, remains a much neglected and overlooked domain. World Health Organization (WHO) has recommended periodic assessment of the use of core drug prescribing indicators as first line measures for assessment and as guidance for actions required to enhance patient safety through rational drug prescribing behavior. [1]

There remains a vital gap in knowledge with regards to drug-prescribing behavior among postgraduates, which has the potential of grave outcomes subsequently. [6] It is visualized that initial assessments and formulation of evidence-based modules on safe and appropriate drug prescription behavior can be instrumental in achieving universal health coverage in the country. This study was undertaken to determine drug prescribing behavior of postgraduate residents in a tertiary care, multispecialty teaching hospital with the aim to identify drug prescription patterns using the WHO core drug prescribing indicators and thus, guide further actions to recommend evidence-based module for learning in medical curriculum.


  Materials and Methods Top


The study was a retrospective historical data-based cross-sectional study conducted in outpatient department (OPD) of a large Teaching Government Hospital in Western Maharashtra. Permission from Institutional Ethics Committee was obtained for the conduct of the study. Calculation of sample size and sampling procedure was based on standard recommendations of WHO for investigation of "drug use in health facilities."

OPD prescription forms initiated by postgraduate residents were included in the study. Faculty prescriptions were excluded from the study. To estimate facility specific percentage core drug use prescription indicators with at least 95% confidence interval and an acceptable deviation of ± 10%, WHO has recommended a minimum sample of 600 with a greater number where feasible. [1] A double sample size of 1200 was selected for the present study, since highly reliable historical data were easily available.

Retrospective data over the past 1 year were accessed from OPD prescription records, which were excellently maintained in the hospital in original format. The final sample was drawn as depicted in [Figure 1]. As the first step, availability and accessibility of medical records were confirmed by thoroughly understanding the organization of medical record keeping in the health care facility. It was found that prescription forms were provided in duplicate to the patients after consultation. The patients were then directed to the pharmacy where a copy of the original hand-written prescription was retained in chronological order. A pilot study was also conducted to check the availability and completeness of the retained prescription forms by comparing them with OPD registers before the study. These retained original prescription forms were then selected as historical data sources for the study.
Figure 1: Sampling procedure for core drug use prescription indicators

Click here to view


The sampling frame consisted of all the original prescription forms for the past 12 months period. Prescriptions were listed and numbered in chronological order to develop sampling frame. A representative sample of the prescription forms was selected using systematic random sampling. Random number for selection of 1 st prescription form was generated using Microsoft Excel worksheet. The first prescription form thus selected was 250 th prescription in the sampling frame. Later, every 72 nd prescription was selected. In case, the selected prescription form was initiated by faculty, or the prescription was not legible, next prescription in the sampling frame was selected. The data were entered in MS Excel and analyzed for determining core drug use prescription indicators, namely, average number of drugs per encounter, percentage of drugs prescribed by generic name, percentage of encounters with an antibiotic prescribed, percentage of encounters with an injection prescribed. Additional indicators suggestive of drug prescribing behavior such as polypharmacy, type of drug prescribed, department wise distribution, percentage of prescription forms with patient identification details, and demographic characteristics of OPD attendees were also calculated. Department wise analysis was not carried out on the basis of guiding principles laid by WHO on the evaluation of drug use in health care facilities. [1]

Operational definitions for measuring prescribing indicators included penicillin and other antibacterial, antidiarrheal preparations containing an antibiotic, anti-infective dermatological, and anti-infective ophthalmological agents as antibiotics. Based on the WHO recommendations, antischistosomal, antileprosy, antitubercular, antifungal, antiamoebic, antimalarial, and antitrypanosomal drugs were not included under a single category of antibiotics. Further, prescribed drug was considered as generic if it was prescribed according to the essential drug list. Prescription of drugs ≥05 in number in a single prescription was considered as polypharmacy. [7] No limitations/conflicts of interest were identified in the study.


  Results Top


OPD services were provided for a total of 315 days in the previous 12 months. Retained OPD prescription forms in pharmacy were available for 294 days, thus, an availability rate of 93.3% OPD days. OPD characteristics are as depicted in [Table 1]. On an average, 294 (±73) prescriptions were initiated in OPDs daily. Date of registration and patient identification details were mentioned in 1200 (100%) and 1087 (90.6%) prescriptions, respectively. Average age of OPD attendees was 40.5 ± 19.39 years. The majority were in the age group of 20-60 years (66.5%) and males (53.5%). Details of the treating doctor and diagnosis were mentioned in 1169 (97.41%) and 576 (48%) prescriptions, respectively.
Table 1: Outpatient Department (OPD) Characteristics


Click here to view


Core drug use prescription indicators are as depicted in [Table 2]. A total of 4096 drugs were prescribed in 1200 prescriptions. Thus, an average of 3.41 (±2.07) drugs per encounter were prescribed. Generic name was used for prescribing 2008 (49.02%) drugs. Antibiotics and injectable were prescribed in 222 (18.5%) and 48 (4%) prescriptions, respectively.
Table 2: Core drug use prescription indicators (n=1200)


Click here to view


Postgraduate residents prescribed <05 drugs in the majority of encounters [Figure 2]. Polypharmacy was seen in 286 (23.8%) of prescriptions. Distribution of drug formulations prescribed is depicted in [Figure 3]. As shown in [Table 3], the strength of all tablets, syrups, and ointments prescribed in an encounter was present in 59.72%, 41.57%, and 2.7%, respectively.
Figure 2: Distribution of number of drugs prescribed

Click here to view
Figure 3: Distribution of drug formulations prescribed

Click here to view
Table 3: Other drug use prescription indicators


Click here to view



  Discussion Top


The present study documents core drug prescribing indicators among postgraduates in a Tertiary Care Teaching Government Hospital in Western Maharashtra. Prescriptions from all departments were included in the study to determine overall prescribing behavior in the institution. Systematic random sampling was carried out to nullify the effect of seasonal variation of diseases and inter-department variations in drug prescription behaviors.

The present study documents a good record keeping system in the institute. Prescription slips were available for 93.3% of OPD days in the past 1 year. Date of registration and patient identification details was mentioned in 100% and 90.6% prescriptions, respectively as compared to a study carried out in public health facilities at Lucknow which documented the lack of patient details in considerable prescriptions. [8] Another study carried out by Ansari et al. found 85% prescriptions without patient details. [9] Studies in other regions of the country as well in Dubai have revealed a lack of patient details in up to 15% of medical prescriptions. [4],[10] However, there is scope of improvement when compared with other apex institutions in the country. A study carried out in New Delhi found patient details in 99.3% prescriptions and authors attributed centralized computerized registration system for the high availability of patient information details. [11] Medicine and allied subjects contributed 54.8% prescriptions, and majority of OPD attendees were males in this study. This was found to be similar to a study for evaluation of prescription patterns where 57.5% prescriptions were prescribed by physicians. [12] Another study carried in a tertiary care center found 77.4% OPD attendees to be males. [13]

Higher number of drugs prescribed invariably increases the cost of treatment for the patient as well as for the health care delivery system. Average number of drugs prescribed per encounter was found to be 3.41 in the study undertaken. Earlier studies conducted in Tertiary Care Centres in Tamil Nadu, Lucknow, Maharashtra, Pune, and Rajasthan found an average number of drugs per prescription to be 3.75, 2.6, 3.62, and 2.81. respectively. [2],[8],[14],[15] A comparative study carried out in Rajasthan documented higher number of drugs being prescribed in private facilities as compared to government hospitals (3.12 and 2.79, respectively). [16] Higher number of drugs per prescription were found in Pakistan (4.51), [17] similar in Iran (3.07), [12] and lower in Ethiopia and UAE (1.9 and 2.2, respectively). [4],[18]

In the present study, 49.02% of drugs were prescribed using generic names. Earlier studies carried across the globe have found varied percentage of drugs being prescribed using generic names. Studies carried out in Pune, Western Maharashtra, Lucknow, Rajasthan and UAE found 3%, 0%, 1.1%, 25.7%, and 4.4% of drugs prescribed by generic names respectively. [4],[8],[10],[14],[19] On the other hand, studies carried out in Tamil Nadu, and Ethiopia found generic names used for 96.5% and 98.7% drugs prescribed. [15],[18] Hospital authorities have repeatedly issued guidelines for the prescription of medicines only by generic name, as is the national guideline on the subject. There appears to be a strong case for the introduction of a module on drug prescribing behavior in initial years of graduate as well as postgraduate medical education to enhance patient safety through rationale use of drugs.

According to the WHO, in regions where infectious diseases are prevalent, 15-25% prescriptions are expected to contain antibiotics. [1] Antibiotics were prescribed in 18.5% prescriptions, in the present study, which was within the recommended limits. Earlier studies carried out in Maharashtra and Rajasthan have reported antibiotics in 46.17% and 75% of the prescriptions, respectively. [2],[10] Internationally, studies carried in Ethiopia, Iran, and Pakistan found antibiotics in 58.1%, 45%, and 13.5%, respectively. [12],[17],[18] Injectable medications were prescribed in 4% prescriptions in the study undertaken. This was found to be lower than studies carried out previously in the country as well as in other developing countries. Prescriptions with injectable medications were found in 7.33%, 38.1%, 41%, and 37.28% of the prescriptions in studies carried in Rajasthan, Ethiopia, Iran, and Pakistan. [10],[12],[17],[18]

Polypharmacy is an established cause for reduction in quality of drug therapy, wastage of resources, emergence of resistance, increased cost of therapy, and increased adverse reactions. Polypharmacy was revealed in 23.8% prescriptions in the present study. Although a substantially high percentage, this was found to be lower than a study conducted earlier in a Tertiary Care Teaching Hospital in Western Maharashtra which found 56.75% prescriptions with polypharmacy. [2] A study carried out by Ansari et al. documented higher tendency toward polypharmacy in primary care centers as compared to secondary and tertiary centers. [9] A study conducted by Saurabh et al. among primary health care facilities found 89% prescriptions with polypharmacy. [10] However, a study carried in the UAE found only 7.5% prescriptions with polypharmacy. [4] Thus, there appears to be a need to sensitize the medical professionals in the country about polypharmacy and its avoidance at every level.

Further, the present study documents lower prevalence of mentioning the strength of the formulation while prescribing syrups and ointments (41.57% and 2.7% respectively) as compared to tablets (59.72%). Similar studies from Western Maharashtra and Rajasthan documented it to be 73.1% and 74% respectively for tablet formulations. [10],[19] Studies carried in other parts of the world have also documented low percentage of drugs being mentioned along with strength and dose of formulations. [4] A short course on prescription writing before the medical student enters the clinical field and monitoring by administrative authorities may help alleviate the problem.


  Conclusions Top


The present study has indicated an essential need to objectively assess drug prescribing behavior at all levels among medical professionals in various health care facilities on periodic intervals. Such detailed studies can contribute vital inputs for the development of evidence-based training modules for rational drug use even at institutional level. All teaching facilities, especially postgraduate teaching institutes must closely monitor and take timely corrective measures to ensure correct prescription practices among the medical students. Availability and accessibility of essential drugs at affordable prices can be achieved with rationale use of drugs. The introduction of regular modules and targeted training would contribute directly to better prescription practices among medical professionals, thereby having a direct impact on the quality and reliability of health care delivery system in the country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
WHO. How to Investigate Drug Use in Health Facilities: Selected Drug Use Indicators. Geneva: World Health Organization; 1993.  Back to cited text no. 1
    
2.
Lalan BK, Hiray R, Ghongane B. Drug prescription pattern of outpatients in a tertiary care teaching hospital in Maharashtra. Int J Pharm Bio Sci 2012;3:225-9.  Back to cited text no. 2
    
3.
Jindal AK. Universal health coverage: The way forward. Indian J Public Health 2014;58:161-7.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Sharif S, Al-Shaqra M, Hajjar H, Shamout A, Wess L. Patterns of drug prescribing in a hospital in Dubai, United Arab Emirates. Libyan J Med 2008;3:10-2.  Back to cited text no. 4
    
5.
Benet L. Principle of prescription order writing and patients compliance. Goodman and Gilman's the pharmacological Basis of Therapeutics. 8 th ed. New York: Pergamon Press Inc.; 1991. p. 1640.  Back to cited text no. 5
    
6.
Mohan P, Sharma AK, Panwar SS. Identification and quantification of prescription errors. Med J Armed Forces India 2014;70:149-53.  Back to cited text no. 6
    
7.
Medeiros-Souza P, Santos-Neto LL, Kusano LT, Pereira MG. Diagnosis and control of polypharmacy in the elderly. Rev Saude Publica 2007;41:1049-53.  Back to cited text no. 7
    
8.
Kumari R, Idris MZ, Bhushan V, Khanna A, Agrawal M, Singh SK. Assessment of prescription pattern at the public health facilities of Lucknow district. Indian J Pharmacol 2008;40:243-7.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
9.
Ansari K, Singh S, Pandey R. Evaluation of prescribing pattern of doctors for rational drug therapy. Indian J Pharmacol 1998;30:43.  Back to cited text no. 9
  Medknow Journal  
10.
Saurabh M, Biswas N, Yadav A, Singhai A, Saurabh A. Study of prescribing habits and assessment of rational use of drugs among doctors of primary healthcare facilities. Asian J Pharm Clin Res 2011;4:102-5.  Back to cited text no. 10
    
11.
Siddarth V, Arya S, Gupat S. A study of prescribing practices in outpatient department of an apex tertiary care institute of India. International Journal of Research Foundation of Hospital & Healthcare Administration 2014;2:31-5.  Back to cited text no. 11
    
12.
Karimi A, Haerizadeh M, Soleymani F, Haerizadeh M, Taheri F. Evaluation of medicine prescription pattern using World Health Organization prescribing indicators in Iran: A cross-sectional study. J Res Pharm Pract 2014;3:39-45.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
13.
Karna K, Sharma S, Inamdar S, Bhandari A. Study and evaluation of medication errors in a tertiary care teaching hospital - A baseline study. Int J Pharm Sci 2012;4:58.  Back to cited text no. 13
    
14.
Kshirsagar MJ, Langade D, Patil S, Patki PS. Prescribing patterns among medical practitioners in Pune, India. Bull World Health Organ 1998;76:271-5.  Back to cited text no. 14
    
15.
Kanakambal S, Murugesh N, Shanthi M. Drug prescribing pattern in a tertiary care teaching hospital in Madurai (Tamil Nadu). Indian J Pharmacol 2001;33:223.  Back to cited text no. 15
  Medknow Journal  
16.
Saurabh M, Yadav A, Gupta P, Singhai A, Saurabh A. Comparative study of prescribing behaviors of government doctors of teaching hospital and private practitioners in Jhalawar City (Rajasthan). J Pharm Sci Res 2010;2:208-15.  Back to cited text no. 16
    
17.
Das N, Khan AN, Badini ZA, Baloch H, Parkash J. Prescribing practices of consultants at Karachi, Pakistan. J Pak Med Assoc 2001;51:74-7.  Back to cited text no. 17
    
18.
Desalegn AA. Assessment of drug use pattern using WHO prescribing indicators at Hawassa University Teaching and Referral Hospital, South Ethiopia: A cross-sectional study. BMC Health Serv Res 2013;13:170.  Back to cited text no. 18
    
19.
Phalke VD, Phalke DB, Syed MM, Mishra A, Sikchi S, Kalakoti P. Prescription writing practices in a rural tertiary care hospital in Western Maharashtra, India. Australas Med J 2011;4:4-8.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


This article has been cited by
1 Outpatient prescribing trends, rational use of medicine and impact of prescription audit with feedback at a tertiary care centre in India
Shubham Atal,Ratinder Jhaj,Akanksha Mathur,Niket Rai,Saurav Misra,Balakrishnan Sadasivam
The International Journal of Health Planning and Management. 2021;
[Pubmed] | [DOI]
2 Drug utilization studies using WHO prescribing indicators from India: A systematic review
Amol Gujar,Dr Vishal Gulecha,Dr Amar Zalte
Health Policy and Technology. 2021; : 100547
[Pubmed] | [DOI]
3 ASSESSMENT OF DRUG PRESCRIBING PATTERN IN THE INPATIENT SURGERY DEPARTMENT AT A TERTIARY CARE TEACHING HOSPITAL USING WHO PRESCRIBING INDICATORS.
Indian Journal of Medical Research and Pharmaceutical Sciences. 2020; 7(10): 12
[Pubmed] | [DOI]
4 ANALYSIS OF PSYCHOTROPICS POLYPHARMACY AND PREVALENCE OF NON-PSYCHOTROPICS PRESCRIBED IN OUTPATIENT PSYCHIATRY UNIT OF A TERTIARY CARE TEACHING HOSPITAL
Sharmila A.,Tejus A.,Md. Fadil Salmani,Salma Malik
Journal of Evidence Based Medicine and Healthcare. 2019; 6(30): 2072
[Pubmed] | [DOI]



 

Top
   
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed2215    
    Printed64    
    Emailed0    
    PDF Downloaded231    
    Comments [Add]    
    Cited by others 4    

Recommend this journal