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
- Number of drugs per prescription,
- Number of antibiotics per prescription,
- Number of drugs prescribed by generic name.
- Number of drugs prescribed from the WHO
Model List of Essential Medicines (EML) and
- 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.
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
- WHO. Drugs and Therapeutics Committees – A
Practical Guide, World Health Organization; 2003.
- 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)
- Souter A, Fredman B, White PF. Controversies in the
perioperative use of nonsteroidal anti-inflammatory
drugs. Anesth Analg 1994; 79: 1178-90.
- 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.
- 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
- 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.
- 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
- M Harmer, KA Davies. The effect of education,
assessment and a standardised proscription on
postoperative pain management. Anaesthesia 1998; 53:
424-430
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
- Number of drugs per prescription,
- Number of antibiotics per prescription,
- Number of drugs prescribed by generic name.
- Number of drugs prescribed from the WHO Model List of Essential Medicines (EML) and
- 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.
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
- WHO. Drugs and Therapeutics Committees – A Practical Guide, World Health Organization; 2003.
- 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)
- Souter A, Fredman B, White PF. Controversies in the perioperative use of nonsteroidal anti-inflammatory drugs. Anesth Analg 1994; 79: 1178-90.
- 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.
- 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
- 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.
- 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
- M Harmer, KA Davies. The effect of education, assessment and a standardised proscription on postoperative pain management. Anaesthesia 1998; 53: 424-430