International Journal of Current Medical And Applied Sciences, 2017, June, 15(1),11-14.

ORIGINAL RESEARCH ARTICLE Study of Prescription Practices in the Field Practice Area of Medical College, Kurnool, . Cynthia Subhaprada S.1, Vijaya kumari S.2 & Venkateswarlu U3 1 Associate professor, 2Assistant Professor, 3Post Graduate student, Department of Community , Kurnool Medical College, Kurnool-518002. Andhra Pradesh. . ------Abstract: Introduction: Prescription is a document of instruction through which doctor, nurse and pharmacist communicate to deliver patient care. Many a time if these documents are not properly written or misinterpreted, patient care is at stake. WHO established prescribing indicators to analyze prescription writing and to promote rational drug use. Objectives: To describe the prescription and dispensing practices in the Primary Health Care facilities in the field practice area of Kurnool Medical College, Kurnool. Materials and methods: A cross sectional study was carried out in the primary health care facilities serving the field practice area under the Department of Community Medicine, Kurnool Medical College, Kurnool, Andhra Pradesh, during November-December, 2015, to study the prescription and dispensing practices, using a semi-structured questionnaire. A total of 501 prescriptions of patients who attended the Out-Patient Department (OPD) of these health facilities in the study area, were collected and evaluated. The data was subjected to descriptive statistical analysis using MS Excel 2007. Results: A total of 501 prescriptions were analyzed. Patient details, diagnosis, drug dosage, direction for use and duration of treatment were completely written in 100% of prescriptions. Abbreviations were used in 80.44% prescriptions and Medical officer’s signature present in 79.04%. Total 12172 drugs were prescribed in 501 prescriptions. Average number of drugs per prescription was 3.38±1.79 (Mean ± SD). Poly-pharmacy prescriptions were 71.25%. Percentage of encounters with antibiotics and injections was 60.47% and 11.37% respectively. 91.29% drugs were prescribed according to Essential Medicine List (EML) of the State of Andhra Pradesh. Conclusions: Poly - pharmacy and antibiotics prescription was high in the present study. Therefore, strict policy according to the standard treatment guidelines is required to promote rational use of drugs. Keywords: Dispensing Practices, Prescription Practices, Primary Health Care Facility, Rational Use of Drugs.

Introduction Although drugs alone are not sufficient to provide Pradesh, in 2010, published essential list adequate health care, they do play an important role in (EML) and standard treatment guidelines (STG) for use protecting, maintaining, and restoring health [1]. In in the primary health care facilities in the State [3]. 1977, WHO published the first Model List of Essential Irrational drug use is a major public health problem with Drugs and subsequently has attempted to improve drug- far reaching economic consequences [4]. Errors in the use practices in developing countries [2]. Shortages of prescription practices are probably one of the most essential drugs often occur due to inadequate selection common types of medical errors. These errors may be of drugs, improper storage, irrational prescribing and committed during prescription or dispensing or non-adherence by patients. The Government of Andhra administering of drugs.

Address for correspondence: Dr. Cynthia Subhaprada S. Access this Article Online Associate Professor, Department of Community Medicine, Website: Kurnool Medical College, Kurnool-Andhra Pradesh. India : 518002. www.ijcmaas.com Email: [email protected] How to cite this article: Cynthia Subhaprada S. , Vijayakumari S. & Venkateswarlu U.: Study Of Subject: Prescription Practices in The Field Practice Area of Kurnool Medical Medical Sciences College, Kurnool, Andhra Pradesh. International Journal of current Quick Response Code Medical and Applied sciences; 2017, 15(1),11-14.

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Cynthia Subhaprada S. , Vijayakumari S. & Venkateswarlu U.

Knowing where and when errors are most likely to Institutional Ethical committee clearance was occur is generally felt to be the first step in trying to obtained and informed consent was obtained from the prevent these errors. patients / their primary caregivers. Permission was According to WHO definition, "Rational use of drugs obtained from the Medical officers after explaining the requires that patients receive medications appropriate scope of the study. to their clinical needs, in doses that meet their own Prescriptions of patients attending Out Patient individual requirements for an adequate period of Department in these health facilities were evaluated, time, at the lowest cost to them and their community" specifically at the time of dispensing drugs at the [5]. Common types of irrational medicine use are poly- pharmacy. 501prescriptions written by medical pharmacy, inappropriate antimicrobial prescription, officers were selected by using simple random over-prescription of injections, failure to prescribe in sampling technique and evaluated. All prescriptions at accordance with clinical guidelines, very short the time of study were hand written on standard dispensing time and poor communication of drug printed prescription order sheets (e-aushadi). A check related information. list of essential parameters according to WHO Practitioners, both qualified and unqualified who guidelines for prescription writing was used to follow such irrational practices are especially common analyze the pattern of prescription [8]. in slums and rural areas, where majority of the public The prescriptions of these patients were reviewed to health problems exist and National Health programs know the details of medicines prescribed using the are poorly implemented. The problem is further standardized data collection form to calculate five compounded by the prevalence of a dispensing prescription indicators, i.e. (i) average number of practice wherein written prescriptions are not medicines per prescription, (ii) percentage of provided and patients' pressure for quick results leads medicines prescribed by generic name, (iii) to widespread dispensing of steroids and use of percentage of prescriptions with antibiotic, (iv) injections. There is wastage of resources due to percentage of medicines prescribed as per the increase in cost and reduced availability. Bacterial essential medicines list, and (v) percentage of resistance and adverse drug reactions will also be on prescriptions with injections. Poly-pharmacy the rise [6]. prescriptions were defined as prescriptions with more Hence the present study was conducted in the Primary than or equal to five drugs per prescription. Health Care facilities serving the field practice area of The patient care indicators were calculated as follows. Department of Community Medicine, Kurnool Medical During the study period, patients exiting from College, Kurnool, Andhra Pradesh, to describe the dispensing room of each health facility were observed, prescription practices and medicine dispensing to arrive at the dispensing time. They were practices. interviewed to know their knowledge about the Materials and Methods: dosage of medicines prescribed. The information A cross -sectional study was conducted in the Primary about the number of medicines prescribed, number of Health Center (PHC), Kallur, Rural Health and Training medicines actually dispensed, and number of Center (RHTC), Parla and Urban Health Center (UHC), medicines adequately labeled with respect to their Sri Ram Nagar, serving the field practice area of the strength, dosage and frequency was obtained from the Department of Community Medicine, Kurnool Medical prescriptions of these patients. College, Kurnool, during November – December, 2015. The facility based indicators i.e. availability of Kurnool city is governed by Kurnool Municipality, Essential Medicine List (EML) and Standard Treatment which comes under the Kurnool Metropolitan Region. Guidelines (STG) were assessed as follows. Physical As per the Census India reports 2011, the urban / verification of the availability of key essential metropolitan population of Kurnool is 478,124 of medicines in the Health centers was conducted by the which 239,401 are males and 238, 723 are females. investigators followed by an interview of the medical Average literacy rate of Kurnool is 78.15% of which officers to assess their awareness about EML and STG. male and female literacy rates were 83.99% and The data was subjected to descriptive statistical 72.39% respectively [7]. analysis using MS Excel 2007.

Observations & Results: Observations made from the present study are as follows. Table 1: Characteristics of the prescriptions by Medical officers: Characteristics of the Observed (n) Total (N) Percentage prescription (%) Illegible 153 501 30.53% Patient’s details 501 501 100% Signs &symptoms 432 501 86.23% Diagnosis 501 501 100% Use of abbreviations 403 501 80.44% Drug details 501 501 100% Signature of the MO 396 501 79.04%

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All the Medical Officers (MOs) (100%) entered details of the patient such as name, age and sex, in all prescriptions. 30.53% of MOs wrote illegible prescriptions. 100% MOs wrote the diagnosis in their prescription but only 86.23% prescriptions had signs and symptoms recorded. 80.44% had abbreviations. Details regarding the drug dosage and schedule were present in 100% of the prescriptions. 79.04% MOs had put their signatures in the prescriptions (Table1).

Table 2: Prescribing practices in the study area: Observed Total Percentage Prescribing indicators (n) (N) (%) Poly-pharmacy prescriptions 357 501 71.25% Encounters with an antibiotic prescribed 303 501 60.47% Encounters with an injection prescribed 57 501 11.37% Information obtained from 501 prescriptions in these primary health facilities gives the following drug use indicators. A total of 12172 medicines were prescribed, with an average of 3.38 drugs per prescription (SD=1.79, Range= 1 to 9). 91.29% of the medicines prescribed were from Essential Medicines List and all (100%) were prescribed by generic name. About 71.25% of the prescriptions were poly-pharmacy prescriptions. Antibiotics and injections were prescribed in 60.47% and 11.37% of the prescriptions respectively (Table 2).

Table 3: Distribution of patient care indicators and facility indicators: Patient care indicators Observed (n) Total N (%) Medicines actually dispensed and adequately labeled 10763 12172 (88.42%) Knowledge of correct dosage 501 501 (100%) Facility indicators Availability of essential medicine list 2 3 (66.67%) Availability of standard treatment guidelines 2 3 (66.67%)

Patient care indicators are as follows. 88.42% study was 60.47% similar to studies from other states medicines were dispensed and adequately labeled of India (Tamil Nadu, Madhya Pradesh) which with a mention of dosage and duration. 82.04% of reported 55%, 60.9% respectively and the percentage prescriptions had a pictogram indicating the of prescriptions with injection was 11.37% similar to frequency of medicine use. All patients interviewed reports by other researchers in India [15, 16]. In the knew the correct dosage schedule for all the medicines present study, 100% drugs were prescribed in generic prescribed. The average dispensing time was 5.54 ± name. Studies from some other parts of India (Tamil 2.70 min. The EML and STG were available in 66.67% Nadu, Madhya Pradesh, Uttar Pradesh, New Delhi, of heath facilities. 85% of the medical officers were Karnataka) reported 62%, 48.5%, 27.1%, 8%, and aware of essential medicines list and standard 16% of prescriptions where generic name was used treatment guidelines (Table 3). [15, 16, 17, 18, 19]. 91.29% drugs were prescribed according to EML Discussion: similar to study conducted in West Bengal where it The present study revealed that 100% of was 90.3% [20]. But it was higher compared to a study prescriptions had patient details and diagnosis and conducted at Madhya Pradesh which was 66.9% [21]. 79% prescriptions had doctor’s signature similar to The quality of care was assessed by examining the that reported by Siddarth et al [9]. Abbreviations were dispensing practices. The average time taken to used in 80.44% prescriptions for dosage form whereas dispense the drugs was 5.54 ± 2.70 minutes for each it was 95.5% in a study by Hazra et al [10]. Rishi et al patient. 88.42% of the prescribed drugs were reported that diagnosis was mentioned in 22.25% of dispensed to the patients, which is higher than prescriptions [11]. 30.53% prescriptions were illegible previously reported studies [10, 11, 22]. All the which was high as compared to Siddarth et al and patients knew when and how to take the correct Phalke et al where it was 6.3% and 17.6% respectively dosage of drugs dispensed which was higher [9, 12]. compared to Karande et al [22]. Based on the WHO prescribing indicators, it was seen that the average number of drugs per prescription was Conclusions: 3.38 which was similar to a study by Potharaju et al This study provides the baseline data regarding and Mirza et al where it was 3.1 and 3.72 medicines prescribing and dispensing practices in outpatient respectively [13, 14]. Prescriptions containing five or department of the primary health facilities in the field more drugs were nearly three fourths of the practice area. It highlights the problem of prescriptions, which shows there is a practice of poly- overprescribing of antibiotics and a trend towards pharmacy among the MOs in the study area. The poly pharmacy. Use of abbreviations may save time for percentage of prescriptions with antibiotic in this prescriber but does not promote patient safety due to

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Cynthia Subhaprada S. , Vijayakumari S. & Venkateswarlu U. prescribing error. Strict guidelines must be followed tertiary care institute of India Int J Res Foundation or electronic prescription should be promoted. Hosp Health Adm. 2014; 2(1):31-35. Illegible prescriptions are difficult to read and may 10. Hazra A, Tripathi SK, Alam MS, Prescribing and increase chance of medication error. So, training of dispensing activities at the health facilities of a non- governmental organization. Natl Med J India 2000; prescriber for legible prescribing should be promoted. 13:177-82. The prescriptions contained drugs from the WHO list 11. Rishi RK, Sangeeta S, Surendra K, Tailang M. Prescri of essential medicines and the use of injections was ption audit: experience in Garwhwal (Uttaranchal), low. Interventions to rectify over prescription of India Trop Doct 2003; 33(2):64-68. antibiotics and poly pharmacy are necessary to 12. Phalke V, Phalke D, Arif S, Mishra A. Prescripton improve rational drug use. writing practices in a rural tertiary care hospital in Western Maharashtra, India Australias Med J 2011; Acknowledgement: 4(1):4-8. The authors take this opportunity to thank Dr. A. 13. Potharaju HR, Kabra SG, Prescription audit of outpatient attendees of secondary level government Sreedevi MD, Professor and HOD of Community hospitals in Maharashtra. Indain J Pharmacol 2011; Medicine, Kurnool Medical College, Kurnool, the 43:150-56. interns posted in the department during November- 14. Mirza NY, Desai S, Ganguly B, Prescribing pattern in December 2015, the Medical Officers of the health a pediatric out-patient department in Gujarat. facilities and patients for their co-operation and active Bangladesh J Pharmacol 2009; 4:39. participation in the study. 15. Gopalakrishnan S, Ganeshkumar P, Katta A. Assessment of prescribing practices among urban References: and rural general practitioners in Tamil Nadu. Indian J Pharmacol. 2013. 1. The selection of essential drugs. Report of a WHO 16. Bhartiy SS, Shinde M, Nandeshwar S, Tiwari SC. Expert Committee. Geneva World Health Pattern of prescribing practices in the Madhya Organization, 1977: 7-35 (WHO Technical Report Pradesh, India. Kathmandu Univ Med J (KUMJ). Series, No.615). 2008; 6(1):55-9. 2. The rational use of drugs. Report of the Conference 17. Kumari R, Idris MZ, Bhushan V, Khanna A, Agrawal of Experts, Nairobi 25-29, Nov, 85. Geneva, World M, Singh SK. Assessment of prescription pattern at Health Organization, 1987. the public health facilities of Lucknow District. 3. Essential Medicines List – Health, Medical and Indian J Pharmacol. 2008; 40(6):243-7. Family Welfare department. G.O.MS.no. 115. Dt: 13- 18. Bapna JS, Tekur U, Gitanjali B, Shashindran CH, 5-2010 from the DME, Andhra Pradesh, . Pradhan SC, Thulasimani M, et al. Drug utilization at 4. Intervention research in rational use of drugs: a primary health care level in southern India. Eur J review. Amanda le Grand, Hans V Hogerzeil and Clin Pharmacol. 1992; 43(4):413-5. Flora M Haaijer-Ruskamp. 19. Patil KK. Prescribing pattern among interns at the 5. WHO. Model list of essential drugs. Geneva: World rural health centre of the medical college, Manipal. Health Organization, 1988. IJCM. 2004; XXIX (3):129-9. 6. George R, Abraham R. Private health in India. 20. Dutta A, Chakraborty S, Practice of rational drug Lancet, 359(9316): 1528, April 27, 2002 uses in a rural area of 24 pgs(s) in West 7. Kurnool City Census 2011 Data, www.census Bengal Journal of Advanced Pharmaceutical 2011.co.in Technology & Research 2010;1(3):358-64. 8. How to investigate drug use in health facilities: 21. Bhartiy SS, Shinde M, Nandeshwar S, Tiwari SC, Patt Selected drug use indicators. Geneva: WHO; 1993. ern of prescribing practices in the Madhya Pradesh, Available from: India Kathmandu University Medical Journal 2008; http://apps.who.int/medicinedocs/en/d/Js2289e/, 6(1):55-59. accessed on September 17, 2013. 22. Karande S, Sankhe P, Kulkarni M. Patterns of 9. Siddarth V, Arya S, Gupta SK, A study of prescribing prescription and drug dispensing. Indian J Pediatr. practices in outpatient department of an apex 2005; 72(2):117–21.

------Conflict of interest: None declared Source of funding: None declared

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