Arunai College of Pharmacy, Velu Nagar, Thenmathur, Tiruvannamalai, Tamilnadu, India.
Background: This study examines the appropriateness of drug prescribing pattern in rural areas of Tamilnadu. To determine the Quality of Prescription, so as to provide the basis for the modification in the futuristic drug usage thereby improve the patients Quality of Life. Methods: A prospective, observational and cross-sectional study which investigated the prescribing practices of prescribers using WHO indicators at selective rural areas of Tamilnadu. We have reviewed 194 outpatient prescriptions found in community pharmacies over the period of three months. Results: Totally 194 Prescriptions were analyzed, Most of them belongs to the age group of 21 to 40 years old; The Gender prevalence higher in females than male. Oral Route was mostly preferred. An average number of drugs per prescription was 3.86. Percentage of drugs prescribed in generic name was 18% only. 62.4 and 37.6 Percent of drugs included in essential drugs list (WHO) 2023 and NLEM India respectively. Total number of prescriptions with antibiotics was 73.6% and Total number of injections in prescription was found to be 17.86%. Conclusion: The finding in this study correlates with most of the previous studies. Most of the prescribing indicators assessed were out of the ranges recommended by WHO implies the irrationality in the prescribing practices. Therefore the well organized intercessions should be implemented by the regulatory bodies found at various levels inorder to improve the quality of prescribing practices as well as to improve patient’s quality of life.
Medicines play crucial role in the delivery of healthcare service across the globe1. The unavailability of medicinal product leads to public confidence in healthcare is dwindled. Nevertheless, not only the availability but also the prescribing manner in which they are prescribed by healthcare professionals, Rationality of the prescription may be a reflection of the quality of life and care delivered to patients and the community. A drug prescribing pattern refers to the manner in which health care providers prescribe medications to the patients. It is used for the analysis of the types of dosage forms and combinations of medications prescribed, as well as their frequency and duration of the treatments. Rational use of medicines is observed when 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 price. Irrational use of medicines is a common phenomenon in developing countries due to over usage of injections, polypharmacy, confusion in drug names and so on. This insist the need for regular assessment in prescribing practices to improve the pharmacotherapy quality, safety and effect. Drug assessment is a systematic and comprehensive evaluation of drugs quality, safety, efficacy and performance. The collection, analysis and interpretation of data related to the drugs chemical, pharmacological, toxicological and clinical properties are involved. World Health Organisation framed the indicators to assess the appropriateness of the prescription1. They are as follows:
1) Prescribing indictors
2) Patient care indicators
3) Facility indicators
1) Prescribing Indicators
Prescribing indicators are a set of metrics used to measure how well health care providers use medicines. These indicators are based on an analysis of patient encounter, which are defined as the time patients interact with a health care provider1.
How to Calculate WHO Prescribing Indicators?
Methodology And Study Design:
The research was conducted as a cross – sectional study in the Out Patients (OP) around rural areas of Tamilnadu which was approved by the institutional authority. This study prospectively assessed prescriptions of patients after consulting doctors in the Out Patient Department of various departments. Each prescription was considered a single patient encountered for calculation of the required parameters. Each prescription from patients of any age and either gender were included in the study. The inpatients prescriptions and discharge medications were excluded from the study.
Data Collection and Analysis:
Five well trained budding pharma researchers were collected the data. The data collected from each prescription was filled up in a predesigned proforma. The various WHO indicators related parameters and demographic profile were recorded. Statistical analysis was performed by using Microsoft Excel 2015 for calculating ranges and percentage. The WHO core drug prescribing indicators were analysed using average number of drugs prescribed per patient encounter, percentage of drugs prescribed by generic name, percentage of encounters with an antibiotic prescribed, percentage of drugs prescribed based on essential drug list or formulary and percentage of encounters with an injection prescribed. The study focused on identifying and analysing prescription errors related to rationality and legibility. The sample size of our study was 194 as per the WHO guidelines “How to investigate drug use in health facilities: selected drug use indicators February 21,1993”. The study was conducted for a duration of November 2024- January 2025 (3 months).
RESULTS:
A total of 194 prescriptions were collected in which 750 drugs were prescribed. The demographic profiles of the patients showed that up to age of 20 years was 15.46%, in between 21-40 years, 41-60 years, 61-80 years and >80 age group were 35.05%, 31.95%,15.46% and 2.06% respectively. (Figure 1).
Figure 1: Age distribution of Patients
Gender Wise Distribution:
In this study, the proportions of Females were higher 54.63% as compared to Males 45.36% (Figure 2).
Figure 2: Percentage of Sex Distribution
Distribution Among Various Route of Administration:
The most common route used were oral route 78.6% followed by parenteral route 17.86% and topical route 2.93%. (Figure 3).
Figure 3: Common Routes Administrated
Distribution Based on Who Prescribing Indicators:
Average number of drugs per encounter was 3.86; Drugs prescribed from Essential Drugs List (India) was 37.6%; Drugs prescribed from Essential Drugs List (WHO) was 62.4%. Total number of Prescriptions with Injections was 17.86%; Total number of prescriptions with antibiotics was 73.6% and Drugs prescribed by Generic name were 18% (Table 1).
Table 1: Prescribing Indicators
|
Parameters |
Observed Table |
|
Total number of prescriptions Analysed |
194 |
|
Total number of drugs prescribed |
750 |
|
Average number of drugs per encounter |
3.86 |
|
Drugs prescribed by generic name |
18% |
|
Drugs prescribed from essential drug list (India) |
37.6% |
|
Drugs prescribed from essential drug list (WHO) |
62.4% |
|
Total number of prescriptions with antibiotics |
73.6% |
|
Total number of prescription with injections |
17.86% |
Drug Category Based Distribution:
The most common drug groups prescribed after antibiotics were Analgesics 18.13% followed by Anti-ulcerants 17.7%, Antibiotics 11.2%, Anti-histamine agents 6.93%, Vitamin Supplements 6.53%, Anti-emetics 5.33%, Anti-hypertensive drugs 5.2%, Sedatives & Hypnotics 4.26%, Anti-diabetic drugs 3.46%, Anti-Asthmatic drugs 3.33% respectively (Figure 4).
Figure 4: Percentage Of Drug Categories
Distribution Based on Disease Prevalence:
Most of the patients had Pyrexia 37.11% followed by Body pain 24.74%, Cough 20.69%, Cold 20.10%, Vomiting 15.46%, Chest pain 8.76%, Stomach pain 7.73% (Figure 5).
Figure 6: Prevalence of Diseases
Distribution Based on Incidence of Polypharmacy:
The incidence of Poly Pharmacy was also common with range of 1 to 9 drugs per prescription. 28 prescriptions had two drugs per prescription. 22.68% of prescriptions had 4 drugs, 19.07% had 5 drugs and 9.27% had 6 drugs per prescription. More than 8 drugs were prescribed in 1.030% prescriptions. Prescriptions contained 4 or more drugs were about 55.135% (Table 2).
Table2: Incidence of Poly Pharmacy
|
No. of drugs prescribed per prescription |
No of prescription |
Percentage |
|
1 |
6 |
3.09% |
|
2 |
28 |
14.43% |
|
3 |
53 |
27.31% |
|
4 |
44 |
22.68% |
|
5 |
37 |
19.07% |
|
6 |
18 |
9.27% |
|
7 |
5 |
2.57% |
|
8 |
2 |
1.03% |
|
>8 |
1 |
0.515% |
DISCUSSION:
Prescription auditing is a vital tool for reviewing as well as assuring the quality in healthcare sector. They should address problems that have serious consequences for patients, if proper pharmacological therapy is not given. The audit data will be of great value to health care providers, for their decision making and drafting policies.
In present study, 194 prescriptions were analysed, contained 750 drugs. Therefore average number of drugs per encounter was found to be 3.86 which is quite similar to the study carried out by Amol Gujar et al.,(3.08)15. This value is contrast to most of the other reference studies. The resultant value is much higher than the WHO’s recommended limit of 1.6 to 1.8. This value is also higher in studies done by Vijayakumar et al., (11.7)17, Binaya et al., (5.85)16, Asha Pathak et al.,(5.11)7, Ahamed Atia et al.,(4.72)14, Mukadam et al.,(4.5)18, Increase in the number of average drugs per prescription may leads to the increase in risk of drug interactions, unwanted adverse drug reactions. It also increases the cost of treatment and increased chances of emergence of drug resistance.
Drugs prescribed by generic names were only in 18 % of cases. Although this is low as compared to standard value 100% but is higher than study done by Binaya et al.,16. The low incidence of this indicator shows the influence of branded products in market. Generic prescribing reduces the chances of dispensing errors which may be due to misinterpretation of like sounding names of drugs and also promotes the cost effectiveness to the community.
Antibiotics prescribed were 73.60% out of all drugs. According to WHO 15-25% of prescriptions with antibiotics are expected in most of the developing countries where infectious diseases are more prevalent. This figure exceeds the standard limits however figure was very high 84.8%, 82.5% and 80.20% in study done by Aggrey et al.,8, Arebu et al.,6 and Belete Birhanu et al.,12 respectively. The exceeded figure in this observed study clearly shows that the increased risk of acquiring antimicrobial resistance which leads patients quality of life quessionable as well as the future of modern medicine field.
Percentage of Injectables were used in the assessed prescription was found to be 17.86 which comes under the standard range recommended in WHO prescribing indicators. The value was much lower than the standard range in the studies done by Lily et al., (0.9%)4, Sharon et al., (2.74%)10 and Alemu et al., (3.1%)13. It is required to reduce the unnecessary use of injectables to prevent HIV and other blood borne infections7.
Drugs from NLEM was very much lower than the standard value ie., 37.6% only which was also too lower than the studies carried out by Belete Birhanu et al., (100%)12 from the reference, This study only attains the recommended range, Solomon et al., (96.7%)11, Aggrey et al., (96.7%)8, Arebu et al., (92%) 6 but these studies were still on the lower side as compared to standard value; Also the percentage of drugs prescribed from the essential drugs list of WHO was only 62.4% which was higher in the study carried by Jimma et al., (73.5%)5 but this also lower range when compared to the standard value. This may be due to lack of awareness about Essential Drug List (EDL). The core list present in EDL carries no assurance as to pharmaceutical quality, it is the responsibility of the relevant national or regional drug regulatory authority to ensure that each product is of appropriate pharmaceutical quality (Including Stability)2.
Nowadays, polypharmacy becoming the major issue in the health care setting by emerging as a common practice, because patient with co-morbidities polypharmacy greater the chance of getting drug interactions and adverse events. Poly pharmacy was clearly detected in our study. Maximum number of prescriptions i.e. 27.31% had three drugs each followed by four drugs (22.68%) which is similar to the study of Asha Pathak et al.,7.
CONCLUSION:
The finding in this study correlates with most of the previous studies. Most of the prescribing indicators assessed were out of the ranges recommended by WHO implies the irrationality in the prescribing practices: Hence there is a need to improve the standard of prescription. This can be achieved by educating and updating Healthcare providers through CME, seminar by providing them Standard Treatment Guidelines, Essential Drug List and various Antibiotic Policy. Therefore the well organized intercessions should be implemented by the regulatory bodies found at various levels in-order to improve the quality of prescribing practices as well as to improve patient’s Quality Of Life.
ACKNOWLEDGEMENT:
Authors are acknowledging The Principal & Institution for approval, The Faculties of Arunai College of Pharmacy, Tiruvannamalai, The participants for providing support & facilities and the fellow students who have contributed to this study.
Funding: No funding sources
Conflict of interest: None declared
REFRENCES
Dr. Aishvarya Vijayakumar*, Senthilkumar S. K., Lekasri T., Malathi C., Mohammed Tamimul Ansari A., Prasanna S., Rizvana B., A Prospective Analysis of Prescribing Practices in Outpatients Through Who Indicators at Rural Areas of Tamilnadu, Int. J. of Pharm. Sci., 2025, Vol 3, Issue 3, 1510-1518. https://doi.org/10.5281/zenodo.15037263
10.5281/zenodo.15037263
