|Year : 2015 | Volume
| Issue : 3 | Page : 223-228
Assessment of drug use pattern using World Health Organization core drug use indicators at Secondary Care Referral Hospital of South India
P Siva Prasad, J Thippe Rudra, P Vasanthi, U Sushitha, M Jaffar Sadiq, G Narayana
Department of Pharmacy Practice, Raghavendra Institute of Pharmaceutical Education and Research, K R Palli Cross, Anantapuramu District, Andhra Pradesh, India
|Date of Web Publication||12-Jun-2015|
Dr. P Siva Prasad
Department of Pharmacy Practice, Raghavendra Institute of Pharmaceutical Education and Research, K R Palli Cross, Anantapuramu District, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Objectives: The aim of this study was to assess the drug use pattern using World Health Organization (WHO) prescribing, patient care and health facility indicators at Secondary Care Referral Hospital of South India. Methods: A cross-sectional study was conducted at Secondary Care Referral Hospital of South India. WHO core drug use indicators questionnaire was used for the assessment of drug use pattern which comprise of five prescribing care indicators, five patient care indicators and two health facility indicators. 603 patient encounters were reviewed prospectively for a 6 months period from November 2013 to April 2014. Data were collected from outpatients of the pharmacy and results were represented in descriptive statistics. Results and Discussion: The average number of drugs prescribed per prescription was 2.7. The percentage of prescriptions in which antibiotics and injections were comprised about 9.6% (n = 159) and 1.6% (n = 27), respectively. The percentage of drugs prescribed by generic and from essential drug list (EDL) was 42.9% (n = 709), and 95.6% (n = 1578), respectively. The average consulting and dispensing time was 3.7 min and 2.3 min, percentage of drugs actually dispensed and adequately labeled was 96.6% and 99.3%. Percentage of patients had knowledge of correct dosage was 89.3%. The copy of EDL was available and the percentage of key drugs available was 88%. Conclusion: On the basis of above findings, the study was concluded that the prescribing indicators were met WHO standard criteria. The patient care and health facility indicators are rational and the importance of these indicators was encouraged by the doctors and the pharmacists. It shows that available drugs are satisfying unlimited healthcare needs of the public. Further, such studies at different regions of India and their review may produce beneficial results for the betterment of the society.
Keywords: Patient care, prescribing pattern, rational drug use, World Health Organization core drug use indicators
|How to cite this article:|
Prasad P S, Rudra J T, Vasanthi P, Sushitha U, Sadiq M J, Narayana G. Assessment of drug use pattern using World Health Organization core drug use indicators at Secondary Care Referral Hospital of South India. CHRISMED J Health Res 2015;2:223-8
|How to cite this URL:|
Prasad P S, Rudra J T, Vasanthi P, Sushitha U, Sadiq M J, Narayana G. Assessment of drug use pattern using World Health Organization core drug use indicators at Secondary Care Referral Hospital of South India. CHRISMED J Health Res [serial online] 2015 [cited 2020 Aug 7];2:223-8. Available from: http://www.cjhr.org/text.asp?2015/2/3/223/158683
| Introduction|| |
Rational drug use is defined as "a right drug, in right dose, at the right time, in right strength, to the right patient, right administration, and with a right cost. This approach will promote appropriate regimen according to the patient need." Essential drugs are defined as drugs which satisfied major health care needs of the population, available at all times in adequate dose and appropriate dosage forms. This concept will promote patient health status and improves health-related quality of life. Essential drug concept and rational drug usage is useful for assessment of quality of prescribing pattern. 
Worldwide not less than half of all medicines are prescribed, dispensed, or sold inappropriate, and most of the patients fails to administer them correctly. Around one-third of world's inhabitants lack access to essential medicine.  This study aims to assess the prescribing pattern using World Health Organization (WHO) core drug use indicators. It will promote the development of standards for prescribing, formulating drug policies and improves rational usage of drugs. This objective will be achieved by measuring prescribing indicators such as average number of drugs prescribed, percentage of generic drugs, antibiotics, injections, and drugs prescribed from essential drug list (EDL). These indicators are widely acceptable and maintain global standards. 
An effective health care delivery is foremost important requirement to better patient care. Delivery of quality service involves minimizing the risks and maximizing the benefits that can promote health of patients. In 1985, WHO conducted an international conference on rational drug usage at Nairobi to develop guidelines for rational usage of drugs.  In 1978, Alma-Ata declaration says appropriate treatment of common diseases and injuries and access of essential medicines are important components of Primary Health Care (PHC). In Indian drug market about 60,000 drug formulations are available. However, only 6,000 drugs are useful to treat common diseases. 
When patients are well informed about the medication and their use, it will promote safe and effective drug therapy, which will promote rational usage of drugs. The main criteria for promoting rational drug is diagnosis accurately, correct prescribing, proper dispensing, right packing, and patient compliance. This study aims to assess health care practice and facilities providing to patients. It can be assessed using patient care indicators and health facility indicators which are recommended by WHO.
The whole study was carried out in a non-benefit expecting, service providing hospital situated in resource-limited settings (away from the urban settings) of Andhra Pradesh. Even, effect of the country side may be considered during the process of the study.
| Methods|| |
It is a prospective, quantitative, cross-sectional study designed to describe the current WHO core drug use Indicators pattern (prescribing practice, patient care, and facility care) at rural secondary care referral hospital situated at resource-limited settings of South India. The study was approved by Institutional Review Board (No: RIPER/IRB/2014/17).
The data collected on WHO core drug use indicators (prescribing indicators, patient care indicators and facility care indicators) prospectively using prescriptions, registration books, patient interview and observing the patients only after getting the consent from the subjects. The specific types of data necessary to measure the prescribing indicators, patient care indicators and facility care indicators were recorded for each patient encounter and entered directly into an ordinary prescribing indicator form, patient care indicator form and facility care indicator form.
According to the WHO, to "investigate drug use in health facilities, at least 600 encounters should be included in a cross-sectional survey" to describe the current prescribing practices, which a greater number if possible.  For this particular study 603 prescriptions were collected prospectively for a 6 months duration from November 2013 to April 2014. The sample was selected using a systematic random sampling method, and the sampling unit was patient encounters taking place at the outpatient health facility for the treatment of acute and chronic illness.
All data regarding prescribing indicators, patient care indicators, and facility care indicators were collected in a suitable form and analyzed using suitable statistical tools expressing for frequencies, averages/means and percentages were reported.
These WHO core drug use indicators are developed to be used as measures of performance in three common areas associated to the rational use of drugs in primary care:
The indicators of prescribing practices measure the performance of health care provider in several key proportions associated to the appropriate use of drugs. 
- Average number of drugs per encounter was calculated to measure the degree of polypharmacy
- Percentage of drugs prescribed by generic name was calculated to measure the tendency to prescribe by generic name
- Percentage of encounters with an antibiotic prescribed
- Percentage of encounters with an injection prescribed was calculated to measure the overall level of use of two important, but commonly overused and costly forms of drug therapy
- Percentage of drugs prescribed from EDL or formulary was calculated to measure the degree to which practices conform to a national drug policy, as indicated by prescribing from the national EDL or formulary for the type of facility surveyed.
Patient care indicators in order to understand the way drugs are used it is important to consider what takes place at health facilities from both the provider's and the patient's point of view. The time that prescribers and dispensers spend with each patient sets important limits on the possible quality of diagnosis and treatment. Patients for whom pharmaceuticals are prescribed should, at a minimum, receive well-labeled medications, and should understand how to take each drug. 
- Average consultation time was calculated to measure the time that the medical person spends with patients in the process of consultation and prescribing
- Average dispensing time was calculated to measure the degree to which health facilities are able to provide the drugs which were prescribed
- Percentage of drugs actually dispensed was calculated to measure the degree to which health facilities are able to provide the drugs which were prescribed
- Percentage of drugs adequately labeled was calculated to measure the degree to which dispenser's record essential information on the drug packages they dispense
- Patient knowledge of correct dosage was calculated to measure the effectiveness of the information's given to patients on the dosage schedule of the drugs they receive.
The health facility indicators are used to identify the ability of prescribe drugs reasonably is influenced by many features of the working location. Two particularly important components are an adequate supply of essential drugs and access to balanced information about these drugs. Without these, it is difficult for health person to function effectively. 
- Availability of copy of EDL or formulary was calculated to measure the extent to which copies of the national EDL or local formulary are available at health facilities. It was calculated by yes or no, per facility
- Availability of key drugs was calculated to measure the availability at health facilities of key drugs recommended for the treatment of some common health problems.
| Results|| |
Total of 603 prescriptions was analyzed prospectively in the outpatient department of rural secondary care referral hospital of South India from November 2013 to April 2014.
A total of 1649 drugs were prescribed. Thus, the average number of drugs per encounter or mean was 2.7. The total number of antibiotics was prescribed in159 prescriptions (9.6%), and an injection was prescribed in 27 prescriptions (1.6%). The total number of drugs prescribed in a generic name was found to be 709 prescriptions (42.9%). All most all drugs prescribed (n = 1578, 95.6%) were on the EDL of India [Table 1].
A total of average consulting time and dispensing time was found to be 3.7 min and 2.3 min. A total of 1593 drugs is actually dispensed (96.6%) and 599 prescription encounters are adequately labeled (99.3%). On the other hand, patient knowledge of correct dosage was found to be 539 prescription encounters (89.3%).
In this hospital having own EDL and other hand availability of key drugs was found to be 88% [Table 2].
| Discussion|| |
The main objective of this study using the WHO core drug use indicators was to find out the rational use of medicines based on the existing prescribing care indicators, patient care indicator and patient health facility indicator in the area of rural secondary care referral hospital situated at resource-limited settings of South India.
The average number of drugs per prescription 2.7, at rural secondary care referral hospital South India, is compared with the standard 1.6-1.8 derived as ideal.  whereas mean item per prescription in an another study conducted in Iran was 3.07.  In a similar study performed in South West Ethiopia at Jimma Hospital, the average number of drugs per encounter was 1.59.  In the study of drug use patterns in developing countries, the average number of drugs per encounter was high in Nigeria (3.8), low in Sudan (1.4), and in Zimbabwe (1.3). ,, A high average no of drugs might be due to earning of money to prescribe more, lack of therapeutic training of prescribers. A low average number of drugs might be due to prescribers having knowledge of therapeutics.
Our study shows that the percentage of generic drugs prescribed was found to be 42.9%, is compared with WHO standard (100%) very low.  In the drug use pattern study in developing countries, the percentage of encounters in which generic drugs prescribed was low in Nigeria (48%), Sudan (63%) and relatively better in Zimbabwe (94%). ,,
Our study shows that the percentage of antibiotics prescribed was found to be 9.6% it is very effective than WHO standard (20.0-26.8%).  A national baseline study on drug use indicators in Ethiopia in September 2002 also showed that the percentage of encounters in which an antibiotic was prescribed to be 58.1%.  In the drug use pattern study in developing countries, the percentage of encounters in which an antibiotic was prescribed was Nigeria (48%), Sudan (63%) and relatively better in Zimbabwe (29%), followed by Uganda (56%) ,,, and a study in inpatient department of teaching hospital of Iran has shown 45% antibiotic prescription.  Drug use evaluation should be done whether the appropriate drugs prescribed or not.
Our study shows that the percentage of injections prescribed was found to be 1.6%. A national baseline study on drug use indicators in Ethiopia carried out in September 2002 found that the percentage of encounters with an injection was 23% which is higher than our study  and in Iran it was 41% in the inpatient department of teaching hospital.  Injections are expensive compared to other dosage forms it required trained persons. However, unhygienic use of injections can increase the risk of transmission of diseases such as hepatitis, HIV/AIDS and blood-borne diseases. The percentage of EDL prescribed was found to be 95.6% and which is almost equal with the WHO standard (100%).
In present study, the average consulting time was found to be 3.7 min. The average consultation time at geographically different region like South Ethiopia was found to be 6.14 min, it was nearly parallel with the study conducted in North West of Ethiopia was found to be 5.75 min  completely differs from a similar study carried out at South India which was 12 min 49 s.  In Jordan, it was 3.90 min  and in India it was found to be 4 min.  United Arab Emirates it was found to be 10 min.  During the consultation time, the doctor has to make patient complete evaluation and select the suitable medication. If the consultation is too short the physician does not complete patient evaluation and it will impact on doctor choose right or wrong medication and during this short period the physician not effectively communicate with patient about their treatment and illness.
In the current study, the average dispensing time was found to be 2.3 min. The average dispensing time at geographically different region like South Ethiopia and North West of Ethiopia was found to be 1.28, 1.9 min.  In Nepal, the dispensing time was found to be 52 s  and in India two studies were conducted and the dispensing time was found to be 14.1 s, 1.4 min. , at a South Indian Hospital, it was 4 min 4 s.  The pharmacists can counsel the patient about dosage regimen, adverse effects of therapy, precautions to be taken along with labeling of envelope in such a short period of time. As per WHO recommendation the pharmacist should spend at least 3 min in each patient but in our study it was less than required.
Our study shows that the average percentage of drugs adequately labeled was found to be 99.3%. This means the patient knows which drug they were taking for their problem. Keohavong et al.  Revealed that 67% of dispensed drugs were adequately labeled. A study conducted in the Islamic Republic of Iran showed that 60% of the drugs were adequately labeled.  A similar study conducted in India showed that the adequate labeling was only 18.5%.  While in another study, 43.8% of dispensed products were inadequately labeled  and in as South Indian Hospital it was 38.35%. 
Our study shows that the average percentage of drugs adequately dispensed was found to be 96.6%. In the West Bengal, all the prescribed drugs were supplied [dispensed] for only 11.6% of prescriptions  and in a South Indian Hospital it was 95.54%. 
Our study shows that the average percentage of patients are having adequate knowledge 89.3%. In Western Nepal, the patient's knowledge on correct drug dosage was found to be 81%. Similar study revealed 52.8% in Chennai, India. 55% in Cambodia, 70% in Brazil and 80.8% in pediatric patients in India.  In South, 24 Parganas district of West Bengal, 64.5% of the patients knew the correct mode of use of dispensed drugs  and in a South Indian Hospital it was 31%. 
Our study shows that the average percentage of key drugs was found to be 88%. An average of 80% of key drugs was available at PHC's in a drug use study in Jordan.  In India, it was found to be 73% of key drugs.  Another study conducted in West Bengal shows that the proportion of prescribed drugs (45.7%) included in the WHO model list of essential drugs fell short of the 50% level  and in a South Indian Teaching Hospital it was 91.67%. 
A copy of EDL available at our health center. Patients response to quality of services provide in the health facility shows that overall patients, good 84.7%, satisfactory 14.9% and unsatisfactory 1.16%. In an another study, in India the overall satisfaction of the patient's attending Primary Care Centre's in Lucknow District was found to be 60%. 
The study has further articulated the dedication of a prescriber through his prescription meant for the betterment of the disease even though he has to surpass many difficulties in his path for healing of the sick. As the study was intentionally carried out in a secondary care referral hospital situated in resource-limited settings, it was also challenging for the researchers to cope up with basic demands of the countryside.
There might be difference in the study outcomes of the present study with that of the other studies already published may be because of the study environment, educational barriers of the study population, geographical difference, difference in food habits, medication availability with reference to the present study, etc. Even though, with the presence of differences in the studies the prescription patterns are almost the same [Table 1] and [Table 2].
| Conclusion|| |
On the basis of above findings, the study was concluded that the prescribing indicators were met WHO standard criteria. The patient care and health facility indicators are rational and the importance of these indicators was encouraged by the doctors and the pharmacists. It shows that available drugs are satisfying unlimited healthcare needs of the public. Further, such studies at different regions of India and their review may produce beneficial results for the betterment of the society.
| References|| |
Thomas M. Rational drug use and essential drug concept. In: Parthasarathi S, Nyfort-Hansen K, Nahata M, editors. A Textbook of Clinical Pharmacy Practice. 1 st
ed. Chennai, India: Universities Press (India) Pvt. Ltd.; 2008. p. 72-83.
World Health Organization. Promoting rational use of medicines; core components. WHO Policy and Perspectives on Medicine No 5 Document WHO/EDM/2002.3. Geneva: WHO; 2002.
Bimo, Chowdhry A, Das A, Diwan V, Kafle KK, Mabadeje A, et al
. How to Investigate Drug Use in Health Facilities. Geneva: WHO; 1993.
World Health Organization. The Rational Use of Drugs. Report of a Conference of Experts, Nairobi. 25-29 November, 1985. Geneva: World Health Organization; 1987.
WHO. How to Investigate Drug Use in Health Facilities: Selected Drug Use Indicators. Geneva: WHO/DAP/93.1; 1993.
Isah AO, Ross-Degnan D, Quick J, Laing R, Mabadeje AF. The Development of Standard Values for the WHO Drug use Prescribing Indicators. Nigeria: ICUM/EDM; 2004.
Karimi A, Haerizadeh M, Soleymani F, Haerizadeh M, Taheri F. Evaluation of medicine prescription pattern using World Health Organization prescribing indicators in Iran: A cross-sectional study. J Res Pharm Pract 2014;3:39-45.
Abdulahi M, Shifera WT. Pattern of prescription in Jimma Hospital. Ethiop J Health Dev 1997;11:263-67.
Hogazeil HV, Bimo, D- Ross Degnan, Laing RO, Adjei DO, Santaso B, et al
. Field test for rational drug use in twelve developing countries. Lancet 1993;342:1408-10.
Bannenberg WJ, Forshaw CJ, Fresle D, Salami AO, Wahab HA. Evaluation of Nile Province Essential Drug Project. Geneva: WHO, WHO/91.10; 1991.
Ministry of Health/Zimbabwe Essential Drug Action Programme. Essential drug survey. Geneva: WHO, 74(WHO/93.1). 1993.
Mengistu S, Shiferaw G, Ibro A, Asfaw M, Berriso H, Yigletu T, et al
. Assessment of the Pharmaceutical sector in Ethiopia. Addis Ababa: Federal democratic republic of Ethiopia Ministry of health, World health organization; 2003.
Christensen RF. A Strategy for the Improvement of Prescribing and Drug Use in Rural Health Facilities in Uganda, Ugandan Essential Drugs and Management Program; 1990.
Melugeta TA, Nasir TW, Raju NJ. Assessment of patterns of drug use by using world health organization prescribing, patient care and health facility indicators in selected health facility in south west Ethiopia. J Appl Pharm Sci 2011;1:62-6.
Mathew B, Gadde R, Nutakki P, Doddayya H. Assessment of drug dispensing practices using who patient care and health facility indicators in a private tertiary care teaching hospital. Int J Pharm Pharm Sci 2013;5:368-71.
Otoom S, Batieha A, Hadidi H, Hasan M, Al-Saudi K. Evaluation of drug use indicators using World Health Organization's prescribing indicators. East Mediterr Health J 2002;8:537-42.
Gopalakrishnan S, Ajitha K, Ganeshkumar P, Selvaraj I, Logaraj M. Assessment of patient care and health facility indicators among urban and rural private practitioners in Kanchipuram district of Tamil Nadu, India. Natl J Res Community Med 2012;1:178-241.
Rasool BK, Fahmy SA, Abu-Gharbieh EF, Ali HS. Professional practices and perception towards rational use of medicines according to WHO methodology in United Arab Emirates. Pharm Pract (Granada) 2010;8:70-6.
Ghimire S, Nepal S, Bhandari S, Nepal P, Palaian S. A prospective surveillance of drug prescribing and dispensing in a teaching hospital in western Nepal. J Pak Med Assoc 2009;59:726-31.
Sutharson L, Hariharan RS, Vamsadara C. Drug utilization study in diabetology outpatient setting of a tertiary hospital. Indian J Pharmacol 2003;35:237-40.
Keohavong B, Syhakhang L, Sengaloundeth S, Nishimura A, Ito K. Rational use of drugs: Prescribing and dispensing practices at public health facilities in Lao PDR. Pharmacoepidemiol Drug Saf 2006;15:344-7.
Cheraghali AM, Nikfar S, Behmanesh Y, Rahimi V, Habibipour F, Tirdad R, et al.
Evaluation of availability, accessibility and prescribing pattern of medicines in the Islamic Republic of Iran. East Mediterr Health J 2004;10:406-15.
Karande S, Sankhe P, Kulkarni M. Patterns of prescription and drug dispensing. Indian J Pediatr 2005;72:117-21.
Hazra A, Tripathi SK, Alam MS. Prescribing and dispensing activities at the health facilities of a non-governmental organization. Natl Med J India 2000;13:177-82.
Kumari R, Idris M, Bhushan V, Khanna A, Agarwal M, Singh S. Study on patient satisfaction in the government allopathic health facilities of Lucknow District, India. Indian J Community Med 2009;34:35-42.
[Table 1], [Table 2]