Descriptive details of the assessed prescriptions
We abstracted total 630 prescriptions, of which 37.3%, 47.5% and 15.2% were respectively from medicine OPDs, Paediatric OPDs and UHTC OPD. Prescriber pattern thus obtained showed majority of prescriptions (42.9%) by faculties (RMO/Demonstrator/Clinical Tutor, Assistant Professor, Associate Professor and Professor.) followed by 39.7% by interns and house staffs and 17.5% by post graduate residents.
511(81.1%) prescriptions were for ARI and 119(18.9%) prescriptions were for diarrhoea. It was found that majority of the patients (63.2% - ARI and 64.7% - diarrhoea) were below 18 years age group. Around 56% and 49.6% patients suffering from ARI and diarrhoea respectively were females. Majority of ARI prescriptions were by faculties (43.8%) while maximum diarrhoea prescriptions were by interns and housestaffs (42.9%).
Assessment of prescribing patterns using the WHO criteria
Component wise analysis showed that age and sex were mentioned in all prescriptions. Body weight was mentioned in only 56.2% prescriptions. Signs and symptoms, provisional diagnosis and follow up visit were mentioned in 90.3%, 4.9% and 48.0% prescriptions respectively. None of the prescriptions had instructions in patient’s vernacular language. Formulation, frequency and duration were not mentioned in 0.6%, 7.2% and 15.3% prescriptions respectively. Average number of drugs prescribed was 4.2 ±1.9 (median – 4). Proportion of prescriptions with generic names, adherent to hospital schedule, with Fixed Dose Combinations were respectively 23.3% ,36.5% and 51.0%. Prescriptions of all drugs with generic names and prescriptions with all drugs from the hospital schedule was much lower than the WHO standard of 100% for both the indicators. Antibiotics prescription rate (APR) was 57%. Multiple antibiotic prescription rate (MPR) was 10%. All the prescriptions for diarrhoea did not contain ORS (81.5%) whereas probiotic was prescribed in 85% of diarrhoea irrespective of specific indication i.e. Antibiotic induced diarrhoea. None of the prescriptions had any injectable formulation hence PAPR was 0% [Table 1]
APR was observed to be higher for diarrhoea (65.5%) than ARI (55.2%). MPR is also high in case of diarrhoea (30%) as compared to ARI (3.9%). Among the diarrhoea cases, antibiotics were prescribed in 64.4% of acute watery diarrhoea and 66.7% in dysentery. Antibiotics of nitroimidazole class followed by quinolones, cephalosporins were mostly prescribed. Fixed Dose Combination of ciprofloxacin, tinidazole/ofloxacin, ornidazole and ofloxacin, metronidazole was also used. The antibiotics most commonly used in ARI was a combination of Amoxycillin and Clavulinic acid (Beta lactamase inhibitor) followed by Azithromycin, Cephalexin, Cefixime, Co- trimoxazole and Amoxycillin alone.
Appropriateness of the prescription and acceptability of the deviations through a consensus committee approach.
Deviation from standard guideline as evaluated by the RUMC and were present in 623 (98.9%) prescriptions. Among them only 60 (9.5%) were found acceptable. Out of 563 unacceptable deviations, 357(63.4%) suffered possibility of Adverse Drug Reactions(ADR), whereas, 421(74.8%) prescriptions had inconsistent/irrational indications. [Figure 1] Majority of the unacceptable deviations were due to antibiotics, followed by bronchodilators , antihistaminics, Proton Pump Inhibitor/H 2 receptor blocker/Antacids, Probiotics. [Table 2] Some of the frequently observed unacceptable deviations were as follows:
- Prescription of bronchodilator in children through systemic route
- Prescription of antibiotic in Upper Respiratory Tract Infection (URTI) without or with fever < 3 days, in absence of patch/ hemorrhage/shortness of breath.
- Prescription of Probiotic without specific indication of Antibiotic induced diarrhoea.
- Prescription of antibiotics (Ciprofloxacin, Metronidazole, Ofloxacin and others) in absence of documented bloody diarrhoea or dysentery.
- Prescription of Montelukast in acute ARI
- For acute disease, prescription of repeatedly used drug such as paracetamol (for fever), without mentioning maximum dose / day
- Prescription of drugs like Pantoprazole, Ranitidine, Famotidine, Vitamin without specified indication.
Appropriateness of prescriptions as per clinician and pharmacologist revealed that only 1.1% of total prescriptions were appropriate according to both clinician and pharmacologist. There were 9.6 % prescriptions which were inappropriate as per pharmacologist but appropriate as per clinician. Agreement between pharmacologist and clinician were observed in 90.4% prescriptions (Kappa – 0.14) [Table -3]. These disagreements were resolved in RUMC meeting on case to case basis with following clarification:
- Prescription of antihistaminic in ARI in children though identified as inappropriate by pharmacologist however a 2nd generation antihistaminic (cetirizine) may be considered as acceptable deviation but 1st generation (Chlorpheniramine) is unacceptable due to excessive sedation.
- Prescription of Azithromycin in URTI identified as inappropriate by pharmacologist, as Azithromycin is not a 1st line antibiotic, but considered acceptable deviation by the clinician as standard practice.
- Drugs prescribed by brand names are considered inappropriate by the pharmacologist but it was considered as an acceptable deviation.
- Prescription of albendazole in children or Vitamin D in infants less than 6 months of age though considered inappropriate by pharmacologist when there is no indication, it is considered as acceptable deviation by consensus it adheres to national programme guideline
- ORS prescribed without specific indication is also an acceptable deviation as it cause no apparent harm.
Completeness of prescriptions as per different criteria in various age groups
Body weight was mentioned in 88.5% of prescriptions of patients below 18 years age group. Of them, body weight was found in 93.4% patients upto 5 years of age, 88.9% of patients aged 5 -< 12 years, and 14.3% patients of 12- <18 years. None of the adult prescriptions had body weight mentioned in them. Signs and symptoms, provisional diagnosis were more commonly mentioned in adult patients whereas follow up visit was more commonly mentioned in <18 years age group. Higher proportion of prescriptions with generic name (27% vs 17%), and from hospital schedule list (41% vs 29%) and lower FDC (44% vs 63%) were observed in prescriptions of < 18 years as compared to adults. APR was also lower for children than adults (48 % vs 71 %).
Prescriptions with deviations were slightly lower in children (98.5% vs 99.5%). However, proportion of acceptable deviations were more in <18 years age group (12% vs 6%). [Data not presented]
Completeness of prescriptions as per different criteria across types ofprescriber
Body weight, signs and symptoms, follow up visit was mentioned most commonly by residents while provisional diagnosis was commonly mentioned by faculties. Prescriptions of all drugs with generic names and from hospital schedule list was mostly prescribed by residents while fixed dose combinations and antibiotics were mostly prescribed by faculties. Deviations were most commonly observed in the prescriptions of interns and housestaffs (99.6%), whereas acceptable deviations were more common among the residents (15%).Out of the unacceptable deviations, chances of ADR was most common among interns and housestaffs whereas prescriptions with inconsistent/irrational indication was most common among the faculties.[Table 4]