Adherence to Prescription Format and Compliance with Who Core Prescribing Indicators

Transcription

1 Adherence t Prescriptin Frmat and Cmpliance with Wh Cre Prescribing Indicatrs H.S. Babar, S. Hussain, Z. Maqsd, H.A. Dad, M. Khan, A.A. Rahman, A. Bukhsh Institute f Pharmaceutical Sciences, University f Veterinary and Animal Sciences, Lahre, Pakistan Abstract The study was dne t see the prescriptin frmat and adherence t WHO cre prescribing indicatrs in the pharmacies surrunding the majr hspitals in Lahre. A ttal f 206 prescriptins were cllected randmly frm different pharmacies. They were analyzed fr their adherence t prescriptin frmat and ratinality f prescriptin. Patient & prescribers identifiers were mentined in mst f the prescriptins, superscriptin was present in 64%, and dse and dsage frm was mentined in 88% and 97% f the prescriptins respectively. Directin fr dsage and ttal amunt f drugs t be dispensed was 97% & 45% respectively. Instructins regarding use were present in nly 16% f prescriptins. Average n. f drugs per encunter was 3.8 which are mre than duble f as stated by WHO. Percentage f antibitics was fund t be 41% & that f injectable was 19%.Number f drugs prescribed frm NEML f Pakistan were 28.4% and generic prescribing was seen in nly 4 prescriptin ut f 206 which came ut t be drastically lw. The quality f prescriptins, in terms f pattern and f the drugs prescribed, was sub-standard. Adherence t WHO cre prescribing indicatrs was als unsatisfactry. Keywrds: Essential medicines list; Prescriptin patterns; Ratinal use f drugs; WHO cre prescribing indicatrs INTRODUCTION Prescriptin writing is a skill as it demnstrates the instructins prvided by the physician t the patient. There are n glbal standards fr the prescriptin writing but Wrld health Organizatin states that sme imprtant things shuld be written in a prescriptin s nt much can g wrng. These are name and address f the prescriber, with telephne number (if pssible), date f the prescriptin, name and strength f the drug, dsage frm and ttal amunt, prescriber's initials r signature, name and address f the patient; age (fr children and elderly) & Infrmatin fr the package label [1]. Patients must receive medicatins apprpriate t their clinical needs, in dses that meet their wn individual requirements, fr an adequate perid f time, and at the lwest cst t them and their cmmunity."[2] In develping as well as in develped cuntries, inapprpriate, futile, and ecnmically ineffective use f drugs ccur in health care system. The csts f such irratinal drug use are massive in terms f adverse clinical cnsequences f therapies. Wrldwide mre than 50% f all medicines are prescribed, dispensed, r sld inapprpriately, while 50% f patients fail t take them crrectly. Mrever, abut ne-third f the wrld's ppulatin lacks access t essential medicines [3]. The study was cnducted t identify the flaws in prescriptin patterns t create an awareness regarding the irratinal use f drugs by giving the feedback t the physicians. Main aims and bjectives f this study were; T check the presence f varius cmpnents f a standard prescriptin frmat, in the prescriptins frm different physicians T suggest any necessary strategies t minimize errrs wing t wrng prescriptin frmat T suggest a standard prescriptin frmat, which needs t be develped by the gvernment authrities and t be implemented T evaluate the cmpliance f physicians twards WHO cre prescribing indicatrs T suggest necessary plicies t be made in the health care system by the authrities t ensure ratinal prescribing f drugs T suggest the utilizatin f NEML while prescribing and the cncept f generic prescribing T measure the degree t which physicians fllw the natinal drug plicy T measure the level t which antibitics and injectins are being prescribed T measure the percentage prescriptin trends f prescribing drugs by generic name. MATERIALS AND METHODS A prspective, descriptive and crss-sectinal study was designed and cnducted n the data cllected frm the prescriptins cllected frm varius cmmunity pharmacies f Lahre. Permissin fr cllecting the data was taken frm managers f all the pharmacies in which the study was cnducted. During the study, 206 prescriptins f ambulatry patients f all categries f diseases and age grups were audited and analyzed. Parameters were evaluated using the snapshts f the prescriptins. The data was cllected n the Frm 1 (Appendix III). The cmpnents f prescriptins were analyzed separately. Presence f patient identifiers, superscriptin, inscriptin, transcriptin, subscriptin, and physician identifiers was checked. Apart frm this, each prescriptin was checked fr the cmpliance f the prescribers with WHO cre prescribing indicatrs. RESULTS AND DISCUSSION Tw parameters were evaluated during this study i.e. adherence t prescriptin frmat and cmpliance with WHO Cre Prescribing Indicatrs. A ttal f

2 prescriptins, taken frm varius pharmacies and medical stres were audited. The results have shwn that mst f the prescriptins were lacking the imprtant patient demgraphics. Mst f the prescriptins were missing Age, Sex and Address f the patient. Out f 206 prescriptins, 180 prescriptins (87%) were cntaining the name f the patient. The remaining 26 prescriptins (13%) were missing the patient s identity. Such prescriptins are always a surce f serius medicatin errrs like dispensing f medicatin t any wrng patient. While a study cnducted in Andrapradesh, India shws that 100% f the prescriptins were carrying patient s identity [5]. Age f the patient is imprtant t be mentined n the prescriptins. This facilitates the selectin f crrect dse f any drug t be dispensed t any patient and may als help in dispensing f the crrect dsage frm f the drug. Age f the patient, accrding t the current study was mentined in 115 prescriptins (55%). This number is still better than the number fund ut in the study cnducted in Andrapradesh, India, which shws that nly 15% f the prescriptins were cntaining the age f the patient [5]. While in a study carried ut in Karachi, Pakistan, 42% f the prescriptins were cntaining the age f the patient [4]. In current study, gender f the patient was mentined in 88 prescriptins (42%), while it was mentined n 24.5% prescriptins in the study carried ut in Karachi, Pakistan [4]. An alarmingly lw number f the prescriptins were cntaining the address f the patient, i.e. nly in 7 prescriptins (3%) ut f the ttal 206. Althugh this percentage may be better than that bserved by Parvani V. et al, wh fund ut that nne f the prescriptins cntained the address f the patient in Warangal, India [5]. The trend f mentining the address f the patient is very lw in ther areas f Pakistan as well. Fr example, nly 1% f the prescriptins analysed in the study cnducted in Dental Teaching Hspitals f Karachi were having the address mentined n them [4]. Hence the current shws that there is lack f practice f mentining the age, gender and address f the patient in the prescriptins in Lahre, Pakistan. Althugh the name is mentined n 87% prescriptins, still this number needs t be increased t 100% t avid any kind f medicatin errrs. Mentining superscriptin is cnsidered imprtant while writing the prescriptin. Superscriptin is usually dented by the sign Rx, r any ther sign may als be used fr this purpse like Hu-Wal-Shafi r any ther wrd as preferred by the physician. In the prescriptins analyzed during this study, 132 prescriptins (64%) ut f ttal 206 were cntaining this cmpnent f the standard prescriptin. This number is relatively mre than that fund ut in prescriptins analyzed in Karachi, Pakistan, where it was fund ut t be 61% [4]. While nly 35% f the prescriptins, analyzed in Waringal, India were carrying the superscriptin [5]. Anther study, cnducted in Jaypur, India shws that 100% f the analyzed prescriptins were carrying this cmpnent [6]. Inscriptin cntains names f the drugs t be taken, dse f the drug t be taken by the patient and the dsage frm f the drug t be dispensed t r used by the patient. In the current study, dse f the drug t be taken by the patient was mentined n 182 prescriptins ut f 206, i.e. 88% f the prescriptins.. This percentage is higher than that fund ut in the study cnducted in Karachi, Pakistan, which shws that the dse was mentined in nly 77.5% f the prescriptins [4]. Dsage frm f the drug was mentined in 201 prescriptins, that makes it 97%. This number is near t ideal, and quite higher than that bserved in the prescriptins analyzed in Waringal, India, where it was fund ut t be 74.8% [5]. While nearly equal percentage f 98.6% was bserved in the study, which analysed the prescriptins in Jaypur, India [6]. Subscriptin is the next imprtant parameter f the prescriptins that was audited in the current study. This cmpnent cnsists f tw parts; directins regarding the dsage, and the ttal amunt f any drug which is t be dispensed. Directins regarding were mentined n 200 prescriptins that cmpses abut 97%. This number is a healthy amunt, althugh all the prescriptins shuld carry such directins, s that ratinal drug utilizatin by the patient and cmpliance with the crrect dsage schedule can be ensured. Ttal number f drugs t be dispensed is quite imprtant t be mentined n the prescriptins. This number is usually mentined in encircled frm after the drug s name and strength t be taken. This cmpnent may als be mentined in terms f the ttal number f days, fr which a prescribed drug is t be taken. This cmpnent assists the drugs dispenser t dispense the exact amunt f the drug t the patient. This cmpnent is quite imprtant t be mentined in case f such drugs like sterids, narctics and antibitics etc., s as t avid any drug misuse r veruse. In the current study, 45% i.e. 93 prescriptins ut f the ttal 206 were cntaining this cmpnent. Althugh this percentage is nt ideal, but is significantly higher than that bserved during the study cnducted in Karachi, Pakistan, which shws that nly 1% f the prescriptins were carrying this cmpnent [4], but is quite lwer than that bserved in Jaypur, India, that is 92.66% [6]. In anther study carried ut in Jammu by Sharma P. et al in 2003, this cmpnent was mentined in 66% f the prescriptins, which is als relatively higher than that bserved in current study [12]. Transcriptin is the next imprtant cmpnent in a standard prescriptin. This cmpnent invlves the written instructins regarding the use f drugs. Instructins may be related t time differences between the medicatin administratin and any rutine event, r it may als invlve any necessary precautin, which is t be kept in mind while taking any medicine. This cmpnent was mentined in 34 prescriptins, which cnstitute nly 16%. Remaining 84% f the prescriptins were devid f the necessary instructins regarding drug utilizatin. And such a high avidance f this cmpnent in the rutine prescriptins may lead t irratinal use f the drugs by the patients. In cntrast t this, in India, the study reveals that nly 32% f the prescriptins were devid f such instructins. Althugh this number is still high, but is quite better in relatin t the current study s results [5]. Prescriber s identifiers include name f the prescriber and the address f the prescriber. In the current study, the name 196

3 f the prescriber was stated n 82% f the evaluated prescriptins i.e. 169 ut f 206 prescriptins. Whereas accrding t the study by Aisha W. et al in Karachi, Pakistan, physician s name was present in nly 1.5% f the prescriptins [4]. S the current study s results shw that there is a much better trend f mentining the physician s name in Lahre as cmpared t Karachi. Address f the prescriber was mentined in 190 prescriptins (92%), which is als much better as cmpared t that fund ut by Aisha W. et al in Karachi [4]. Table 1 summarizes the results f all the parameters discussed abve. Table 1: Parameters t Evaluate Standardizatin Prescriptin Pattern S. N Parameters t be evaluated %age bserved 1 Name f patient was mentined 87% 2 Age f patient was mentined 55% 3 Sex f patient was mentined 42% 4 Address f patient was mentined 03% 5 Rx sign was present in prescriptin 64% 6 Name f drug was mentined 100% 7 Dse f drug was mentined 88% 8 Dsage frm f drug was mentined 97% 9 Directins f dsage ware given 97% 10 N. f drugs t be dispensed was mentined 45% 11 Instructins abut use were given 16% 12 Name f prescriber was mentined 82% 13 Address f prescriber was mentined 92% Ratinal drug prescribing is defined as the use f the least number f drugs, t btain the best pssible effects in the shrtest perid at a reasnable cst [13]. Plypharmacy ften leads t a high chances f drug-drug interactins, txic drug effects and high cst f the treatment. In current study, the average number f the drugs per encunter was fund ut t be 3.8. This number highly deviates the standard prvided by Wrld Health Organizatin, accrding t which, the average number f drug per encunter shuld be between 1.6 and 1.8 [14]. This study reveals similar results as that f the studies cnducted in Warangal, Jaypur, and Lucknw in India, in which average number f drugs prescribed per encunter were 3.41 [5], 3.7 [6] and 3.1 [7] respectively. Whereas anther study cnducted in tertiary hspitals f Nigeria shws that this number was 3.04 [8]. Average number f drugs per encunter was fund ut t be 1.9 in Ethiupia by Desalegn A. [9], which is quite clse t the standard value prvided by WHO. S there is a need t decrease the ttal number f the drugs prescribed, t the extent pssible, s as t avid the ply pharmacy that may lead t increased number f medicatin errrs, increased number f side effects and an increased burden n the patient and the sciety as a result f increased cst f therapy. Generic prescribing has several merits as well as demerits. But in case f generic prescribing, the benefits verweigh the lsses. S a huge emphasis is laid by WHO n prescribing f the drugs by their generic name. Accrding t the WHO standards, 100% f the drugs shuld be prescribed generically. An alarmingly lw number f the drugs were mentined by their generic names. During this study, 6 categries were made t define the extent f generic prescribing. Only 2% f the prescriptins were falling in the categry in which generic prescribing was between 1 and 25% f the ttal prescribed drugs, as shwn in table 2. A ttal f 4 drugs ut f 792 drugs were stated by their generic names, which cnstitute nly 0.5 %. In cntrast, the percentage f the drugs prescribed by the generic name in Ethipia was fund ut t be 98.7% by Desalegn [9] where as in Kan, Nigeria, in tertiary health care facilities, the drugs prescribed by generic name was 42.7% [8], while in India, in Jaypur, nly 8.33% prescriptins were by generic names [6] and in Lucknw, abut 27.1% f the drugs were mentined by the generic name [7]. Hence accrding t these stats, the number f drugs prescribed by generic name is very pr as cmpared t ther cuntries. There is a need t implement the plicy f generic prescribing in Pakistan, as it reduces the cst f the drug, bth t the patient and pharmacies and als reduces the chances f generic duplicatin, that may lead t hazardus side effects and drug induced txicity. This will als help t minimize unethical marketing strategies adpted by sme industries. Irratinal use f antibitics is always assciated with a vast number f side effects and emergence f resistant strains f micrbes. Antibitics shuld be prescribed after culture sensitivity reprt. And cmplete curse f antibitic fr a particular infectin shuld be ensured. In Pakistan, antibitics are usually prescribed abundantly and irratinally. In current study, it was bserved that 86 prescriptins i.e. 41% f the prescriptins were carrying ne r mre antibitic(s) prescribed in them. Accrding t the standard values given by WHO, the number f prescriptins carrying antibitics prescribed shuld be between 20.0% and 26.8% [14]. S the value bserved during the current study is much mre than the standard ne. This value was 34.4% accrding t a study cnducted in Nigerian Tertiary Care Hspitals [8], while in India, in different cities, different percentages f antibitics encunters were seen; in Jaipur, it was as high as 63.33% [6], whereas in Lucknw, it was 20.6 [7]. In an Ethipian study, this number was fund ut t be 34.3% [9]. While in Nepal, this number was as lw as 18% which is an ideal value [10]. Our study demnstrates that in Lahre, Pakistan, an excessive use f antibitics is there. This may lead t abve stated unwanted circumstances, s there is a need t minimize the prescribing f antibitics. Injectins need a great care t be emplyed while administratin t the patient. Althugh injectable frmulatins have varius benefits, but they need expertise and great precautins t be taken while administratin. They als increase the cst f therapy and burden n the patient r sciety. In current study, 40 prescriptins f the 206 (19%) were cntaining injectable drugs in them. Accrding t WHO standards, % f the prescriptins may cntain injectable items in them [14] % prescriptins were cntaining injectables accrding 197

4 Jaipur s study in India [6] while in Ethipia, this number was 38.1 accrding t Desalegn A. et al [9] and in Nepal, 30% f the prescriptins were carrying injectables [10]. This number was very lw in Nigeria, i.e. 4%, accrding t Tamun I. et al [8]. The percentage f injectables prescribed is nt higher than the standard limits, s the need is there t maintain the current levels. Essential Medicine List f any cuntry identifies thse drugs, that fulfill the need f maximum number f patients in any cuntry. WHO gives a great emphasis n develpment f EML, and t fllw its cncept in true sense. If there is a brief number f drugs that are usually prescribed, it wuld be easy t maintain and cntrl the full inventry f thse drugs. But nrmally in Pakistan, cncept f Essential Medicine List is nt usually fllwed during prescribing. This study reveals that a very small number f the drugs are prescribed frm the EML. WHO states that 100 percent f the drugs must be prescribed frm the Essential Medicine List f any cuntry [14]. But in the current study 225 drugs ut f the ttal 792 drugs, in 206 prescriptins were prescribed frm the Essential Medicine List, which makes it %. This number is very lw when cmpared with WHO Standard value, i.e. 100% as well as that fund in ther cuntries, such as Jrdan, where this percentage was 93% as described by Otm S. et al [11] ; and Ethipia, where 96.6% f the drugs are prescribed frm EML as per the study f Desalegn [9] and in Nigeria, where this percentage was fund t be 94% by Tamun I. et at [8]. In Nepal, 75% f the f the drugs are prescribed frm EML as illustrated by Sapkta S. et al [10], while in Lucknw India, this percentage was as much as 89% [7]. Number f the drugs, prescribed frm EML needs t be increased while prescribing in Pakistan, s as t match the number with the WHO standards. The ver-all results f the cmpliance with the WHO prescribing agents are summarized in table 2. Table 2: Analysis f WHO Cre Prescribing Indicatrs S. n Indicatrs Results Standard Average number f drugs per encunter Percentage f drugs prescribed by generic name Percentage f encunters with an antibitic prescribed Percentage f encunters with an injectin prescribed Percentage f drugs prescribed frm essential drugs list r frmulary % 100% 41% 20%-26.8% 19% 13.4%-24.1% 28.40% 100% CONCLUSION Frm the current study, we cnclude that prescribing practices in Pakistan are nt up t the mark, as they are in varius ther cuntries. Adherence t the standard prescriptin frmat is very pr. Mstly patient demgraphics, instructins fr drug use and prescriber identifiers are missing in the prescriptin. There is a need fr regular refresher curses and training prgrams during the service f the physicians and during huse-jb. Medical students shuld als be emphasized t learn abut writing the prescriptins in a standard way during the curse f their degree. There is a need fr the regulatry agencies t develp a standard prescriptin frmat, and implement it thrughut the cuntry. Als it was bserved during the study that irratinal practices f prescribing the drugs is quite cmmn. There is a pr cmpliance f the physicians with WHO Cre Prescribing Indicatrs. Irratinal prescribing is quite cmmn, that is usually assciated with varius undesired drug effects, txicities, tlerances and resistance. Ply-pharmacy is quite cmmn and the cncept f generic prescribing is negligible. Excessive use f antibitics is cmmn, that is leading twards emergence f resistant strains f micrbes. Injectable drugs prescriptin is within the standard limits accrding t this study. There is a pr trend f prescribing the drugs frm NEML. Regulatry agencies shuld arrange seminars, wrkshps and regular training prgrams in rder t get the values f these cre prescribing indicatrs within the range f standard values laid by the WHO. Regulatins regarding the prescribing f drugs by generic names shuld be made and strictly implemented. Well established standard treatment guidelines abut the prescriptin f varius antibitics must be develped and full curse f any antibitic must be emplyed. Strict cnditins must be implemented abut the prescriptin and administratin f the injectable drugs and their use shuld be minimised t the extent pssible. There is als a need t emphasise the physicians abut prescribing the drugs frm Natinal Essential Medicine List. Availability f Natinal Frmulary and NEML shuld be ensured in every health institutin. By taking all these steps, adherence t the standard prescriptin pattern and cmpliance with WHO Cres Prescribing Indicatrs can be ensured. ACKNOWLEDGMENT We thank ur supervisr f this prject, Mr. Allah Bhuksh Awan fr the valuable guidance and advice. We wuld like t thank Dr. Farzana Chwdhary, Directr f the Institute f Pharmaceutical Sciences, University f Veterinary and Animal sciences Lahre, fr her cntinuus supprt and prviding us with all facilities t cmplete this prject. We wuld like t thank Dr. Talat Naseer Pasha, Vice Chancellr f University f Veterinary and animal sciences Lahre fr prviding us the facilities in the university. We thank all the Cmmunity Pharmacies which prvided us the data necessary fr ur research and fr being really supprtive thrughut this prject REFERENCES Guidelines: 1 Guide t Gd Prescribing by WHO (http//apps.wh.int/medicinedcs/en/d/jwhzip23e/5.4.html) 2 Prmting Ratinal Use f Medicines Cre Cmpnents - WHO Plicy Perspectives n Medicines, N. 005, September 2002 (http//apps.wh.int/medicinedcs/en/d/jh3011e/1.html) 3 Prmting Ratinal Use f Medicines Cre Cmpnents - WHO Plicy Perspectives n Medicines, N. 005, September

5 (http//apps.wh.int/medicinedcs/en/d/jh3011e/2.html) Jurnals: 4 Assessing Prescriptin-Writing Skills f Huse Officers in Dental Teaching Hspitals f Karachi, Pakistan; Aisha Wali, Anwar Ali, Talha Mufeed Siddiqui, Hamza Jafri; http// =4056&Type=FREE&TYP=TOP&IN=_eJurnals/images/JP LOGO.gif&IID=320&isPDF=YES 5 Study f Prescribing Pattern fr Evaluatin f Ratinal Drug Therapy in Warangal; Pavani V, Mihir. Y. P, Shravani K, Prabhakar R V; St. Peters Institute f Pharamceutical Sciences, Vidyanagar, Hanamknda, Warangal, Andhra Pradesh , India; Link http//ijpp.rg/oct%20- %20Dec,%202011/77-79.pdf 6 Assessment f prescriptin pattern in a private teaching hspital in India; Shipra Jain, Zafar Yab Khan, Prerna Upadhyaya* and Kumar Abhijeet; Department f Pharmaclgy, Mahatma Gandhi Medical Cllege & Hspital, Jaipur, India http//ijps.aizenpublishers.net/cntent/2013/3/ijps pdf 7 Assessment f prescriptin pattern at the public health facilities f Lucknw district; Ranjeeta Kumari, M.Z. Idris, Vidya Bhushan, Anish Khanna, Mnika Agrawal, and Shivendra Kumar Singh; http// 8 Drug Prescriptin Pattern in a Nigerian Tertiary Hspital; Igbiks Tamun and Jseph O Fadare; Department f Pharmaclgy, Faculty f Medicine, Bayer University, Kan, Nigeria & Department f Internal Medicine, Federal Medical Centre, Id-Ekiti, Nigeria(http// Drug_Prescriptin_Pattern_in_a_Nigerian_Tertiary_Hspit al) 9 Assessment f drug use pattern using WHO prescribing indicatrs at Hawassa University teaching and referral hspital, suth Ethipia a crss-sectinal study; Anteneh Assefa Desalegn, Pharmaclgy Unit, Schl f Medicine, Hawassa University, Hawassa, Ethipia; http// 10 DRUG PRESCRIBING PATTERN AND PRESCRIPTION ERROR IN ELDERLY A RETROSPECTIVE STUDY OF INPATIENT RECORD; SUJATA SAPKOTA, NAWIN PUDASAINI, CHANDAN SINGH, SAGAR GC; Department f Pharmacy, Kathmandu University, Kavre, Nepal; (http// 11 Evaluatin f drug use in Jrdan using WHO prescribing indicatr ; Otm S, Batieha A, Hadidi H, Hasan M, Al- Saudi K (http//eurpepmc.rg/abstract/med/ /relad=2;jsess inid=p9nphb1rbil3jbnhd4.56) 12 Sharma P, Kapr B. (2003). Study f Prescribing Pattern fr Ratinal Drug Therapy. J K Sci. 5(3) Shankar P R, Upadhyay D K, & Subish P, et al., Drug utilisatin amng lder inpatients in a teaching hspital in Western Nepal, Singapre Med J, 2010; 51(1) The develpment f standard values fr the WHO drug use prescribing indicatrs http//archives.wh.int/icium/icium1997/psters/1a2_txt.html 199