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Indian Journal of Community Medicine

Prescribing Habits of Physicians in Medical College, Calcutta

Author(s): Ranadeb Biswas, P. Chatterjee, Malay Mundle*

Vol. 25, No. 4 (2000-10 - 2000-12)

Deptt. of PSM, All India Institute of Hygiene & Public Health, Calcutta-700073 *Deptt. of Community Medicine, Medical College, Calcutta

Abstract:

Research questions: 1. Is provisional diagnosis mentioned in prescription? 2. What types of drug formulations are prescribed and how many are available from the hospital? 3. Do doctors write generic names or proprietary names? 4. What are the prescribing indicators? 5. What are the patient care indicators?

Objective: To ascertain characteristics of prescriptions and to calculate prescribing indicators and patient care indicators.

Study design: It was a cross-sectional institutional observational study including record analysis.

Setting: Medical College Hospital.

Participants: Prescriptions of all patients attending for the first time for their current illness in the 4 OPDs viz. Medicine male, medicine female, paediatric medicine and gynaecology.

Statistical analysis: Z test for difference of proportions or 2 (chi square) tests were applied wherever required.

Results: Provisional diagnosis was mentioned in only 13.6% of prescriptions. 73% of available drugs were tablets, 24.9% syrups, 1.9% injections and only 0.2% were ointments. 2.57 drugs were prescribed per encounter, of which 32.6% were by generic names, 44.5% of encounters had an antibiotic, 1.82% had an injection but only 18.77% of drugs belonged to the Hospital formulary. Average consultation time was 127.99 21.9 Sec. and average dispensing time being 49.13 8.45 Sec. 51.54% of drugs were actually dispensed, 21.43% of drugs were adequately labelled, only 44.67% of the patients knew the correct dosage of drugs given to them.

Conclusions: Prescriptions are generally not according to recommended guidelines. There is also need to train pharmacists to properly label and explain the dosage of drugs as only 44.67% patients could tell the correct dosage of the drugs dispensed.

Keywords : Generic drugs, Proprietory drugs, Prescribing indicators, Patient care indicators

Introduction:

Out of 3390 health care institutions in West Bengal, 1265 are health Centres, 1177 are clinics, 551 are dispensaries and 397 are hospitals1. The health budget of West Bengal was 683.45 crores in 96-97. The major heads under this latter category include Urban Allopathic Services which consume 357.94 crores of the tax payer's money and also rural allopathic Services which account for 91.89 crores. The lion's share of the Urban Allopathic budget goes to hospitals and dispensaries accounting for 251.53 crores (70.3%). Among the urban allopathic hospitals and dispensaries, Calcutta hospitals receive 85.83 crores (34.1%). Of this amount, Medical College Calcutta receives 17.77 crores (20.7%), Medical College Hospital staff take home as salary and allowances 13.12 crores (73.8%) while expenditure for drugs account for just 2.04 crores (11.5%). Hence, the present study was conducted to understand the appropriateness of utilisation of these 2 crores meant for medical care out of 683.45 crores. It is a part of monitoring and supervision of current treatment practices and specific drug use behaviour and an exercise to compare the performance of individual facilities within Medical College Calcutta2,3.

Material and Methods:

The study was conducted in Medical College Hospital in 97-98 in the Medicine OPD male, Medicine OPD female, Paediatric medicine OPD and Gynaecology and Obstetrics OPD. It was a cross-sectional, institutional observational study including record analysis.

The sample size recommended for drug utilisation studies has been 600 per health facility4. The number of prescriptions screened in each of the 4 departments were more than 6004. The study tool utilized was universally accepted standardised Core Drug Use indicators5. All persons who attended these OPDs for the first time were screened after they consulted the concerned physicians.

Results:

Table I: Frequency distribution of record of diagnosis in prescriptions of OPDS of different Department.
Department Total Diagnosis recorded Z test/p value
Medicine OPD
Male (a) 602 74 (12.3%) a vs b = 62.5 p<0.05 
a vs e = 0.8 p<0.05
Female (b) 604 48 (8.0%) b vs e = 4.3 p<0.05
Pad. medicine OPD SNM (c) 603 127 (21.1%) c vs e = 4.2 p<0.05
Gynaecology & obstetric OPD (d) 602 78 (13.0%) d vs e = 0.4 p>0.05
Total*(e) 2411 327 (13.6)  

*Reference category for statistical test (Z/p)

Only 13.6% doctors noted the provisional diagnosis on hospital prescription. The situation was worse in Medicine OPD (female) being 8.0% (z=4.3, p<0.05) while it was better in Sishu Nivas Medical OPD being 21.1% (z=4.2, p<0.05).

Table II: Frequency distribution of availability of drugs prescribed in different departments from the hospital dispensary.

Department Total Available from
hospital No. (%)
Z test/p value
Medicine OPD
Male(a) 1672 994 (59.5) a vs b = 3.17 p<0.05
Female(b) 1863 1295 (69.5)   b vs e = 12.77 p<0.05
Paed. Medicine OPD SNM (c) 1523 999 (65.6) c vs e = 8.95 p<0.05
Gynaecology & obstetric OPD (d) 1131 127 (11.2) d vs e = 38.9 p<0.05
Total(e) 6189 3415 (55.2)
X2=1,136; p<0.05

The proportion of drugs available from the hospital dispensary was overall 55.2%, being highest in Medicine OPD female (69.5%) and a pathetic low of just 11.2% in Gynaecology and Obstetrics OPD where patients had to buy most of the major drugs from outside. The difference between number of drugs available from hospital and the number not available was statistically significant (X2=1136, p<0.05, coefficient of contingency Pearson's p=0.39).

The type of drugs prescribed showed overall 17.3% of all drugs being antibiotics, 14.5% antiallergic, 15.4% pain-killers, 15.9% vitamins and tonics and 20% antihelminthics. Pain-killer drugs were prescribed more from Medicine OPD male while antihelminthics were written more in Medicine OPD female. More than half the drugs prescribed from SNM OPD were antibiotics and antiallergics. The highest vitamin or tonic prescriptions came from Gynaecology-Obstetrics OPD. Most of these proportions were different from the total (z>1.96, p<0.05). Out of 5 drugs prescribed, one was an antihelminthic or drug acting on GI system. Out of 6 drugs prescribed, one was an antibiotic, another a musculoskeletal, a third an antiallergic and a fourth a vitamin tonic.]

Table III: Types of preparations prescribed and their availability in the hospital dispensary.

Department Total
available
Tablets
available
Syrup
available
Ointments
available
Injections
available
No. (%) No. (%) No. (%) No. (%)
MOPD 994 819 (82.4) 169 (17.0) 1 (0.1) 5 (0.5)
FOPD 1295 1011 (78.1) 279 (21.5) 0   5 (0.4)
SNM 999 592 (59.3) 400 (40.0) 1 (0.1) 6 (0.6)
G&O 127 72 (56.7) 2 (1.6) 4 (3.1) 49 (38.6)
Total 3415 2494 (73.0) 850 (24.9) 6 (0.2) 65 (1.9)

Table III shows that 2,494 or 73.0% of all drugs available from the hospital were tablets, 24.9% were syrups, 0.2% were ointments and 1.9% were injections. Most of the drugs not available from hospital were also tablets (51.9%) and syrups (42.51%). This trend was also prevalent in most of the OPDs except Gynaecology and Obstetrics where tablets were 56.7% while injections accounted for 38.6% of those available from the hospital. The syrups in SNM OPD accounted for 40% of the available drugs as well as 56.5% of the drugs prescribed which had to be bought from the market.

The proportion of tablets available from the hospital was far more than those which were not available except in Gynaecology and Obstetrics OPD where this ratio was reversed. Similarly, for syrups prescribed in Gynaecology and Obstetrics OPD mostly they were not available from hospital dispensary.

Table IV: Generic versus proprietory drugs prescribed in the different outpatient departments.

Department Total
generic
proportion
Available
from
hospital (a)
Not
available (b)
Z test/p
value a vs. b
Medicine OPD
Male(a) 651:1021
(1:1.57)
648:346
(1:0.53)
3:675

(1:225)
42.66
P<0.05
Female(b) 970:893
(1:0.92)
963:332
(1:0.35)
7:561(1:80.1) 70.01
p<0.05
Paed. Medicine OPD SNM (c) 394:1129
(1:2.87)
390:609
(1:1.56)
4:520
(1:130)
24.83
p<0.05
Gynacology & Obstetric OPD(d) 84:1047
(1:12.46)
80.47
(1:0.59)
4:1000
(1:250)
13.11
p<0.05
Total 2099:4090
(1:1.95)
2081:1334
(1:0.64)
18:2756
(1:153.1)
71.58
p<0.01

Table IV shows that among the available drugs, generic names were used in greater proportion (1:0.64), except in SNM OPD (1:1.56). Among the non-available drugs, use of proprietary names was in overwhelming majority (99.3%). Overall, only the medicine OPD female showed higher generic name use (52.1%) than proprietary names. All these differences were statistically significant (p<0.05).

Table V: Prescribing indicators in the different outpatients departments.

Prescribing
indicators*
Medicine SNM OPD Gyn. Obst. OPD Total
Male Female
Average no. of drugs per encounter 2.78 3.08 2.53 1.83 2.57
% of drugs prescribed by generic names 38.9 52.1 21.5 6.6 32.6
% of encounters with an antibiotic prescribed 51.7 39.2 65.9 21.1 44.5
% of encounters with an injection prescribed 2.16 0.17 1.66 3.32 1.82
% of drugs prescribed from EDL/formulary 18.7 26.9 18.8 5.4 18.77
*Selected drug use indicators, Geneva, WHO, 1993; EDL - Essential drug list.

Table V shows that 2.57 drugs were prescribed per first encounter and this exceeded in both Medicine OPD male and female, the latter having maximum drugs prescribed i.e. 3.08 per encounter. But medicine OPD female had 52.1% of drugs prescribed by generic names, whereas SNM had 21.5% and gynaecology obstetrics OPD a pathetic 6.6%. Overall, generic names account for 32.6% of all drugs. Antibiotic was prescribed in 44.5% of all prescriptions, being highest in SNM OPD (65.9%) and lowest in Gynaecology & Obstetrics OPD i.e. 21.1%. But the latter had highest injections prescribed (3.32%) as compared with 1.82% overall. Medicine OPD female adhered to drugs from essential drugs list (EDL) or Formulary, more (26.9%) than others (average 18.77%) (z=4.1, p<0.05).

Table VI: Patient care indicators in different out patient departments.

Patient care
indicators*
Medicine SNM
OPD
Gyn.
Obst. OPD
Average
Male Female
Average consultation time in secs. 105.49+24.58 75.86+11.21 120.53+23.07 210.07+28.73 127.99+21.90
Average dispensing time X X X X 49.13+8.45
Percentage of drugs actually dispensed 59.5 69.5 65.6 11.2 51.45
Percentage of drugs adequately labelled X X X X 21.43
Percentage of patients with knowledge of correct dosage X X X X 44.67
*Selected drug use indicators, Geneva, WHO, 1993.

Table VI shows that consultation time was longest in Gynaecology and Obstetrics OPD being 210.07 28.73 secs, but shortest in Medicine OPD female i.e. 75.86 11.21 secs. Average dispensing time was 49.13 8.45 sec, while 21.43% of drugs were found to be adequately labelled. Only 44.67% of the patients could tell the correct dosage of the drugs dispensed.

Discussion:

The provisional diagnosis was mentioned in 13.6% of the prescriptions only. In medicine OPD female it was 8.0% probably because only 2 medical officers were available to examine the patients showing a time constraint. In SNM OPD it was 21.1% because of more than 6 attending physicians.

Most of the drugs prescribed from Gynaecology and Obstetrics Deptt. were specific and hormonal preparations which were neither on the hospital formulary nor available for distribution. So the availability of prescribed drugs was more in medicine OPD female and male.

73% of all drugs available from the hospital were tablets, 24.9% were syrups, 1.9% were injections and 0.2% were ointments. SNM OPD prescriptions were mostly in syrups.

Generic names were used in greater proportion of those drugs available from the hospital dispensary, but of the others, brand names were more popular.

This study shows that 2.57 drugs were prescribed per prescription as compared to 3.94 by general practitioners and 1.97 by specialists as shown by Dr. J. Mitra in a study in Chetla6.

In the same study by Dr. J. Mitra, vitamins and tonics were the main group of drugs prescribed like in the present study, followed by drugs acting on the GI system and antibiotics6.

In the present study 32.6% of the drugs prescribed were by generic names and 44.5% of encounters had an antibiotic, while only 1.82% of encounters had an injection prescribed. Only 18.77% of drugs prescribed belonged to the hospital formulary.

Average consultation time was 127.99 21.9 seconds while average dispensing time was 49.13 8.45 seconds. 51.45% of drugs were actually dispensed, but 21.43% of these drugs were adequately labelled. Only 44.67% of the patients had knowledge of the correct dosage.

Thus, it is evident that prescriptions from Medical College were not as per recommended guidelines.

References:

  1. Govt. of West Bengal, Health on the March, State Bureau of Health lntelligence, 1994-95: 27-30.
  2. Govt. of West Bengal, Publication No. 17, Detailed demand for grants 1996-97, June 96.
  3. Govt. of West Bengal, Demand No. 32,33,34. Budget Speech 1996-97.
  4. WHO Regional Publications, studies in drug utilisation, European Series No. 8, Copenhagen, WHO Regional Publications, 1979.
  5. WHO, How to investigate use in health facilities, Selected drug use indicators, Geneva WHO, 1993 WHO/DAP/93(1): 1-87.
  6. Ghosh BN, Mitra J, Das KK: Prescription habits of physicians in an urban locality. Indian Journal of Public Health Vol. XXXI, No. 2, April-June 87: 120-8.

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