Presentation On :

Assessment of doctors prescription trend and rationality of drug prescribing in Bangladesh.

Presented By :Rajib Barua

PG14-03-11-030Batch : 3A

DEPARTMENT OF PHARMACYFACULTY OF SCIENCE

STATE UNIVERSITY OF BANGLADESH

ABSTRACT

Medically inappropriate and economically inefficient use of medicines is observed throughout the world. This study was carried out to evaluate the prescription rationality and drug prescribing practice of physicians in around Sylhet Division of Bangladesh. A prospective cross-sectional descriptive study was conducted using World Health Organization (WHO) core drug use indicator. A total of 3231 prescriptions were encountered with the total of 9591 drugs prescribed. The average number of drug per prescription was 2.5. Only 13% (n= 9591) of drugs were prescribed by generic name. Percentage of drug prescribed from WHO model list of Essential drugs, Essential drug list of Bangladesh and Bangladesh National Formulary was 21.7%, 32.8% and 42.3% respectively. Antibiotics and injections encountered were 28.3% and 3.1% respectively. Average cost per prescription was found to be Bangladeshi Taka (Tk.) 285.99. Patient knowledge on correct use of drugs and appropriate labeling was found to be approximately 15% and 1.4% respectively. Average dispensing time per prescription was 52 seconds. Majority of fixed dose combinations were prescribed for cardiovascular patients and diabetic patients. The drugs prescribed in the generic names were remarkably lower. Majority of the prescribed drugs were not followed the WHO model essential list. Irrational prescribing can be avoided by sticking to the ideal prescription writing. This study revealed that a lot of scope for prescriber education to improve prescribing patterns.

Introduction …..

Prescription writing is a science and an art, as it conveys the message from the prescriber to the patient (Kumari et al., 2008). More than 50% of all medicines worldwide are prescribed, dispensed, or sold inappropriately and 50% of patients fail to take them correctly (WHO, 2002). Rational use of medicines requires that “patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community”( World Health Organization. 1985). In simple words rational use means prescribing right drug, in adequate dose for the sufficient duration and appropriate to the clinical needs of the patients at lowest cost. The five important criteria for rational drug use are accurate diagnosis, proper prescribing, correct dispensing, suitable packing and patient adherence (Alam et al., 2006).

The aim of this study was to describe the prescribing pattern of physicians and rationality of Prescriptions in around Sylhet Division of Bangladesh.

The focus was not on to the drugs that are indicated for the patient's illness, but on the layout and content of the prescription. In particular, I wished to study the quality of the prescriptions in terms of the adequacy and clarity of the information contained and to describe the types and number, of medicines prescribed by doctors.

The study can increase awareness of problems and thereby assist to develop interventions for improving patient care by rational use of drugs.

Materials And Methods……..

A prospective study was carried out over three months April 2012 -July 2012 in out-patient department of private clinics and hospitals around Sylhet Division, Bangladesh. Prescriptions were collected during the study period from the patients (690) attending community pharmacies near to the private clinics and hospitals taken for the analysis.

Prescriptions were collected by taking their image. The parameters of audit for prescribing pattern were patient details (patient’s name and address and date of consultation). The following parameters are used to measure for assessment of rationality of the prescription, CIMS (Current Index of Medical Specialties) drug manual was used to decode the brand name of drugs to generic names for the purpose of analysis.

1. Total number of drugs prescribed.2. Average number of drugs per

prescriptions.3. Number of drugs in generic name.4. Duration of therapy.5. Dosage of drug and dose strength.6. Number of Antibiotics prescribed.7. Number of injections prescribed in the

prescription.8. Number of fixed dose combination

prescribed.9. Percentage of drugs which were from

the national list of essential drugs.10. Cost of the prescription.11. Monitoring of Drug-drug interactions.

Result……..

A total number of 3231 encounters with 9591 drugs were prescribed. The mean age of the patients was 34.68 ± 19.95 years. Among the total 4231 prescriptions, majority were from the Medicine department.

The average number of drugs per prescription was found to be highest in the Gynecology and Obstetrics department are listed in Table-1.The details of the therapeutic category of drugs prescribed are listed in Table-2.And finally ,The details of the antibiotics encountered is listed in Table-3.

Table-1: Average number of drugs per prescription.

Department Total number of drugs Average drug per prescription

Gynecology and Obstetrics 652 2.9

Medicine 2251 2.8

Otolaryngology 1044 2.7

Dermatology 1373 2.6

Orthopaedics 872 2.4

Psychiatry 741 2.4

Paediatrics 565 2.1

Surgery 385 2.0

Dental 219 2.0

Emergency 45 2.0

Ophthalmology 555 1.9

Medical oncology 19 1.6

Operation theatre 1 1.0

Not mentioned* 869 2.4

*= the departments were not mentioned in the following prescriptions.

Table-2: Therapeutic category of drugs prescribed (n= 9591)

Therapeutic classification Number of drugs Percentage

Antimicrobials 1627 20.1Analgesic and anti-inflammatory

drugs 1055 14.7

Drugs acting on gastrointestinal system 1149 10.8

Vitamins, minerals and dietary supplements 961 9.1

Drugs acting on central nervous system 941 8.9

Drugs acting on cardiovascular and renal system 838 7.9

Antiallergic drugs 733 6.9

Drugs acting on respiratory system 647 6.1Dermatological and other topical

agents 231 2.2

Ophthalmic preparations 202 1.9

Antiparasitic drugs 163 1.5

Antidiabetic drugs 139 1.3

Therapeutic classification Number of drugs Percentage

Antispasmodic drugs 126 1.2

Antiseptic, anti- infectives 114 1.1

Fixed dose combinations difficult to classify

114 1.1

Hormone and hormone antagonists 111 1.0

Oral care preparations 77 0.7

Vaccines 36 0.3

Anticancer agents 17 0.2

Miscellaneous 310 2.9

Table-3: Encounters with an antibiotic prescribed (n= 1196).Departments Number Percentage

Otorhinolaryngology 242 62.7

Medicine 219 18.8

Dermatology 128 24.6

Paediatrics 122 46.2

Ophthalmology 109 37.5

Obstetrics and Gynaecology 84 37.0

Surgery 61 31.6

Dental 59 55.1

Orthopaedics 7 1.9

Emergency 6 27.3

Psychiatry 3 1.0

Medical oncology 1 8.3

Operation theatre 1 100

Not mentioned* 154 4 2.7

*= the departments were not mentioned in the following prescriptions.

Doctor’s preference

In this, studies showed that doctors always followed following parameters to prescribe the drugs. For prescription generation …….

01. Product quality preference :-

02. Service preference :-

03. Sample preference :-

Best Average Least yes

Best Average Least

yes

Best Average Least

yes

04. Gift preference :-

05. Literature/pad preference :-

06. CME preference :-

07. MIO/MPO/MA quality preference :-

Best Average Least

yes

Best Average Least

yes

Best Average Least

yes

Best Average Least

yes

08. Doctor’s attendance influence :-

09. Chemist influence :-

10. Product safety & clinical trial preference :-

Best Average Least

yes

Best Average Least

yes

Best Average Least

yes

Discussion and Conclusion……….

• The finding of the present study indicates that the average number of drug per prescription was significantly higher than recommended by WHO, antibiotics and injections prescribed were considerably higher.

• The drugs prescribed in the generic names were remarkably lower. Majority of the prescribed drugs were not in accordance with the WHO model essential list.

• The results indicate a considerable scope for improving the prescribing pattern of drugs in the medical out-patient departments.

• Irrational prescribing can be avoided by sticking to the ideal prescription writing.

• There is some evidence that interventions such as short problem-based training course in pharmacotherapy (Vries et al., 1995) and rational use focused workshops (Thomas et al., 1997) can improve prescription behavior and skills.

References…..

• World Health Organization Promoting rational use of medicines: core components. WHO Policy Perspectives on Medicines no. 5.Document WHO/EDM/2002.3. Geneva, WHO, 2002. Available at URL: http://www.who.int/medicines

• WHO., 2010. Model list of essential medicines 16th list. http://www.who.int/medicines/publications/essentialmedicines/en/.

• Kumari, R., M.Z. Idris, V. Bhushan, A. Khanna, M. Agrawal and S.K. Singh, 2008. Assessment of prescription pattern at the public health facilities of Lucknow district. Indian J. Pharmacol., 40: 243-247.

• Alam, K., P. Mishra, M. Prabhu, P.R. Shankar, S. Palaian, R.B. Bhandari and D.A. Bista, 2006. Study on rational drug prescribing and dispensing in outpatients in a tertiary care teaching hospital of Western Nepal. Kathmandu Univ.Med.J.,4:436-443.

• Vries, T.P., R.H. Henning, H.V. Hogerzeil, J.S. Bapna and K.K. Kafle et al., 1995. Impact of a short course in pharmacotherapy for undergraduate

• Thomas, M., A.M. Cherian and D. Mathai, 1997. Measuring the impact of focused workshops on rational drug use. Trop Doct., 27: 206-210.

Thank You For Your Patience Hearing…..