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Indian Journal for the Practising Doctor

Original Paper
Drug Prescribing Pattern in Surgical Wards of a Teaching Hospital in North India

Author(s): Salman MT, Akram MF, Rahman S, Khan FA, Haseen MA, Khan SW

Vol. 5, No. 2 (2008-05 - 2008-06)

Salman MT, Akram MF, Rahman S, Khan FA, Haseen MA, Khan SW


ISSN : 0973-516X

Dr MT Salman, Dr SZ Rahman and Dr FA Khan are from the Department of Pharmacology; and Dr MA Haseen and Dr SW Khan from the Department of Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India – 202002.

Correspondence: Dr SZ Rahman, Deptt of Pharmacology, Jawahar Lal Nehru Medical Collrege, AMU, Aligarh, 202002


Abstract

Irrational use of medicines is widespread throughout the world. The main problems include the unnecessary prescription of drugs, particularly antimicrobials and injections. To investigate the situation in surgery wards, the present study was undertaken. Ninety six prescriptions were collected prospectively from post-operative patients admitted in surgery wards of the JN Medical College Hospital, AMU, Aligarh, and subjected for analysis according to the WHO/INRUD Indicators. VEN method was also applied to ascertain quality of drug procurement. It was revealed that the proportion of drugs from Essential Medicines List (EML) was 61.4%, while no drug was prescribed by generic name. Groups of drugs most commonly prescribed by general surgeons were antibiotics (93%), analgesics (60%), antacids (43%) and antiemetics (10%). The most extensively prescribed drugs from each of the above groups were injections Ceftriaxone and Amikacin, tablets Voveron, Pantoprazole and Metoclopromide, respectively. The average number of drugs prescribed per patient and cost per day per prescription was 4.8 and 246.1 INR, respectively. Average number of antibiotics prescribed per prescription was 2.2 and the average number of injections per prescriptions was 2.3. The results showed that the pattern of drug prescribing is not based on WHO criteria for rational use of drugs. The system is not at all evidence-based. It is thus necessary to make surgeons aware about good prescribing habit by following 5 steps of the WHO Program on Rational use of Drugs (RUD).


Introduction

Rational use of medicines requires that patients receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate period of time and at the lowest cost to them and their community. The irrational use of drugs is a major problem of present day medical practice and its consequences include ineffective treatment, unnecessary prescription of drugs – particularly antimicrobials and injections, development of resistance to antibiotics, adverse effects and economic burden on patients and the society. In spite of extensive programs on rational use of drugs and the Emergency Medicine List (EML) of WHO, which are being promoted by various national and international agencies working on health sector, irrational prescription is still a common practice.

Irrational drug combinations, banned drugs and withdrawn drugs are still being prescribed by both qualified physicians and quacks. There is a need of mass awareness amongst physicians and consumers about the concept of essential medicines, advantages of generic drugs prescription and use of rational combinations. This study was undertaken to audit the pattern of drug prescribing by surgeons to postoperative patients.

Materials and methods

Ninety six prescriptions of postoperative patients admitted in the General Surgical wards of the Jawaharlal Nehru Medical College Hospital, Aligarh, were collected prospectively between March 2007 and May 2007. These were analyzed according to the WHO/INRUD indicators1 for

  1. Number of drugs per prescription,
  2. Number of antibiotics per prescription,
  3. Number of drugs prescribed by generic name.
  4. Number of drugs prescribed from the WHO Model List of Essential Medicines (EML) and
  5. Number of injections per prescription.

The cost per prescription was also studied. Moreover, the commonly prescribed groups of drugs were also looked into. Vital, Essential and Non-Essential (VEN) Method1 was also applied for the above study to ascertain the quality of drug procurement. This information was compiled, scored and analyzed in consultation with a surgeon using WHO guidelines.

Results

Among the studied prescriptions, the most common groups of drugs (Figure 1) prescribed by surgeons were antibiotics (93%), analgesics (60%), antacids (43%) and antiemetics (10%). The most extensively prescribed drugs from each of the above groups were Injections Ceftriaxone and Amikacin, Tablets Voveron, Pantoprazole and Metoclopromide, respectively. Since these were postoperative patients, no vital drug was prescribed. The average number of drugs prescribed per prescription was 4.8±1.5 (antibiotics per prescription was 2.3±0.7 and injections per prescription was 2.3±2.1). Since there is no hospital formulary, the prescription of drugs was studied from the WHO Model List of Essential Medicines (EML). Only 62.2±18.1% of drugs were prescribed from the EML. None of the drugs was prescribed by generic name. The average cost incurred by the patient was 246.1±86.3 INR per day.

Fig 1. Groups of drugs commonly prescribed and percentage of prescriptions containing them in postoperative wards.

Groups of drugs commonly prescribed

Discussion

The review showed that the pattern of drug prescribing was not based on WHO criteria for rational use of drugs. The prescribing system was not at all evidence-based. The proportion of drugs prescribed from EML was low with an average prevalence of more than 2 broad spectrum antibiotics given unnecessarily along with extensive use of other drugs, with no drug prescribed by generic name. An interesting observation pertaining to the choice of antibiotic prophylaxis in surgery was the use of Ceftriaxone with Amikacin in majority of cases despite the awareness of similar gram negative coverage inherent in this combination. The most commonly prescribed analgesic was the NSAID, Diclofenac, although the suitability of NSAIDS for relief of postoperative pain remains controversial3. Also, proton-pump-inhibitors were prescribed too often. Routine polypharmacy leads to economic burden on patients and society and makes healthcare unaffordable to the common Indian masses. It is, thus, necessary to make surgeons aware about the use of drugs from EMLs, importance of prescribing drugs with generic names and, for patients’ point of view, the vital factor of costbenefit. Also there is a clear need for the development of prescribing guidelines and educational initiatives to encourage the rational and appropriate use of drugs in surgery4,5.

Improvement through continuing education (CME) is desired on part of prescribes to ensure a good standard of care and avoid practices that may increase antimicrobial resistance. Drug information services including side effects and drug interactions for professionals and consumers at the hospital are highly desirable. There is need of CMEs based on Good Clinical Practices (GCP) and Standard Treatment Guidelines (STG). These should be followed by drug utilization studies and feedback to the surgeons regarding prescribing behavior since the use of feedback has been shown to have a a significantly favorable impact on surgeons’ compliance with hospital guidelines, especially on antimicrobial prescribing.6,7 Similarly, it has been seen that a standardised process of education, assessment and standardised guidelines on postoperative pain management lead to significant reduction in postoperative pain, nausea, vomiting, as well as postoperative complications.8 Every institution must have a Drugs and Therapeutic Committee.

Conclusion

Results indicate that there is scope for improving prescribing habits among the fraternity and minimizing the use of antimicrobial agents. For rational prescribing of drugs, there is a need of mass awareness amongst surgeons about good prescribing habit by following five steps of WHO Program on Rational Use of Drugs (RUD).

References

  1. WHO. Drugs and Therapeutics Committees – A Practical Guide, World Health Organization; 2003.
  2. Trainers’ Guide. Implementing a drug use indicators study. Available at http://dcc2.bumc.bu.edu/prdu/Word_PowerPoint_Files/ Trainer_Guides_Word/7_implementingtg.doc (last accessed: 22/05/2007)
  3. Souter A, Fredman B, White PF. Controversies in the perioperative use of nonsteroidal anti-inflammatory drugs. Anesth Analg 1994; 79: 1178-90.
  4. de Vries TPGM, Henning RH, Hogerzeil HV, Fhresle DA. Guide to Good Prescribing (A practical manual). World Health Organization Action Programme on Essential Druge, Geneva. WHO/DAP/94.11.
  5. Hogerzeil HV, Barnes KI, Henning RH, Kocabasoglu YE, Moller H. Smith AG, Summers RS, de Vries TPGM. Teachers’ Guide to Good Prescribing. World Health Organization, Department of Essential Drugs and Medicines Policy, Geneva, Switzerland. WHO/EDM/PAR/2001.2
  6. Arnold FW, McDonald LC, Smith RS, Newman D, Ramirez JA. Improving antimicrobial use in the hospital setting by providing usage feedback to prescribing physicians. Infect Control Hosp Epidemiol. 2006;27(4):378-82.
  7. Willems L, Simoens S, Laekeman G. Follow-up of antibiotic prophylaxis: impact on compliance with guidelines and financial outcomes. J Hosp Infect. 2005 ;60 (4):333-9
  8. M Harmer, KA Davies. The effect of education, assessment and a standardised proscription on postoperative pain management. Anaesthesia 1998; 53: 424-430
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