|Year : 2013 | Volume
| Issue : 1 | Page : 49-52
Comparisons of anti-diabetic prescriptions of private practitioners and hospital prescribers: A survey
Ananya Mandal1, Manab Nandy2, Arijit Ghosh1, Samar Banerjee3, Krishnangshu Ray4
1 Department of Pharmacology, Nilratan Sircar Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Pharmacology, National Medical College and Hospital, Kolkata, West Bengal, India
3 Department of General Medicine, Vivekananda Institute of Medical Sciences and Ramkrishna Mission Seba Pratisthan, Kolkata, West Bengal, India
4 Department of Pharmacology, School of Tropical Medicine, Kolkata, West Bengal, India
|Date of Web Publication||17-Apr-2013|
No. 41B, Dr. G. S. Bose Road, Kolkata 700 039
Source of Support: None, Conflict of Interest: None
Monotherapy as well as effective and safe combination therapy for diabetes is practiced widely by both private and government hospital prescribers. This study attempted to compare the prescriptions of government and private practitioners to obtain a fair idea of the trends of diabetes management in either group. Prescriptions for diabetic patients from both private practitioners and government medical college prescribers were collected. These were analyzed for parameters such as number and type of drugs, cost, and generic prescription. Private prescribers were not significantly different from hospital prescribers in terms of number of drugs per prescription, cost of therapy, and treatment regimens. However, there was a dearth of generic prescriptions from private consultants (33% vs. 9%). Metformin and Glimepiride were the most prescribed drugs in both groups. However, private practitioners preferred Gliclazide, Glipizide, and Glibenclamide more than hospital prescribers.
Keywords: Diabetes mellitus, generic, hypoglycemic, prescribing pattern
|How to cite this article:|
Mandal A, Nandy M, Ghosh A, Banerjee S, Ray K. Comparisons of anti-diabetic prescriptions of private practitioners and hospital prescribers: A survey. Int J Health Allied Sci 2013;2:49-52
|How to cite this URL:|
Mandal A, Nandy M, Ghosh A, Banerjee S, Ray K. Comparisons of anti-diabetic prescriptions of private practitioners and hospital prescribers: A survey. Int J Health Allied Sci [serial online] 2013 [cited 2020 Jul 14];2:49-52. Available from: http://www.ijhas.in/text.asp?2013/2/1/49/110565
| Introduction|| |
Diabetes mellitus (DM) and its associated conditions are on the rise globally and more so among Asians, especially in India.  Over the last 30 years, diabetes has emerged from being a relatively less common disease affecting the elderly and some genetically prone individuals to one of the major causes of mortality and morbidity among the youth and the middle aged. Although there is a rise in type 1 diabetics, the major thrust of the epidemic arises from type 2 diabetes. The International Diabetes Federation estimates the total number of diabetic subjects to be around 40.9 million in India, and this is further set to increase to 69.9 million by 2025. 
Drug therapy for diabetes has developed over time. Monotherapy as well as effective and safe combination therapy is practiced widely by both private and government hospital prescribers. Although some studies have studied the prescribing trends among physicians treating diabetic patients, prescription patterns of anti-diabetic agents among private consultants and government hospital prescribers have not been compared earlier. We attempted to compare the prescriptions of government and private practitioners to obtain a fair idea of the trends of diabetes management in either group.
| Materials and Methods|| |
Subjects were screened and recruited at the diabetes clinic of a tertiary care hospital in Eastern India. We also surveyed patients at other departments and private consultant's chambers to gather prescriptions given by diabetologists outside the government setup. The preparatory groundwork, data management analysis, and report preparation were conducted at the Department of Pharmacology of the tertiary care hospital and the medical college.
We randomly selected prescriptions from patients suffering from DM as the primary complaint. All prescriptions were audited using pre-determined criteria.
- One of the major criteria was to include only the first-visit prescriptions
- Prescriptions for diabetic patients of both sexes and all ages were included in the study
- Prescriptions of patients with fasting plasma glucose (FPG) ≥100 mg/dl or post-prandial plasma glucose (PPG) ≥140 mg/dl
- Medicines given to treat the primary disorder (DM) in prescriptions were only audited setting aside the other medications.
- Repeat prescriptions were excluded. This was done to remove bias or influence of other prescribers
- Prescriptions made by any physician without a DM in endocrinology were excluded from the study to maintain uniformity
- Prescriptions of any other out-patient department (OPD) other than diabetic OPD
- Prescriptions where other associated diseases that might influence the prescribing patterns of the anti-diabetic medications, and prescriptions containing anti-diabetic medications along with medicines of questionable efficacy including drugs of other systems of medicines such as homeopathy and unani were also excluded.
All participants were individually interviewed after consultation. The average time of interview was 20 min. The mode of interview was verbal and the medium was either Bengali or Hindi, as the case may be. All prescriptions were copied into a specially designed prescribed proforma and entered into a database for further analysis.
All sample prescriptions were categorized into two major groups: Prescriptions that were prescribed in the diabetic OPD by the consultant at the rank of professor (with DM in endocrinology) were grouped as hospital prescription (HP) and prescriptions that were prescribed for the same patient by private practitioners (with DM in endocrinology) were grouped as private prescription (PP).
The confidentiality of the study subjects was maintained throughout the study duration. The study was approved by the Institutional Ethical Committee before commencement of work.
Statistical analysis was carried out using statistical software Graph Pad Prism version 4.03 for Windows (Graph Pad Software Inc., San Diego, CA, USA). Standard tests for descriptive statistics and Chi square test and unpaired t tests were used. P value of less than 0.05 was considered to be statistically significant.
| Results|| |
A total of 380 prescriptions were randomly selected. The mean age of all patients was 47.25 years (standard deviation of 12.17 years). It was noted that fasting blood glucose (FBG) was unavailable in 139 patients, and these patients were diagnosed based on Post prandial blood sugar (PPBS). Of the remaining 241 patients, 47 patients had fasting blood sugar less than 100 mg/dl, i.e. normal. Based on FBG 26 (of the 241 patients) and based on PPBS, 93 (of 349 patients) were deemed to be pre-diabetic (FPG: 100-125 mg/dl and PPBS: 146-199 mg/dl). Regarding the duration of diabetes, maximum number of patients (116 out of 380; 30.52%) reported to the OPD within 1 month of diagnosis. Fifty patients reported between 1 and 6 months duration (13.15%). Only 36 patients (09.47%) had diabetes for more than 4 years. The demographic details of the patients are presented in [Table 1].
|Table 1: Demographic details of patients whose first prescriptions were included in the study|
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Of the 380 prescriptions, 180 prescriptions were made by private practitioners and 200 prescriptions were made by government-employed diabetologists.
HPs included 33% drugs prescribed in the generic name compared to 9% in case of PPs. In the 180 PPs, 369 drugs were prescribed, indicating an average of 2.05 drugs prescribed per prescription. A total of 356 drugs were prescribed among in the HP group (average 1.78). The difference was statistically insignificant.
Metformin was the most commonly prescribed in both PPs and HPs, although the percentage of prescription was less. Metformin was prescribed in 33.52% of HP and 29.6% in PP. The percentages of prescriptions of Glimepiride, Metformin, Pioglitazone, Rosiglitazone, and Insulin were less in PP compared with HP, but the percentages of Glipizide and Glibenclamide were far more in PP than in HP. There were no prescriptions containing α-Glucosidase inhibitors in PPs. The results are shown in [Table 2]. Chi square test was applied to determine whether there was any significant difference between the two groups.
|Table 2: Percentage of drugs prescribed among hospital prescriptions and private prescriptions|
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[Figure 1] shows the difference between PP and HP in terms of prescription regimens. Significant difference applying the Chi square test between groups was noted only in Group 4 regimen that compared PP and HP that contained Metformin, Glimepiride, and a thiazolidinedione. This combination was favored more by government hospital prescribers than by private practitioners.
|Figure 1: The difference between private prescribers and hospital prescribers. Group 1 – Glimeperide only; Group 2 – Metformin only; Group 3 – Glimepiride +Metformin; Group 4 – Glimeperide +Metformin +a thiazolidinedione; Group 5 – Metformin + Thiazolidinedione; Group 6 – Any prescription containing Sulphonylureas other than Glimeperide (e.g., Glipizide, Glibenclamide, Gliclazide); Group 7 – Any prescription containing insulin injection; Group 8 – No medication (lifestyle modification only); Group 9 – Thiazolidinedione only; Group 10 – Glimepiride + Thiazolidinedione. P = 0.002|
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We also noted an interesting phenomenon of prescription conversion from PP to HP in patients who presented at the diabetes clinic. Only 62 PP were available for analysis of this type of conversion at the diabetes clinic. Five cases of Group 1 patients (on Glimepiride only) were shifted from PP to Group 1 once, Group 3 (Glimepiride + Metfoirmin) thrice, and Group 4 (Metformin, Glimepiride, and a thiazolidinedione) once. Among the group 2 patients (on Metformin only) a similar pattern of conversion was noted wherein the eight patients were shifted to Groups 3, 4, and 5 (Metformin + thiazolidinedione) or to Group 7 (any prescription with insulin). This implies that Metformin required combination with other anti-diabetic drugs for optimum efficacy in these patients. Majority of patients on Group 6 (any prescription containing sulphonylureas other than Glimeperide, e.g., Glipizide, Glibenclamide, and Gliclazide) in PP were shifted to Group 4, indicating that most of the hospital prescribers preferred Glimepiride over other sulphonylureas.
To analyze the cost, the number of hypoglycemic agents, their doses, and strength were calculated first. Cost was assessed from the Concise prescribing information (CIMS), April-July, 2006). A great variation of cost of a particular drug depending upon their manufacturer was noted. To arrive at a common value, we selected five most commonly prescribed brand names of a particular drug and their mean was considered as the cost of that particular drug. From this average cost and dose schedule, a monthly cost was evaluated. A parallel between HP and PP was drawn from these data. Using the unpaired t test to compare the average monthly cost of anti-diabetics between PP and HP, we found that there was no significant difference between the two types of prescribers in terms of cost to the patient (P > 0.1).
| Discussion|| |
With the rising incidence of diabetes and the growing armament of drugs to manage these patients, a survey of prescribing patterns among hospital and private practitioners becomes imperative. Although some studies have been conducted in the United States, Barbados, and in South Africa to determine the patterns of prescriptions, such studies have not been attempted in India and other Asian countries. ,,, As India is fast rising to become the diabetes capital of the world, it is all the more important to assess the common prevalent prescribing patterns.
The earliest such study was conducted in 1985.  A study by Fraser et al. assessed the prescribing patterns for hypertension and DM. They noted that private practitioners prescribed insulin less often. Private consultants also prescribed more sulphonylureas than Metformin compared to a reversed trend in HPs. The authors found that although the number of prescribed drugs was low in PPs, the cost of individual drugs was much higher compared to hospital prescribers. Our study showed that more drugs were prescribed per prescription in private clinics although the difference between this and government hospital prescribers was non-significant. We also found that costs of the drugs prescribed from both setups were similar.
A 1998 study reported by Truter  surveyed anti-diabetic prescriptions in South Africa. They found that Gliclazide was the single most frequently prescribed oral anti-diabetic drug, accounting for 38.2% of all oral agents, and biphasic insulin was the most frequently prescribed class of insulin. We also noted a propensity of private practitioners to prescribe sulphonylureas other than Glimepiride including Glipizide, Glibenclamide, and Gliclazide.
A study published in 2003 by Cohen et al.  surveyed anti-diabetic prescriptions over 3 years and noted that there was a decline in monotherapy with sulphonylureas, but monotherapy with thiazolidinedione, metformin, and other oral anti-hyperglycemics increased over time. Combinations of sulfonylureas and metformin; sulfonylureas and thiazolidinedione; metformin and thiazolidinedione; and sulfonylureas, metformin, and thiazolidinedione each increased over the time interval. Insulin monotherapy decreased, as did insulin combination therapy with sulfonylureas. The combination of insulin and metformin increased, whereas the combination of insulin and thiazolidinedione was stable over the span of the study.
A more recent study from India by Vengurlekar et al.  assessed prescriptions for diabetic patients at a single hospital setup. It was noted that both Metformin and Glimepiride were one of the largest prescribed oral hypoglycemic agents. Metformin and Glimepiride combination was also the most favored combination therapy among prescribers. This study also found that use of insulin was low.
Our study had some limitations. One of the major limitations of our study was our lack of assessment of daily defined doses of the medications. At present, further progression of the survey is in motion and we hope to incorporate other parameters of prescription survey at a later stage. Another limitation of our study was our inability to compare the years of prescribing experience of the government and private practitioners. The government prescribers included were of the ranking of professor whereas the private prescribers (although of similar qualifications) tended to vary in years of experience.
| Conclusions|| |
From our study we concluded that private prescribers were similar to hospital prescribers in terms of number of drugs per prescription, cost of therapy, and most of the treatment regimens. However, there was a dearth of generic prescriptions from private consultants. Only 9% of the PP was made in generics whereas 33% of the HP was made in generics. Metformin and Glimepiride were the most commonly prescribed drugs in both groups. However, private practitioners also preferred sulphonylureas such as Gliclazide, Glipizide, and Glibenclamide more than hospital prescribers. The data from our study indicates that further research and educational strategies are required to make the therapy of diabetes more uniform and to improve prescribing practices.
| Acknowledgment|| |
We would like to thank the faculty and patients of Department of Endocrinology, Nilratan Sircar Medical College for their support and help in the study.
| References|| |
|1.||Huizinga MM, Rothman RL. Addressing the diabetes pandemic: A comprehensive approach. Indian J Med Res 2006;124:481-4. |
|2.||Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res 2007;125:217-30. |
|3.||Fraser HS, Prescod LA, Jones R. Prescribing practices for hypertension and diabetes mellitus in government and private clinics in Barbados. West Indian Med J 1985;34:31. |
|4.||Steyn R, Burger JR, Serfontein JH, Lubbe MS. Investigation into the prescribing patterns and cost of antidiabetic medicine in South Africa. Health SA Gesondheid 2007;12:26-36. |
|5.||Truter I. An investigation into antidiabetic medication prescribing in South Africa. J Clin Pharm Ther 1998;23:417-22. |
|6.||Cohen FJ, Neslusan CA, Conklin JE, Song X. Recent antihyperglycemic prescribing trends for US privately insured patients with type 2 diabetes. Diabetes Care 2003;26:1847-51. |
|7.||Vengurlekar S, Shukla P, Patidar P, Bafna R, Jain S. Prescribing pattern of antidiabetic drugs in Indore city hospital. Indian J Pharm Sci 2008;70:637-40. |
[Table 1], [Table 2]