Indian Journal of Pharmacology Medknow Publications on behalf of Indian Pharmacological Society ISSN: 0253-7613 EISSN: 1998-3751 Vol. 43, Num. 2, 2011, pp. 150-156

Indian Journal of Pharmacology, Vol. 43, No. 2, March-April, 2011, pp. 150-156

Research Article

Prescription audit of outpatient attendees of secondary level government hospitals in Maharashtra

Hanumantha Rao Potharaju¹, SG Kabra²

¹ Administrative Staff College of India, Hyderabad - 500 082, India
² Administrative Staff College of India, 15, Vijayanagar, D Block, Malaviya Nagar, Jaipur - 302 017, India

Correspondence Address: Hanumantha Rao Potharaju, Administrative Staff College of India, Hyderabad - 500 082, India, drphrao@asci.org.in

Date of Submission: 12-Jan-2010
Date of Decision: 29-Oct-2010
Date of Acceptance: 06-Jan-2011

Code Number: ph11041

DOI: 10.4103/0253-7613.77350

Abstract

Keywords: Essential Medicines, International Classification of Diseases, Morbidity Pattern, prescription audit, secondary level hospitals

Introduction

The main objective of the Maharashtra Health Systems Development Project (MHSDP) is to enhance the quality of care in the secondary level hospitals in the state. The secondary level hospitals in Maharashtra comprise of four categories, namely: (a) district hospitals (DH), (b) sub-district hospitals with 100 beds (SDH 100), (c) sub-district hospitals with 50 beds (SDH 50), and (d) select Community Health Centers (CHC). Improvement in the prescribing practices of doctors working in the project hospitals is one of the initiatives taken up, to improve the quality of care. A prescription audit was considered appropriate to improve the usage of drugs by the MHSDP doctors.

The World Health Organization (WHO) proposed core-prescribing indicators ^[1] for prescription audit and drug utilization studies. The focus of Indian studies ^{[2],[3],[4],[5]} has mainly been on the WHO core-prescribing indicators such as the range and number of drugs per prescription. Another study reported that half of the patients received more than one antibiotic. ^[6] Chemist- and hospital pharmacy-based studies reported that polypharmacy was the norm ^[7],[8] and about 75 percent of the prescriptions contained Fixed Dose Combinations (FDCs). ^[9] An analysis of prescriptions for diarrhea also revealed that about 60 percent contained FDCs. ^[10] Another study of 292 prescriptions for diarrhea reported use of 63 different drugs. ^[11]

The prescription audit studies have been conducted in diverse settings like outpatients and inpatients in hospitals, hospital pharmacy, retail medical stores in the community, private medical practitioners, and so on, mostly with a small sample size. Few studies used a prescription audit to generate a morbidity profile, and prepared the essentials medicines list based on that morbidity profile.

Objective

A prescription audit was conducted among outpatient attendees of a representative sample of the MHSDP hospitals, at the behest of the Government of Maharashtra. The objectives of the audit were,

1. To understand the morbidity pattern currently being handled in the OPDs, detect the frequently prescribed drugs to treat the patients attending the OPDs, and to prepare an essential medicines list (EML) for the four categories of project hospitals, for OPD use.
2. To analyze the prescription of drugs at the four categories of hospitals and generate information on the core prescribing indicators proposed by the WHO.
3. To articulate measures to improve prescription practices of the doctors working in the project hospitals.

Materials and Methods

The present study followed the prospective methodology. Before starting the study an initiation workshop was conducted, to explain the objectives of the study, method of using the specially designed forms, and also to address the apprehensions of the doctors. The form designed was quite similar to the regular OPD chit used in MHSDP hospitals. The forms were printed in duplicate with pre-inserted carbon.

The form was given only to the ′new cases,′ as the study was aimed at ′First Encounter Prescriptions.′ The hospitals were asked to use the specially designed forms in place of the regular OPD papers, till the supply was exhausted. The doctor retained the carbon copy in an envelope, with doctor details. The filled in forms were collected from the participating doctors and analyzed using MS Access and SPSS.

The diagnoses in the filled-in prescription forms were coded using International Classification of Diseases - 10 (ICD 10). ^[12] The Anatomical Therapeutic Chemical (ATC) Classification, ^[13] developed by the World Health Organization, was used for coding the drugs.

Sample Size and Distribution

The study included 32 hospitals, covering all eight administrative regions of the state and all categories of MHSDP hospitals. The number of forms given to each category of hospitals is shown below.

• District Hospital - 1000
• SDH100 - 500
• SDH50 - 300
• CHC - 200

Results

District hospitals accounted for the maximum number of prescriptions. Further details are shown in [Figure - 1].

General OPDs contributed to about 60 percent of the prescriptions. In the case of SDH 50 and CHC all the prescriptions were considered as general OPD. Details of contribution by the OPD and hospital category are shown in [Table - 1].

Profile of Participating Doctors

A total of 212 doctors participated in the study. About 81 percent of the samples were male. About 10 percent of the participating doctors were GPs, while 75 percent were specialists. The remaining 15 percent were ayurvedic and other general duty doctors.

Patient Profile

The proportion of females was marginally higher, at 51.4 percent, while children (14 years or less) constituted 28.4 percent, adolescents (15 - 19 years) constituted 7.9 percent, adults (20 - 59 years) formed 52.1 percent and the 60 and above age group formed 10.5 percent.

Morbidity Pattern;

Out of the 14,004 prescriptions about 77 percent of the prescriptions contained a single diagnosis, while about 18 percent contained two diagnoses, the remaining five percent contained three diagnoses. The detailed morbidity pattern, according to the type of hospital, is given in [Table - 2].

The following five are the most frequent diagnoses:

• Diseases of respiratory system - ICD code J00-J99 - 12.7 percent
• Infectious and parasitic diseases - ICD Code A00-B99 - 8.2 percent
• Diseases of musculoskeletal system - ICD Code M00-M99 - 5.8 percent
• Diseases of digestive system - ICD Code K00-K99 - 5.7 percent
• Diseases of skin and subcutaneous tissues - ICD Code L00-L99 - 5.4 percent

Frequently Prescribed Drug Groups

The top 15 drug-groups prescribed in different categories of hospitals are shown in [Table - 3].

In the district hospitals, the top 15 drug groups accounted for 84.1 percent. The corresponding figures for SDH 100, SDH50, and CHC are 81.6, 78.8, and 79.9 percent.

Diagnostic Tests

Use of diagnostic tests enables the physician to provide evidence-based treatment instead of offering empirical treatment. In case of 30 percent, a diagnostic test is advised. The average number of tests per prescription is 2.06. Peripheral smear for malaria, test for hemoglobin, and different urine-based examinations are the most frequently prescribed tests / investigations, which account for about 46 percent of the investigations.

Follow-up Advice

Follow-up advice facilitated continuation of treatment and making any changes in the treatment wherever necessary. Advice on follow-up was mentioned only in about 18 percent of the cases. A period of three days was the most frequently prescribed follow-up duration (42 percent), followed by five days (18.5 percent).

Referral

A referral was indicated in only 3.7 percent of the cases. The proportion of referrals was relatively more at higher-level institutions (SDH100 and DH) compared to lower level facilities (SDH50 and CHC). Referrals to four specialties namely surgery, physician, orthopedics, and ophthalmic accounted for about 56 percent. A few referrals were also to the lower level institutions, for the purpose of continuation of treatment in diseases like TB and leprosy.

WHO Core Prescribing Indicators

The core prescribing indicators of MHSDP are shown in [Table - 4].

Discussion

The ′Prescription Audit′ of the Outpatient Attendees in MHSDP Hospitals was an enabling exercise in spirit. Its main aim was to provide an objective basis, namely, morbidity pattern and actual use of drugs by the MHSDP doctors, for preparing an essential medicines list (EML) for the MHSDP hospitals.

Prescribing Practices

Assessment of the rationality of prescriptions by a doctor in a hospital is appropriate if the hospital has Standard Treatment Guidelines (STGs) and the doctors are made aware of the STGs and are provided with the guidelines, at least for the diseases commonly treated by them. At the time of the study the MHSDP did not have any STGs to be followed by the project hospital doctors.

However, based on the findings of the study some prescription practices may be considered for improvement.

Complete details: Formulation was mentioned in about 95 percent of the drugs prescribed. However, all details namely (a) strength, (b) dose, and (c) number of days were mentioned only in 38.8 percent of the tablets, in 50.1 percent of the capsules, and in 16.1 percent of the injections. By default in project hospitals drugs were given for three days, unless the prescription mentioned otherwise. Some doctors stated that there was no need to mention the details because packs of only limited strength were available in the hospital.

Number of drugs per prescription: About 31 percent of the prescriptions contained four or more drugs. By comparing with the STGs for diseases for which such prescriptions were made, they could be justified or categorized as irrational prescriptions.

Use of Brand Names: Still about 40 percent of the doctors used brand names. The reasons for using brand names need to be understood (such as comfort ability with brand names, opinion that generic drugs are of low quality, etc.) and addressed with appropriate interventions.

FDCs: Among the FDCs with high usage (100 or more prescriptions) in MHSDP hospitals:

• Three, namely (a) Cotrimoxazole, (b) ORS, and (c) Iron + Folic Acid are included in WHO EML
• Five namely (a) Vitamin Bcomplex, (b) Aluminium Hydroxide + Magnesium Trisilicate, (c) Multivitamins, (d) Fortified Procaine Penicillin, and (e) Etophylline + Theophylline are included either in the national or state level EMLs
• Five, namely, (a) Multivitamin + B complex, (b) Cough Expectorant, (c) APC, (d) Antacids, and (e) Framycetin +Dexamethasone + Gramicidin are not included in any EML.

An Essential Medicines List (EML) for OPD use in MHSDP hospitals has been prepared for all four categories of hospitals. The core list of EML has 133 drugs. The list is provided as Appendix 1.

The drugs included in the core list have been identified based on the following criteria.

i. They are frequently prescribed or required as identified

• From the top 25 drugs prescribed in the ten OPDs, as found from the study
• From the frequency of usage, as a whole (above 20 prescriptions in case of single ingredient drugs and five and above prescriptions in the case of combinations)
• From the drugs mentioned as required frequently, by the groups of different specialists, during the dissemination workshop on 27 November, 2003, in Mumbai.

A complementary list of 37 medicines was also suggested, which was prepared based on the following criteria:

1. Drugs frequently used or required, but not included in the core list
2. Drugs needed for special conditions or specific groups of patients

Measures suggested to promote Rational Prescription Practices

• The state should formulate a drug policy as it did not have one, addressing issues like EML, procurement, and so on.
• The drugs included in the core list of EML covered about 80 percent of the morbidity load of OPDs. Hence, the project should ensure adequate supply of these drugs of assured quality and effectivity. Non-availability of the drugs in EML may result in prescribing other alternatives and use of brand names.
• Promotion of rational prescription practices requires that the MHSDP hospital doctors are provided with the Standard Treatment Guidelines (STGs).
• The following information, education, and communication (IEC) interventions are needed to create an enabling environment and promote behavior change.

• The drugs provided under MHSDP must be of good quality
• Doctors must give medicines like vitamins, IV saline, and injections as per the patient′s needs. Patients should not insist on the prescription of saline or strong / powerful medicines
• Doctors must not prescribe unnecessary medicines and if needed, essential medicines must be prescribed. The medicines taken without doctor′s prescription may be harmful

1. The drugs provided under MHSDP are of good quality. They could be obtained at a lower cost because of procurement practices of the project like, (a) buying directly from the manufacturer, (b) centralized procurement practices, and (c) buying generics instead of brands. This is essential because some of the MHSDP doctors commented that the drugs supplied by the government are of inferior quality. Hence, they prescribe well-known brands
2. Doctors should use antibiotics very carefully by putting in place an antibiotic policy. Otherwise they will lose their effectiveness
3. Doctors should be made aware of the advantages of prescribing drugs using generic names, such as, (a) cost effectiveness and (b) minimizing medication errors, due to sound alike brand names.
4. More stringent measures like those initiated by the Government of Orissa, ^[14] such as, recovery of the cost of drugs if the prescription is found unjustified, could also be considered by the MHSDP.

Conclusions

Prescription audit is an important mechanism to improve the quality of care afforded by the hospitals. Data generated on the morbidity pattern coupled with the current practices of treatment of these diseases provided an objective basis for preparing an EML. Comparing the current usage of drugs with the standard treatment guidelines will enhance the effectiveness of treatment and render it cost-effective.

References

Copyright 2011 - Indian Journal of Pharmacology

The following images related to this document are available:

Photo images