Sir
As per the estimates of the World Health Organization (WHO) worldwide more than half
of all the medicines are prescribed, dispensed or sold inappropriately and about one-third
of the world's population lack access to essential medicines1
2. Irrational use of medicines has several severe consequences including adverse drug
reactions, drug resistance, protracted illness and even death. Inappropriate use and
over-use of medicines waste resources, resulting in increased out-of-pocket expenditure
by patients1
2.
The Government of Karnataka in 2005 published essential medicines list (EML) and standard
treatment guidelines (STG) for use in the primary health care facilities in the State3
4. Since the implementation of these guidelines there was no formal assessment of
the prescription practices and availability of essential medicines in the State. Hence,
a study was conducted to describe the medicine prescription practices of the medical
officers, and medicine dispensing practices of the pharmacists in primary health centres
(PHCs) of Shimoga district, Karnataka, following the WHO guidelines for investigation
of drug use in health facilities5.
Twenty of the 65 PHCs in Shimoga district were randomly selected. From each PHC, 30
consecutive patients were contacted on each Monday during the study period (December
2011-April 2012). The prescriptions of these patients were reviewed to abstract the
details of medicines prescribed using the standardized data collection form to calculate
five prescription indicators, i.e. (i) average number of medicines per prescription,
(ii) percentage of medicines prescribed by generic name, (iii) percentage of prescriptions
with antibiotic, (iv) percentage of medicines prescribed as per the essential medicines
list, and (v) percentage of prescriptions with injections.
For calculating the patient care indicators, ten consecutive patients exiting from
dispensing room on each Monday during the study period were observed from each PHC
to calculate the dispensing time, and were interviewed to know their knowledge about
the dosage of medicines prescribed. From the prescriptions of these patients, the
information about the number of medicines prescribed, number of medicines actually
dispensed, and number of medicines adequately labelled with respect to their strength,
dosage and frequency was abstracted.
To calculate the facility based indicators [availability of essential medicine list
(EML) and STG, percentage availability of key indicator medicines], we physically
verified the availability of 20 key essential medicines in the PHC and interviewed
the medical officers and pharmacists to assess their awareness about EML and STG.
Averages and proportions were calculated for the medicine use indicators. To assess
the degree of rational prescribing, the Index of Rational Drug Prescribing (IRDP)
was calculated6. This index system has been validated for use in medical and health
research6
7
8. The index of individual prescribing indicator was calculated by dividing the optimal
level recommended for that indicator with the observed level in the survey. IRDP was
calculated by adding up all the five indices described above. The study was approved
by the institutional ethics committee of National Institute of Epidemiology (NIE),
Chennai.
For describing the prescription indicators, information was abstracted from 600 prescriptions
from the 20 sampled primary health centres. A total of 2059 medicines were prescribed
in these prescriptions (average: 3.43, SD=1.53, range: 1-9). Most of the medicines
prescribed were from EML (94%) and were prescribed by generic name (84%). About a
quarter of the prescriptions were poly-pharmacy prescriptions (defined as prescriptions
with 5 or more drugs). Antibiotics and injections were prescribed in 49 and 61 per
cent of the prescriptions respectively (Table I).
Table I
Indicators of rational drug use, Shimoga, Karnataka, India, 2012.
The 200 prescriptions surveyed for patient care indicators contained 673 medicines,
of which 93 per cent medicines were dispensed in the PHC. Only 25 per cent of the
medicines dispensed were adequately labelled with a mention of strength, dosage and
duration. All prescriptions had a pictogram indicating the frequency of medicine use.
Majority (75%, 149/200) of patients interviewed knew the correct dosage schedule for
all the medicines prescribed. The average dispensing time was 86 ± 32.36 sec.
Overall, 82 per cent of the essential medicines were available in the PHCs. The EML
and STG were available in three (15%) and 11 (55%) PHCs, respectively. Seventeen of
the 20 (85%) medical officers and 15 of the 20 pharmacists (75%) interviewed were
aware of essential medicines list. Twelve doctors (60%) were aware of standard treatment
guidelines.
The overall IRDP of the Shimoga district was 3.42 compared to the optimal level of
5. The indices of rational antibiotic prescribing and injection use were low at 0.68
and 0.19, respectively (Table II). The findings of our study indicated that majority
of the health facilities in Shimoga district had the key essential medicines. However,
the index of rational drug prescribing was below the optimal level with high proportion
of prescriptions containing injections and antibiotics. The findings of our study
were comparable with the findings of studies conducted in 35 low-income countries
which reported 45 per cent (range: 22-77%) of prescriptions had antibiotics2. It is
a well established fact that overuse of antibiotics leads to bacterial drug resistance,
which is an important public health problem in many developing countries9
10.
Table II
Index of rational drug prescribing (IRDP) in primary health centres of Shimoga, Karnataka,
India, 2012.
Overuse of injection was the most prominent manifestation of irrational prescribing
in Shimoga with more than 60 per cent prescriptions containing at least one injection
as compared to the optimal level of 10 per cent. High proportion of prescriptions
with at least one injection was reported from several studies in India11
12.
Our study had certain limitations. First, the prescribers were aware about the study,
which could have biased the prescribing indicators in a socially desirable direction.
Second, determining the quality of diagnosis and evaluating the appropriateness of
choice of medicine was beyond the scope of our study. Third, the study was conducted
in only one district of Karnataka and hence it would not be possible to generalize
the findings in other districts.
In conclusion, prescription and dispensing practices of health care providers in Shimoga
district were found to be below the optimal level, especially with respect to prescribing
injection and antibiotics. It is, therefore, necessary to train the health care providers
in the district about the rational use of injections and antibiotics. Interventions
such as interactional group discussion on safety of injection to doctors working in
the primary health centres have shown to reduce injection prescribing13. It is also
necessary to ensure that the EML and STG for antibiotic use are made available in
every primary health centre. Shimoga is one of the better performing districts in
the State with respect to health indicators14. The prescribing indicators observed
in the district are, therefore, likely to reflect the best case scenario in the State
and are likely to be better compared with other districts.