|Year : 2016 | Volume
| Issue : 3 | Page : 138-142
Drug utilization study from a government sponsored pharmacy in a tertiary care teaching hospital of rural West Bengal: A cross-sectional study
Tanmoy Gangopadhyay1, Ananya Mandal1, Sonai Mandal1, Bishan Basu2, Tamoghna Maiti1, Abhijit Das1, Soumitra Mandal1, Sekhar Mandal1
1 Department of Pharmacology, Bankura Sammilani Medical College, Bankura, West Bengal, India
2 Department of Radiotherapy, Bankura Sammilani Medical College, Bankura, West Bengal, India
|Date of Web Publication||5-Aug-2016|
Dr. Ananya Mandal
41B, Dr. G.S. Bose Road, Kolkata - 700 039, West Bengal
Source of Support: None, Conflict of Interest: None
Context: Newly started government sponsored pharmacies providing discounts have been available to the public at the medical college hospitals in West Bengal. Aims: The present study was undertaken to evaluate the drug prescribing trends from the prescriptions at such a pharmacy at a tertiary care hospital. Methods: The study was a prospective cross-sectional study that spanned for a period of 1-month from 1 to 31 August 2015. Prescriptions were reviewed and analyzed using the World Health Organization indicators for drug utilization studies. Statistical Analysis: Tools of descriptive statistics were used to analyze the collected data. Results: During the study period, a total of 3300 prescriptions were recorded and analyzed with a total number of drugs prescribed being 10,560. The average number of drugs per prescription was 3.2. Only 3.83% of the prescriptions contained injections which were due to the fact that the prescriptions were mostly from outpatient departments and on discharge. It was noted that 79.19% of the drugs were prescribed in generics and 23.06% of the drugs prescribed were antimicrobials. Irrational usage of vitamins, nutritional supplements, etc., was not noted. Conclusions: This study provided a picture of pattern of drug usage and prescription at a government sponsored subsidized pharmacy in rural West Bengal. Nearly a quarter of all prescriptions contained antimicrobials and a high proportion of prescriptions were made in generic names. Need was felt of a hospital antibiotic policy and prescriptions in accordance. Further, long-term studies are warranted.
Keywords: Antimicrobials, drug prescribing, drug utilization study, generic drug, pharmacy, rational drug use
|How to cite this article:|
Gangopadhyay T, Mandal A, Mandal S, Basu B, Maiti T, Das A, Mandal S, Mandal S. Drug utilization study from a government sponsored pharmacy in a tertiary care teaching hospital of rural West Bengal: A cross-sectional study. Int J Health Allied Sci 2016;5:138-42
|How to cite this URL:|
Gangopadhyay T, Mandal A, Mandal S, Basu B, Maiti T, Das A, Mandal S, Mandal S. Drug utilization study from a government sponsored pharmacy in a tertiary care teaching hospital of rural West Bengal: A cross-sectional study. Int J Health Allied Sci [serial online] 2016 [cited 2020 Feb 25];5:138-42. Available from: http://www.ijhas.in/text.asp?2016/5/3/138/187795
| Introduction|| |
Rational drug use refers to judicious and correct use of drugs in a community. A conference of experts on the rational use of drugs convened by the World Health Organization (WHO) in Nairobi in 1985 defined rational drug use as "Rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and the lowest cost to them and their community."  This can be further classed as five basic rights as follows: 
- The right drug
- At the right dose
- By the right route
- At the right time
- For the right patient.
Sadly, these requirements are routinely not met. Irrational prescription is a global problem. It includes inappropriate and unnecessary use of drugs, polypharmacy, inappropriate dosage, underdosing, and use of parenteral drugs despite the availability of oral drugs, misuse and overuse of antibiotics. These medication errors put patient health in jeopardy and also cause unnecessary economic burden to the patient or to the institution or community. There are several hurdles to rational drug use. Lack of proper knowledge of the physicians, overzealous treatment, peer pressure, and incentives from drug companies all may lead to an erroneous and irrational prescription.
There are various ways to limit inappropriate use of drugs. Some of the measures include setting up committees to make proper policies of drug utilization, making proper clinical guidelines based on consensus and forced implementation of those guidelines, regular monitoring and vigilance to provide feedback to the prescribers, public education, and increasing of awareness against the vices of self-medication.
Prescription audit and drug utilization studies are the types of vigilant activities that can describe the prescription pattern in a given setup, as well as provide feedback regarding the implementation of the clinical guidelines and the performance of the prescribers. These drug utilization studies can be used to compare the situations between two different setups and may be used to measure the impact of any interventions taken. They can also be used as supervisory tools to detect the shortcomings in the performance standard of any individual or a particular health facility.
Considering the huge potential of these studies to implement rational prescriptions, the WHO has setup some "core prescription indicators" that includes prescribing indicators, patient care indicators, and facility indicators and they have been successfully used in outpatient and inpatient setups in different institutions.  In this study, we have endeavored to conduct a study based on those tools to obtain data for promoting rational drug use.
| Methods|| |
The present study was a prospective, cross-sectional one that spanned for a period of 1-month from 1 to 31 August 2015 at a tertiary care teaching hospital of rural Bengal. The study was conducted with the approval of the Institutional Ethical Committee. The prescriptions were collected from the government sponsored medicine shop inside the hospital. The prescriptions were scanned and information transcribed onto a proforma containing all patient particulars and applicable WHO core indicators for drug utilization studies.  Only one encounter prescriptions were selected from the prescriptions collected. All prescriptions collected at our visit were included. Only 38 prescriptions that were too illegible to decipher were excluded from the study.
The parameters recorded for the purpose of the study included patient characteristics such as age, sex, and diagnosis.
The following drug utilization study indicators were evaluated: Core drug prescribing indicators: (a) Average number of drugs per encounter, (b) percentage of drugs prescribed by generic names, (c) percentage of encounters with an antibiotic, (d) percentage of encounters with an injection, and (e) percentage of drugs prescribed from the essential drugs list or formulary. The other indicators such as "Core health facility indicators" including (a) availability of key drugs and (b) availability of a copy of essential drug list or formulary could not be evaluated. The complementary indicators evaluated were as follows:
- Whether prescriptions were in accordance with standard treatment guidelines
- Average dispensing time
- Percentage of drugs actually dispensed
- Percentage of drugs adequately labeled
- Patient's knowledge of correct dosage.
Some of the other complementary indicators like average consultation time were not assessed as they could not be determined accurately at the pharmacy. Moreover, drug data including the name of the drug, dosage schedule (form, route, frequency, and duration), and duration of pharmacotherapy were recorded. All drugs were coded as per the WHO anatomical therapeutic and chemical classification coding system.  Adherence to the WHO daily defined dose for each drug used could not be evaluated. All information was transcribed onto a Microsoft Excel sheet database and subsequently statistically analyzed using tools of descriptive statistics.
| Results|| |
The total number of prescriptions obtained from the pharmacy were 3300. These were scanned and the soft copies were analyzed in the Department of Pharmacology at Bankura Sammilani Medical College. Among the 3300 prescriptions, there were 60.48% (1996) for male patients. The age distribution was found to be even with no significantly higher percentage of any age group. There were 12.27% (405) prescriptions made for children <12 years of age. Of the prescriptions, 5.20% (1716) were for pregnant women.
Analysis of the clinical indications for prescriptions included gastroesophageal reflux disorder and dyspepsia, menorrhagia, urinary tract infections, fever, cough, low back pain, hemorrhoids, anal fissure, hypertension, epilepsy, diabetes, hypothyroidism, otitis external, benign hypertrophy of the prostate, scabies, joint pain, pain abdomen, kidney calculus, retrocalcaneal bursitis, fractures, breast cancer and cervical cancer, dog bite, and tuberculosis.
In 112 prescriptions collected, no diagnosis was specified. In addition, in 38 prescriptions, the handwriting was illegible so the diagnosis or drugs could not be deciphered. These 38 were discarded from the study. The final number of prescriptions analyzed came up to 3300.The diagnosis was based on clinical evaluation and serial investigations and the major disease profiles were as per the disease classification of the WHO International Classification of Diseases 10 version 2006.
Analysis of the WHO core drug-prescribing indicators is summarized in [Table 1].
|Table 1: Assessment of the World Health Organization core prescribing indicators |
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Since the prescribers had no existing knowledge about the National List of Essential Medicines 2003,  the analysis of adherence to this list was carried out at the Department of Pharmacology, which had access to this list.
Assessment of complementary indicators showed the results summarized in [Table 2].
|Table 2: Assessment of the World Health Organization complementary prescribing indicators |
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The average cost per encounter and percentage cost of antibiotics and injections could not be calculated as many drugs which were not available from the hospital stores had to be purchased from the local chemists and their prices varied to a great extent. Another complementary indicator was the availability of accurate and impartial drug information. Access to unbiased information about drugs was available in the form of standard textbooks which were readily available to all prescribers.
Regarding the drug prescribing trends, we found that a total of 10,560 drugs were prescribed. Only 3.83% (405) of the prescriptions contained injections. This could be attributed to the fact that the prescriptions were mostly from outpatient departments and on discharge. Oral and topical drugs thus were preferred. Almost all injections were of insulin. In contrast to the common prevalent practice of prescribing drugs in nongeneric names, the prescribing trend in our study showed that 79.19% (8363) of the drugs were prescribed in generics. This could be attributed to the recent emphasis on generic prescriptions in all government and private medical institutions. This trend was encouraging and commendable.
Nearly, a quarter of all prescriptions were antimicrobials. It was seen that 2436 drugs of the 10,560 were antimicrobials. Of these, 75.36% (1836) were administered systemically and the rest topically. List of the most frequently used systemic and topical antimicrobial/chemotherapeutic groups is depicted in [Figure 1]. Fluoroquinolones included ciprofloxacin, norfloxacin, ofloxacin, and levofloxacin. Penicillins include amoxicillin/clavulanate and ampicillin. Cephalosporins include cefalexin, cefadroxil, cefuroxime axetil, cefixime, and cefpodoxime proxetil. Tetracyclines include doxycycline and minocycline. Aminoglycosides include topical preparations of tobramycin, framycetin, and neomycin. Macrolides include azithromycin and clarithromycin. Antifungal drugs include clotrimazole, miconazole, ketoconazole, fluconazole, and griseofulvin. Antiviral drugs include acyclovir topical and oral preparations. Antimalarials include chloroquine, primaquine, quinine, mefloquine, and artesunate. Antiamebic agents include tinidazole, secnidazole, and ornidazole. Anthelmintic agents include albendazole and mebendazole. Other agents include linezolid and mupirocin. One of the most prescribed groups of antimicrobials is the cephalosporins followed closely by fluoroquinolones and penicillins. Irrational usage of vitamins, nutritional supplements, etc., was not noted.
|Figure 1: Percentage of the use of antimicrobials and chemotherapeutic agents of different groups|
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| Discussion|| |
This was a study undertaken for a short period of time to assess the drug use pattern from the government sponsored pharmacies that have provided low-cost healthcare to a large number of poor populations in our study area. We analyzed 3300 prescriptions and noted that majority of the prescriptions made by the government prescribers of the attached hospital were rational, and there was no indiscriminate use of antibiotics or vitamins and other supplements. In addition, our study also showed that because the dispensers at the government sponsored pharmacies are bound to dispense the drugs in their generic forms, most of the drugs prescribed (79.19%) were in their generic names. The average number of drugs per prescription was also acceptable at 3.2. In addition, very few injections were prescribed on an outpatient basis (mostly insulin).
India has only around 2.4% of the world land area and supports about 16.87% of the world's population.  The problem of accessibility to health-care facilities and medications in this vast developing nation is a primary one. Seventy-two percent of the Indian population lives in rural areas, and this compounds the problem of reaching out to the thousands. 
While drug utilization studies have been conducted in cities and in district towns, less focus has been put on the rural areas. An earlier study  focused on the drug utilization pattern in this same setup but only among pregnant mothers. Our study is the first to analyze the effectiveness of low-cost medicine availability in this population and in this setup.
One major problem with drug use today is the menace of medication errors. The target of health-care facilities is not only to reach out to the masses living in remote rural areas where electricity and water availability itself is difficult but also to reduce medication errors and improve patient safety. Improving the judicious use of medications and minimizing adverse drug reactions deals with rational therapeutics. The basic tenet of this is the "the five rights."  These requirements of rational therapeutics will be fulfilled if the prescribing process covers the following steps: (a) Defining patient's problems (diagnosis); (b) defining effective and safe treatments (drug and nondrug treatments), (c) selecting appropriate drugs, dosage, and duration; (d) writing a clear prescription; (e) giving patients adequate information and counseling; and finally (f) planning to evaluate treatment responses.
Unfortunately, in the real world, prescribing patterns do not always conform to these ideals and what prevails instead is inappropriate, irrational, or "pathological" prescribing. Common examples of irrational prescribing seen in day-to-day practice include the use of drugs when no drug therapy is indicated, for example, antibiotics for viral upper respiratory infections; wrong drug for a specific condition requiring drug therapy, for example, an antibiotic in childhood viral diarrheas requiring ORS; drugs with doubtful/unproven efficacy, for example, antimotility agents in acute infective diarrhea; correct drugs but incorrect administration, dosages, or duration, for example, use of intravenous metronidazole when an oral formulation would be appropriate; unnecessarily expensive drugs, for example, a third generation, broad-spectrum antimicrobial when a first-line, narrow spectrum, agent would suffice; and multivitamins and "tonics" and so forth. The list could go on and on.
One major problem in our study area noted was the prescription and purchase of drugs that were already available free-of-cost to the patients from the hospital pharmacy. This could be minimized by better information percolation system to the prescribers, as well as to the patients. In addition, it was noted that all patients leaving the pharmacy were not aware of the drug dosing pattern and timing of taking their drugs. Due to the time concerns at the outpatient departments and at the pharmacy, many patients are left without vital knowledge of the use of the medications. This is a potential cause for medication errors. We noted this as a problem in our study.
| Conclusions|| |
To conclude, our cross-sectional, short-term study showed relatively high rates of rational and generic prescribing. A wide range of diseases and drugs were covered in the short period of time. Future long-term studies are being planned to understand the exact prescribing patterns and utilization of medications from these subsidized government sponsored pharmacies.
The authors would like to thank all the departments of the institute and the prescribers and patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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National List of Essential Medicines; 2003. Available from: http://www.cdsco.net
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Benjamin DM. Reducing medication errors and increasing patient safety: Case studies in clinical pharmacology. J Clin Pharmacol 2003;43:768-83.
[Table 1], [Table 2]