RESEARCH ARTICLE
Analysis of drug utilization in government tertiary care institution of
South India
Meeradevi Alagar
Department of Pharmacology, Government Medical College and ESIC Hospital, Coimbatore, Tamil Nadu, India Correspondence to: Meeradevi Alagar, E-mail: meerabaskar.a@gmail.com
Received: November 16, 2021; Accepted: February 09, 2021
ABSTRACT
Background: Drug is an active chemical molecule used for diagnosis, prevention, and treatment of a disease. Drug utilization study is a potential tool in the evaluating the health-care system of a country since drug therapy accounts for major health expenditure. These studies also facilitate rational use of drugs among people of various age groups. Aims and Objectives: This study aims to analyze the utilization pattern of drugs in the pediatric outpatient department (OPD) and also to analyze drug prescribing indicators of the World Health Organization. Materials and Methods: A prospective observational study was conducted in the pediatric outpatient department (OPD) of Government Kilpauk Medical College Hospital, Chennai for one month during October 2014. A total of 600 prescriptions were collected. Patient-related information and drug-related information were analyzed. Drug prescribing indicators of the World Health Organization were also analyzed. Results: The most common age group was 1–6 years. Average number of drug per prescription was 1.96. Antimicrobial agents were most commonly prescribed drugs. About 93.6% of them were generic drugs. About 90.33% of drugs were from National Essential Medicine List 2011. Conclusion: This study helps us to identify potential targets so as to make improvement in prescribing and dispensing policies of drugs in the hospital. KEY WORDS: Drug Utilization Study; World Health Organization Core Drug Prescribing Indicators; Antimicrobial
Agents; Essential Medicine List INTRODUCTION
The World Health Organization defines drug utilization study as “The marketing, distribution, prescription, and use of drugs in society with special emphasis on the resulting medical, social, and economic consequences.”[1] Drug utilization study helps in identifying the clinical use of drugs among various populations and their impacts on health-care system.[2] These studies began in early 1960s and gained importance because
Access this article online
Website: www.njppp.com Quick Response code
DOI: 10.5455/njppp.2021.11.11314202009022021
National Journal of Physiology, Pharmacy and Pharmacology Online 2021. © 2021 Meeradevi Alagar. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creative commons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.
of increase in discovery and marketing of new drugs, variation in the drug prescribing patterns of drug, delayed adverse effects, and the cost of drugs. Drug utilization study is a crucial part of pharmacoepidemiology as it gives about the nature, extent, and various aspects of drug exposure. Hence, now, these studies act as a major weapon in evaluating the health-care systems. It is an ongoing, systematic process intended to preserve the correct and effective use of medications. It involves a comprehensive review of a health and medication of the patient so as to achieve appropriate decision-making therapeutically and positive patient outcome.
Anatomical Therapeutic Chemical/Defined Daily Dose (WHO ATC/DDD) methodology is used as the standard reference for drug utilization study.[3] Defined daily dose for each drug is defined by the Collaborating Centre for Drug Statistics and Methodology of the World Health Organization
as an assumed average maintenance adult dose per day for main indication. Hence, it is an international unit used for international or regional comparisons and it is not the recommended or prescribed daily dose. Many studies have reported discrepancies between defined daily dose and prescribed daily dose for various groups of drugs.[4,5]
Many studies have reported drug usage patterns among various age groups around the world. Since children belong to vulnerable population and only limited studies are available, we conducted our study in the pediatric outpatient department (OPD) to generate data and analyzed the drug prescriptions for the World Health Organization core drug prescribing indicators. The results of our study can be considered as basis for identifying the potential targets so that improvements can be made in prescribing and drug dispensing policies of a hospital.
Primary Objective
The primary objective of the study was to study the drug utilization in the pediatric OPD of a tertiary care hospital. Secondary Objectives
The secondary objective of the study was to analyze the World Health Organization’s core drug prescribing indicators such as average number of drugs per prescription, percentage of encounters with an injection, percentage of drugs in generic names, percentage of antibiotics prescribed, and percentage of drugs prescribed from the essential drugs list.
MATERIALS AND METHODS
A prospective observational study was conducted in the pediatric OPD of Government Kilpauk Medical College Hospital, Chennai, for during October 2014 after getting approval from the Institutional Ethics Committee. All new cases coming to the OPD for treatment were included in the study. Infants and children coming for vaccination, children with chronic ailments for weekly drugs, and those not willing to give the treatment particulars were excluded from the study. The prescription written by the pediatrician to the patient was the collected. The details of patient-related information such as age, sex, and diagnosis and drug-related information such as drug name, dose, formulations, dosing schedule, route of administration, and duration of treatment were entered in the data sheet. Total numbers of prescriptions analyzed were 600. All the details entered in the customized data collection sheet were statistically analyzed based on the following World health organization’s core drug prescribing indicators like analysis of various groups of drugs prescribed, average number of drugs per prescription, analysis of each group, analysis of various routes of drugs prescribed, average number
of drugs per prescription, percentage of drugs prescribed by generic names, and also from essential drug list.
The drugs were coded as per the Anatomical Therapeutic and Chemical Classification coding system of World Health Organization. National Essential Medicines List 2011 (EML 2011) of India[6] was used to analyze the drugs prescribed. Statistical Analysis
Data were reported as number, percentage, mean, and median and entered into Microsoft access 2007 version database for statistical analysis. There was no statistical hypothesis tested. RESULTS
The findings of our study are shown in the Tables 1-3 and Figures 1-3.
DISCUSSION
The children between the age groups of 1 and 6 years (352/600) were the major group consulted by the pediatricians and male children accounted for 58% of the total cases, as shown in Table 1. Percentage of drugs prescribed varied according to the indications and the most common indication was respiratory tract infection contributing to 59%, as shown in Figure 1. The drugs belonging to gastrointestinal system, respiratory system, antimicrobials, and nutrients were prescribed, as shown in Figure 2. The most commonly prescribed drugs were antimicrobial agents (29.93%) followed by nonsteroidal anti-inflammatory drugs (NSAIDs) (22.87%) and antihistamines (21.17%), as shown in Figure 2. Antibiotics were prescribed in more than 50% prescriptions (54.16%). Amoxicillin was the most common antimicrobial agent followed by erythromycin and septran. The drug prescriptions were analyzed for the World Health Organization’s core drug prescribing indicators, as shown in Table 3. Average number of drug per prescription was 1.96. Percentage of prescriptions with 1, 2, 3, and 4 drugs was 31, 45, 20, and 4.4%, as shown in Figure 3. The most common route of drug administration was oral route (98.67%) followed by parenteral route, as shown in Table 2. About 93.6% of drugs were prescribed as generic drugs except septran and bifilac. About 90.33% of drugs were prescribed from the National List of Essential Medicines, 2011 of India which is modeled in the Essential Drugs List of the World Health Organization. The children between the age groups of 1 and 6 years (352/600) were the major group consulted by the pediatricians and male children accounted for 58% of the total cases, as shown in Table 1. This was similar to the study conducted by Ajitha Sharma were majority of them were male patients and 1-5 years age group was the major group.[7] However, the difference is that in our study, those prescriptions with
vaccination were excluded and in their study immunization alone constituted 24.7% (249) which might have accounted for major group as 1–5 years.
The major classes of drugs prescribed are shown in Figure 2. The most commonly prescribed drugs are antimicrobial agents (29.93%) followed by NSAIDs (22.87%) and antihistamines (21.17%). Antibiotics were prescribed in more than 50% prescriptions (54.16%). This is comparatively same as
the studies conducted by Bansal, Flemming, and Mital[8-10] and their studies were conducted in tertiary care centers of various departments. The reason for antibiotic usage in our study was that the most common indication was respiratory tract infection (upper respiratory infections and lower respiratory infections). Hence, the diagnosis of the patient was the core factor which influences the prescribing pattern of drugs. Furthermore, commonly prescribed drugs are most commonly available drugs. The antibiotics were prescribed based on the clinical diagnosis without culture sensitivity. This could be sometimes responsible for rising incidence of microbial resistance. There is a need to make changes in the hospital antibiotic policy to limit inappropriate prescription of antibiotics. Hence, implementation of antibiotic restriction program in a hospital with the help of multidisciplinary team of physicians and clinical pharmacist is very essential. The triumph of this program in decreasing antibiotic utilization was demonstrated by the study conducted by Mansouri et al.[11] The prescriptions analyzed for the WHO core indicators [Table 3] showed that the average number of drug per prescription was 1.96 [Figure 3]. This was similar to the study of Ajitha Sharma where the average was 1.9. The reason for low average could be due to limited and rational drug prescribing practice by the pediatricians. Average number of drug per prescription in our study is different from the studies conducted by Mital[10], Seetharam et al.,[12] and Gawali[13] which show that average number of prescriptions with drugs was more than 3 as their study group was adult population with varied ailments. Polypharmacy has many drawbacks such as poor patient compliance, high health-care cost, and more incidents of adverse events. Hence, monitoring continuously is needed to identify the predictors of polypharmacy so as to bring amendments in prescribing practices by health professionals.
The most common route of drug administration in our study was oral route (98.67%) followed by parenteral route [Table 2] and this is similar to the study conducted by Sharma.[7] The high percentage of oral route of drug administration was
Table 1: Gender- and age-wise distribution of patients
Gender Number of cases
Male 348
Female 252
Total 600
Age‑wise distribution Percentage
<1 year 4
1–6 years 58.67
6–12 years 37.33
Table 2: The percentage of various routes of drug administration
Routes of drug administration Percentage of patients
Oral 98.67
Injectables 0.5.
Topical 10.5
Table 3: About the WHO core indicators
WHO core indicator Percentage
Prescriptions with oral route of drug
administration 98.67
Encounters with antibiotics 29.93
Average number of drugs per prescription 1.96 Percentage of prescriptions with generic
drugs 93.6
Percentage of drugs from EML 2011 90.33
attributable OPD study with patients mostly coming for acute illnesses.
In our study, 93.6% of drugs were prescribed as generic drugs except septran and bifilac [Figures 4 and 5] compared to 60.2% of the drugs prescribed using generic name in the study conducted by Sharma.[7] This variation is due to common practice by the pediatricians of our hospital prescribing the drugs by generic names. Pharmaceutical step therapy approach explains the importance of drug prescription by generic names instead of brand names and is an useful strategy in drug cost savings.[14,15]
In our study, 90.33% drugs were prescribed from the National List of Essential Medicines, 2011[6] of India which is modeled on the Essential Drugs List of the World Health Organization. This percentage in our study was high when compared with the studies conducted by Sharma[7] and Mittal et al.[10] were 70–80% of drugs were from essential medicine list. This may be due to the availability of drugs in our hospital. The list of
medicines in essential list remains a national responsibility and is formulated based on the country’s disease burden, priorities of health concerns, affordability, etc. Ministry of Health and Family Welfare, Government of India, released the first National List of Essential Medicines of India in 1996 consisting of 279 medicines. The list was subsequently revised. The 2011 list had 348 medicines..
Limitations
Defined daily dose was not used as per standard practice of methodology of drug utilization study since our study was conducted in the pediatric outpatient. The drugs belonging to cardiovascular system, central nervous system, and genitourinary system were not encountered as study population belongs to OPD of pediatrics.
CONCLUSION
Our study by analyzing the drug utilization pattern in the outpatient department of pediatrics states the need to modify prescription patterns as per the need of the patients. This study also improves the drug dispensing policies of the hospital. Drug utilization studies vary among different health institutions and sometimes within the same institute due to changing trends in disease over a period of time. Hence, conducting periodic studies in various hospital settings or patient populations are essential to critically analyze the current hospital drug policies so as to make recommendations to improve drug usage pattern in the future.
REFERENCES
1. World Health Organization. Introduction to Drug Utilization Research. What is Drug Utilization Research and Why Is It Needed? Ch. 1. Geneva: World Health Organization; 2003. p. 8-12. Available from: http://www.apps.who.int/medicinedocs/ pdf/s4876e/s4876e.pdf. [Last accessed on 2014 Aug 21]. Figure 2: Various drug categories. Antimicrobials – 29.93%, NSAID – 22.87%, and antihistamines – 21.17%
Figure 3: The average number of drugs per prescription. 1 – 186, 2 – 273, 3 – 120, and 4 – 21. Average number of drug per prescription – 1.96
2. World Health Organization. How to Investigate Drug use in Health Facilities. Selected Drug Use Indicators-EDM Research Series No. 007. Geneva: World Health Organization; 1993. Available from: http://www.apps.who.int/medicinedocs/en/d/ js2289e/8.6.html. [Last accessed on 2014 Aug 21].
3. ATC/DDD Classification: Drug Utilization Data Constrains in Developing Countries, WHO Drug Information; 2002. p. 233-40. Available from: http://www.apps.who.int/medicinedocs/ pdf/s4951e/s4951e.pdf. [Last accessed on 2014 Aug 21]. 4. Muller A, Monnet DL, Talon D, Hénon T, Bertrand X.
Discrepancies between prescribed daily doses and WHO defined daily doses of antibacterials at a university hospital. Br J Clin Pharmacol 2006;61:585-91.
5. Grimmsmann T, Himmel W. Discrepancies between prescribed and defined daily doses: A matter of patients or drug classes? Eur J Clin Pharmacol 2011;67:847-54.
6. National List of Essential Medicine; 2011. Available from: http:// www.cdsco.nic.in/nedl.pdf. [Last accessed on 2014 Aug 21]. 7. Sharma A, Shweta O. Assessment of drug prescription
pattern in children: A descriptive study. Natl J Physiol Pharm Pharmacol 2016;6:74-80.
8. Bansal V, Medhi B, Jose V, Pandhi P. Changing trend in the use of antimicrobials over ten years in a tertiary care hospital. Indian J Pharmacol 2011;43:365-7.
9. Flemming B, Mabeck CE. Use of Antibiotics in general practice in Denmark. Scand J Prim Health Care 1986;4:101-4. 10. Mital N, Mittal R, Singh I, Shafiq N, Malhotra S. Drug
utilisation study in a tertiary care center: Recommendations for improving hospital drug dispensing policies. Indian J Pharm
Sci 2014;76:308-14.
11. Mansouri MD, Cadle RM, Agbahiwe SO, Musher DM. Impact of an antibiotic restriction program on antibiotic utilization in the treatment of community-acquired pneumonia in a Veterans Affairs medical center. Infection 2011;39:53-8.
12. Seetharam JC, Nagarajaiah BH, Shivakumar K. Drug utilization pattern in geriatric inpatients of Medicine wards at a government tertiary care hospital. Natl J Physiol Pharm Pharmacol 2019;9:320-7.
13. Gawali UP, Khobragade RS. Drug utilization and prescription pattern study in medicine intensive care unit at tertiary care teaching hospital. Natl J Physiol Pharm Pharmacol 2019;9:674-7.
14. Haas JS, Phillips KA, Gerstenberger EP, Seger AC. Potential savings from substituting generic drugs for brand-name drugs: Medical expenditure panel survey, 1997-2000. Ann Intern Med 2005;142:891-7.
15. Motheral BR. Pharmaceutical step-therapy interventions: A critical review of the literature. J Manag Care Pharm 2011;17:143-55.
How to cite this article: Alagar M. Analysis of drug utilization in government tertiary care institution of South India. Natl J Physiol Pharm Pharmacol 2021;11 (Online First). DOI: 10.5455/ njppp.2021.11.11314202009022021
