|Year : 2011 | Volume
| Issue : 2 | Page : 150-156
Prescription audit of outpatient attendees of secondary level government hospitals in Maharashtra
Hanumantha Rao Potharaju1, SG Kabra2
1 Administrative Staff College of India, Hyderabad - 500 082, India
2 Administrative Staff College of India, 15, Vijayanagar, D Block, Malaviya Nagar, Jaipur - 302 017, India
|Date of Submission||12-Jan-2010|
|Date of Decision||29-Oct-2010|
|Date of Acceptance||06-Jan-2011|
|Date of Web Publication||6-Mar-2011|
Hanumantha Rao Potharaju
Administrative Staff College of India, Hyderabad - 500 082
Source of Support: None, Conflict of Interest: None
Objective : The main objective of the prescription audit of the secondary level government hospitals under the Maharashtra Health Systems Development Project (MHSDP) was to develop a list of essential drugs. Other objectives were to articulate measures for improving the prescription practices and to generate information on the core prescribing indicators proposed by the World Health Organization (WHO).
Materials and Methods : The study was conducted among a representative sample of 31 secondary level hospitals under MHSDP. A copy of the prescription was obtained with the help of a pre-inserted carbon, in a special format. Data for only 'first encounter prescriptions' was collected for all patients attending the Outpatient Department (OPD).
Results : About 77 percent of the prescriptions contained only one diagnosis. The average number of drugs per prescription was 3.1. About 60 percent of the drugs were prescribed by generic names and about 23 percent of the prescribed drugs were in combination. About 25 percent of the prescriptions contained at least one injection, while 35 percent contained at least one antibiotic. In 16 percent of the prescriptions a vitamin or tonic was prescribed. About 46 percent of the single ingredient formulations were as per the WHO 2003, Essential Medicines List (EML). Based on the findings of the Prescription Audit an EML was prepared for each category of the secondary level hospitals, for use in the OPD.
Conclusions : Prescription audits are useful in generating data on morbidity, which forms the basis for preparing the list of essential medicines. Mechanisms necessary for improving prescription practices are suggested.
Keywords: Essential Medicines, International Classification of Diseases, Morbidity Pattern, prescription audit, secondary level hospitals
|How to cite this article:|
Potharaju HR, Kabra S G. Prescription audit of outpatient attendees of secondary level government hospitals in Maharashtra. Indian J Pharmacol 2011;43:150-6
|How to cite this URL:|
Potharaju HR, Kabra S G. Prescription audit of outpatient attendees of secondary level government hospitals in Maharashtra. Indian J Pharmacol [serial online] 2011 [cited 2019 Jul 20];43:150-6. Available from: http://www.ijp-online.com/text.asp?2011/43/2/150/77350
| » Introduction|| |
The main objective of the Maharashtra Health Systems Development Project (MHSDP) is to enhance the quality of care in the secondary level hospitals in the state. The secondary level hospitals in Maharashtra comprise of four categories, namely: (a) district hospitals (DH), (b) sub-district hospitals with 100 beds (SDH 100), (c) sub-district hospitals with 50 beds (SDH 50), and (d) select Community Health Centers (CHC). Improvement in the prescribing practices of doctors working in the project hospitals is one of the initiatives taken up, to improve the quality of care. A prescription audit was considered appropriate to improve the usage of drugs by the MHSDP doctors.
The World Health Organization (WHO) proposed core-prescribing indicators  for prescription audit and drug utilization studies. The focus of Indian studies ,,, has mainly been on the WHO core-prescribing indicators such as the range and number of drugs per prescription. Another study reported that half of the patients received more than one antibiotic.  Chemist- and hospital pharmacy-based studies reported that polypharmacy was the norm , and about 75 percent of the prescriptions contained Fixed Dose Combinations (FDCs).  An analysis of prescriptions for diarrhea also revealed that about 60 percent contained FDCs.  Another study of 292 prescriptions for diarrhea reported use of 63 different drugs. 
The prescription audit studies have been conducted in diverse settings like outpatients and inpatients in hospitals, hospital pharmacy, retail medical stores in the community, private medical practitioners, and so on, mostly with a small sample size. Few studies used a prescription audit to generate a morbidity profile, and prepared the essentials medicines list based on that morbidity profile.
| » Objective|| |
A prescription audit was conducted among outpatient attendees of a representative sample of the MHSDP hospitals, at the behest of the Government of Maharashtra. The objectives of the audit were,
- To understand the morbidity pattern currently being handled in the OPDs, detect the frequently prescribed drugs to treat the patients attending the OPDs, and to prepare an essential medicines list (EML) for the four categories of project hospitals, for OPD use.
- To analyze the prescription of drugs at the four categories of hospitals and generate information on the core prescribing indicators proposed by the WHO.
- To articulate measures to improve prescription practices of the doctors working in the project hospitals.
| » Materials and Methods|| |
The present study followed the prospective methodology. Before starting the study an initiation workshop was conducted, to explain the objectives of the study, method of using the specially designed forms, and also to address the apprehensions of the doctors. The form designed was quite similar to the regular OPD chit used in MHSDP hospitals. The forms were printed in duplicate with pre-inserted carbon.
The form was given only to the 'new cases,' as the study was aimed at 'First Encounter Prescriptions.' The hospitals were asked to use the specially designed forms in place of the regular OPD papers, till the supply was exhausted. The doctor retained the carbon copy in an envelope, with doctor details. The filled in forms were collected from the participating doctors and analyzed using MS Access and SPSS.
The diagnoses in the filled-in prescription forms were coded using International Classification of Diseases - 10 (ICD 10).  The Anatomical Therapeutic Chemical (ATC) Classification,  developed by the World Health Organization, was used for coding the drugs.
Sample Size and Distribution
The study included 32 hospitals, covering all eight administrative regions of the state and all categories of MHSDP hospitals. The number of forms given to each category of hospitals is shown below.
Out of the 14,535 filled-in forms collected, only 14,004 filled-in prescriptions could be used for analysis. The data was collected during May and June, 2003.
- District Hospital - 1000
- SDH100 - 500
- SDH50 - 300
- CHC - 200
| » Results|| |
District hospitals accounted for the maximum number of prescriptions. Further details are shown in [Figure 1].
General OPDs contributed to about 60 percent of the prescriptions. In the case of SDH 50 and CHC all the prescriptions were considered as general OPD. Details of contribution by the OPD and hospital category are shown in [Table 1].
|Table 1: Contribution of prescriptions by different OPDs by hospital category|
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Profile of Participating Doctors
A total of 212 doctors participated in the study. About 81 percent of the samples were male. About 10 percent of the participating doctors were GPs, while 75 percent were specialists. The remaining 15 percent were ayurvedic and other general duty doctors.
The proportion of females was marginally higher, at 51.4 percent, while children (14 years or less) constituted 28.4 percent, adolescents (15 - 19 years) constituted 7.9 percent, adults (20 - 59 years) formed 52.1 percent and the 60 and above age group formed 10.5 percent.
Out of the 14,004 prescriptions about 77 percent of the prescriptions contained a single diagnosis, while about 18 percent contained two diagnoses, the remaining five percent contained three diagnoses. The detailed morbidity pattern, according to the type of hospital, is given in [Table 2].
The following five are the most frequent diagnoses:
In case of 33 percent, the treatment was provided based on symptoms and signs (ICD Code R00-R99).
- Diseases of respiratory system - ICD code J00-J99 - 12.7 percent
- Infectious and parasitic diseases - ICD Code A00-B99 - 8.2 percent
- Diseases of musculoskeletal system - ICD Code M00-M99 - 5.8 percent
Diseases of digestive system - ICD Code K00-K99 - 5.7 percent
- Diseases of skin and subcutaneous tissues - ICD Code L00-L99 - 5.4 percent
Frequently Prescribed Drug Groups
The top 15 drug-groups prescribed in different categories of hospitals are shown in [Table 3].
In the district hospitals, the top 15 drug groups accounted for 84.1 percent. The corresponding figures for SDH 100, SDH50, and CHC are 81.6, 78.8, and 79.9 percent.
Use of diagnostic tests enables the physician to provide evidence-based treatment instead of offering empirical treatment. In case of 30 percent, a diagnostic test is advised. The average number of tests per prescription is 2.06. Peripheral smear for malaria, test for hemoglobin, and different urine-based examinations are the most frequently prescribed tests / investigations, which account for about 46 percent of the investigations.
Follow-up advice facilitated continuation of treatment and making any changes in the treatment wherever necessary. Advice on follow-up was mentioned only in about 18 percent of the cases. A period of three days was the most frequently prescribed follow-up duration (42 percent), followed by five days (18.5 percent).
A referral was indicated in only 3.7 percent of the cases. The proportion of referrals was relatively more at higher-level institutions (SDH100 and DH) compared to lower level facilities (SDH50 and CHC). Referrals to four specialties namely surgery, physician, orthopedics, and ophthalmic accounted for about 56 percent. A few referrals were also to the lower level institutions, for the purpose of continuation of treatment in diseases like TB and leprosy.
WHO Core Prescribing Indicators
The core prescribing indicators of MHSDP are shown in [Table 4].
| » Discussion|| |
The 'Prescription Audit' of the Outpatient Attendees in MHSDP Hospitals was an enabling exercise in spirit. Its main aim was to provide an objective basis, namely, morbidity pattern and actual use of drugs by the MHSDP doctors, for preparing an essential medicines list (EML) for the MHSDP hospitals.
Assessment of the rationality of prescriptions by a doctor in a hospital is appropriate if the hospital has Standard Treatment Guidelines (STGs) and the doctors are made aware of the STGs and are provided with the guidelines, at least for the diseases commonly treated by them. At the time of the study the MHSDP did not have any STGs to be followed by the project hospital doctors.
However, based on the findings of the study some prescription practices may be considered for improvement.
Complete details: Formulation was mentioned in about 95 percent of the drugs prescribed. However, all details namely (a) strength, (b) dose, and (c) number of days were mentioned only in 38.8 percent of the tablets, in 50.1 percent of the capsules, and in 16.1 percent of the injections. By default in project hospitals drugs were given for three days, unless the prescription mentioned otherwise. Some doctors stated that there was no need to mention the details because packs of only limited strength were available in the hospital.
Number of drugs per prescription: About 31 percent of the prescriptions contained four or more drugs. By comparing with the STGs for diseases for which such prescriptions were made, they could be justified or categorized as irrational prescriptions.
Use of Brand Names: Still about 40 percent of the doctors used brand names. The reasons for using brand names need to be understood (such as comfort ability with brand names, opinion that generic drugs are of low quality, etc.) and addressed with appropriate interventions.
FDCs: Among the FDCs with high usage (100 or more prescriptions) in MHSDP hospitals:
- Three, namely (a) Cotrimoxazole, (b) ORS, and (c) Iron + Folic Acid are included in WHO EML
- Five namely (a) Vitamin Bcomplex, (b) Aluminium Hydroxide + Magnesium Trisilicate, (c) Multivitamins, (d) Fortified Procaine Penicillin, and (e) Etophylline + Theophylline are included either in the national or state level EMLs
- Five, namely, (a) Multivitamin + B complex, (b) Cough Expectorant, (c) APC, (d) Antacids, and (e) Framycetin +Dexamethasone + Gramicidin are not included in any EML.
An Essential Medicines List (EML) for OPD use in MHSDP hospitals has been prepared for all four categories of hospitals. The core list of EML has 133 drugs. The list is provided as Appendix 1.[Additional file 1]
The drugs included in the core list have been identified based on the following criteria.
i. They are frequently prescribed or required as identified
ii. They are included in the essential drugs list of WHO and / or government of India and / or other States (included in at least two of the states)
- From the top 25 drugs prescribed in the ten OPDs, as found from the study
- From the frequency of usage, as a whole (above 20 prescriptions in case of single ingredient drugs and five and above prescriptions in the case of combinations)
- From the drugs mentioned as required frequently, by the groups of different specialists, during the dissemination workshop on 27 November, 2003, in Mumbai.
A complementary list of 37 medicines was also suggested, which was prepared based on the following criteria:
- Drugs frequently used or required, but not included in the core list
- Drugs needed for special conditions or specific groups of patients
Measures suggested to promote Rational Prescription Practices
- The state should formulate a drug policy as it did not have one, addressing issues like EML, procurement, and so on.
- The drugs included in the core list of EML covered about 80 percent of the morbidity load of OPDs. Hence, the project should ensure adequate supply of these drugs of assured quality and effectivity. Non-availability of the drugs in EML may result in prescribing other alternatives and use of brand names.
- Promotion of rational prescription practices requires that the MHSDP hospital doctors are provided with the Standard Treatment Guidelines (STGs).
- The following information, education, and communication (IEC) interventions are needed to create an enabling environment and promote behavior change.
- The drugs provided under MHSDP must be of good quality
Doctors must give medicines like vitamins, IV saline, and injections as per the patient's needs. Patients should not insist on the prescription of saline or strong / powerful medicines
- Doctors must not prescribe unnecessary medicines and if needed, essential medicines must be prescribed. The medicines taken without doctor's prescription may be harmful
- The drugs provided under MHSDP are of good quality. They could be obtained at a lower cost because of procurement practices of the project like, (a) buying directly from the manufacturer, (b) centralized procurement practices, and (c) buying generics instead of brands. This is essential because some of the MHSDP doctors commented that the drugs supplied by the government are of inferior quality. Hence, they prescribe well-known brands
- Doctors should use antibiotics very carefully by putting in place an antibiotic policy. Otherwise they will lose their effectiveness
- Doctors should be made aware of the advantages of prescribing drugs using generic names, such as, (a) cost effectiveness and (b) minimizing medication errors, due to sound alike brand names.
- More stringent measures like those initiated by the Government of Orissa,  such as, recovery of the cost of drugs if the prescription is found unjustified, could also be considered by the MHSDP.
| » Conclusions|| |
Prescription audit is an important mechanism to improve the quality of care afforded by the hospitals. Data generated on the morbidity pattern coupled with the current practices of treatment of these diseases provided an objective basis for preparing an EML. Comparing the current usage of drugs with the standard treatment guidelines will enhance the effectiveness of treatment and render it cost-effective.
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[Table 1], [Table 2], [Table 3], [Table 4]
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