Study on prescribing pattern in the dermatology outpatient unit of a tertiary care hospital

 

Shakuntala B^1*, Nithiya D², Pandiamunian J³

 

¹Assistant Professor, ²Postgraduate student, Department of Pharmacology, Vijayanagara institute of medical sciences, Ballary, Karnataka, INDIA.

³Associate professor, Department of Pharmacology, Vinayaka Mission Medical College, Karaikal, Tamilunadu, INDIA.

 

Abstract               Background: Prescription is an important skill, which is to be assessed and refined accordingly. Now a day irrational prescription is a common problem in clinical practice that too in the skin diseases. Irrational prescription has a various impact on cost effectiveness and health burden, results in wastage of resources. Objective: To analyze the prescribing pattern of drugs in the dermatology outpatient department. Methods: It was cross sectional study, conducted in the dermatology outpatient department of a tertiary care hospital, VIMS, Ballari. Data collected were used in the assessment of WHO core prescription indicators. Results: The prescriptions of 5468 participants among the patients attended dermatology OPD with various dermatological conditions were analyzed and found that a total of 21921 numbers of drugs were prescribed. Poly pharmacy found in 98% prescriptions. The average number of drugs per prescription was 4.12%, percentage of drugs prescribed by generic name was 14.56%, percentage of drug encounter with antibiotics was 20.2%, percentage of drug encounter with injections was 1.2%, and percentage of drugs prescribed from EDL is 11.05%. Conclusion: In our study Poly pharmacy was very high, the average number of drugs per encounter was more, Percentage of drugs prescribed from EDL and Percentage of drugs prescribed in generic name is very less when compare to WHO standards..

Key Words: Dermatology OPD, WHO prescribing indicators, prescription pattern.

 

INTRODUCTION

Skin diseases constitute huge disease burden globally. It affects the quality of life by increasing the sufferings in terms of physical, social, psychological and also the financial burden as most of the skin diseases are chronic and require longer duration of treatment. Collectively skin disease is the 18th leading cause of health burden worldwide and it was 4th leading cause of nonfatal health burden in 2013 globally.¹Prescription is an important skill, which is to be assessed and refined accordingly; it reflects the diagnostic skill and attitude of doctor in selecting rational and useful drugs which are cost effective. Now a day irrational prescription is a common problem in clinical practice that too in the skin diseases. Irrational prescription has a various impact on cost effectiveness and health burden, results in wastage of resources.² Prescribing is a complex process—one which tests the healthcare provider’s knowledge and application of sound therapeutics principles, communication skills, as well as their approach to and appreciation of risks and uncertainties³. Subsequent to the determination of goals, a treatment is then selected. Often, prescribers are confronted with the task of choosing from many options⁴. Ideally, the final pharmacological choice should be arrived at through a benefit–risk analysis based on medicine and patient factors, incorporating other issues such as availability and cost^{3, 5}. In India there are many problems in prescription pattern, like overuse of multivitamins, inappropriate use of antibiotics in fungal infections and using same class of drugs results in development of resistance.⁶ Irrational treatment leads to conditions like tinea incognito, scabies incognito and all the diseases showing extensive resistance and decrease in cure rate. Periodic prescription audit is a way to control misuse, unnecessary use of drugs; it helps in the selection of appropriate drug and in planning cost of therapy according to the need of the population. The aim of this study is to analyze the prescription pattern using the WHO core prescription indicators to achieve rational prescription by dermatologist; reduce adverse drug interaction and development of resistance.⁷

 

MATERIALS AND METHODS

It was cross sectional study, conducted in the dermatology outpatient department (OPD) of a tertiary care hospital, VIMS, Ballari after obtaining the institutional ethical clearance. And it was for a period of 3 months during August 2019 to October 2019. Written Informed consent was obtained from study participants who satisfied inclusion criteria. Demographic data, Disease patterns encountered, Category of drugs, Number of drugs prescribed per prescription, Dosage forms, drugs from WHO list of essential drugs, drugs prescribed in generic name were collected in preformed Case recording form. Data collected were used in the assessment of WHO core prescription indicators.

Inclusion criteria:

1. Patients of all age, either gender attending the Dermatology OPD.
2. Patients who were prescribed at least one drug.

Exclusion criteria:

1. Patients who were hospitalized with dermatological condition.

Data analysis

The collected data were analyzed using descriptive statistics. WHO core prescribing indicators were compiled at the end of the study to know the number of prescriptions with poly pharmacy, percent of prescriptions with injectables, percent of drugs prescribed from Essential Drugs list, percent of drugs with generic name and percent of prescriptions with antibiotics.

The Formula adopted from the WHO’s manual for prescribing indicators assessment is.

1. Average number of drugs per encounter= Total number of drugs prescribed/Total number of encounters.
2. Percentage of drugs prescribed by generic name= (Number of drugs prescribed by generic name/Total number of drugs prescribed) x100
3. Percentage of encounters with an antibiotic prescribed= (Number of patient encounters with an antibiotic/ Total number of encounters sampled) x100
4. Percentage of encounters with an injection prescribed= (Number of patient encounters with an injection prescribed/Total number of encounters sampled) x100
5. Percentage of drugs prescribed from essential drugs list= (Number of drugs prescribed from essential drugs list/ Total number of prescribed drugs) x100.

RESULTS

Table 1: Age and sex of the participants

 

Table 2: Disease patterns encountered

Others*= Keloid, chickenpox, Measles, Warts, Diaper rash, Cold sore, Blister, Hives, Latex allergy, Melanoma, Lupus, Gonorrhea, Syphilis

 

Table 3: Category of drugs prescribed

Others** = anti septic, anti-inflammatory agents, antacid, Hormones, Psychotropic agents, Hematinics

 

Table 4: Dosage forms among prescribed drugs

Others***: Emolients, Gel, Sunscreen, Face wash, Shampoos, Soap, Syrup

 

Table 5: Number of drugs prescribed per prescription

 

 

 

 

Table 6: Assessment of WHO prescribing indicators

 

This was a prospective cross sectional study conducted in a dermatology outpatient department of a tertiary care hospital over a period of 3 months and included patients of all age group and both the gender. Total numbers of participants were 5468, where male accounts for 2597 (47.5%) and female accounts for 2871 (52.5%) and among the age groups; 21 to 30 years group were more in numbers (32.4%) followed by 31 to 40 years group (19%). [Table 1] Among the participants more number of patients were diagnosed with Dermatophytosis (22.5%) followed by Atopic dermatitis (14.3%), Acne vulgaris (11.4%) and Scabies (11.2%). [Table 2] The various dermatological conditions were treated with different category of drugs; where antihistaminic category was most commonly used (22.1%) followed by antifungals (18.3%) and glucocorticoids (14.8%) and antibiotics (13.7 %). [Table 3] Different dosage forms were used to treat the different dermatological conditions; of which tablet/ capsule dosage form is most commonly used (49.2%) than cream/ lotion/ ointment dosage form (in total 37.4%), injection form was used in less numbers (1.2%). [Table 4] Most of the dermatological conditions were treated with more than one drug. Maximum numbers of patients (98%) were prescribed with poly pharmacy. More number of prescriptions contain 4 drugs (38.4%) followed by 5 drugs (31.4%) and 3 drugs (20.3%). [Table 5]

DISCUSSION

In this study the diagnosis made in the prescription was analyzed and it was found that Dermatophytosis (22.5%) was most common disease followed by Atopic dermatitis (14.3%), Acne vulgaris (11.4%) and scabies (11.2%). Studies conducted by Gambre R et al⁶, Sarkar et al⁸ and vineeta et al⁹ were having similar findings. But it is in contrast with the findings of the study conducted by pathak et al¹⁰ where acne was highest. This may be due to hot-dry weather in this area and deficient water supply in urban slums leading to unhygienic state which increases the occurrence of scabies, pyoderma, and fungal infections in the dwellers of these areas. In this study, Antihistaminics (22.1%) was the most commonly prescribed drug category followed by Antifungals (18.3%), Glucocorticoids (14.8%) and antibiotics (13.7 %).

These findings are similar with the studies conducted by Sumana M H², Gambre R et al⁶, Sarkar et al⁸, Pathak et al¹⁰, and Patil A et al¹¹. But in contrast with the study conducted by Noor N et al¹², and Tegegne A¹³ where steroids were commonly prescribed. This may be due to the disease pattern encountered here with more cases of dermatophytosis, atopic dermatitis, scabies, eczema, seborrhic dermatitis and allergic contact dermatitis require antihistaminics in their treatment. In this study most commonly used dosage forms among prescribed drugs was Tablet/ Capsule (49.2%) followed by Cream/ Lotion/ Ointment (37.4%). These findings are similar with the study conducted by Gambre R et al⁶, Pathak et al¹⁰, and Patil A et al¹¹. This could be due to the therapy that eases the symptoms of a disease demands more number of drugs than the number of drugs used to treat the disease proper where the Dermatologists prefer Tablet/ capsule dosage form as they are cost effective than the dosage forms used for topical application. In this study injectables less commonly used (1.2%). This could be due to no supply of procaine penicillin injection in government hospitals during the study period! This is a drug of choice in impetigo and pyoderma¹⁴. Benzyl penicillin compliance in outpatient is poor, because of the reason; it is short acting penicillin requires to be given 3 times a day, non-acceptance by patients because of pain. Avoidance of injectables by the physician in anticipation of hypersensitivity reaction, availability of alternate dosage forms. In this study, overall 21921 drugs were prescribed among 5468 encounters, where poly pharmacy accounts for 98% and mono pharmacy in 2% prescriptions. These findings are similar with the study conducted by Sarkar et al⁸ and Pathak A et al¹⁰. This may be due to most of the dermatological conditions requiring local as well as oral/ parenteral route of drug administration in their treatment. In our study W.H.O core prescription indicators were analyzed, average number of drugs per encounter is 4.12, which is more than the standard given by W.H.O, but similar findings were found with the studies done by Gambre R et al⁶, Pathak A et al¹⁰, and Noor N et al¹². This could be due to most of the dermatological conditions requiring local as well as oral/ parenteral route of drug administration in their treatment. Percentage of drug encounter with antibiotics is 26.2%, which is in accordance with WHO prescribing indicators. Similar finding seen with the studies done by Gambre R et al⁶, Mohamed Saleem T K¹⁵ but these findings are in contrast with the studies done by Patil A et al¹¹, Noor N et al¹², and G N S Sangeethalakshmi¹⁶. Percentage of drugs prescribed in generic name is 7.8%, which is too less to the standard given by WHO, but similar findings were found with the studies done by Noor N et al¹² and Mohamed Saleem T K¹⁵. This is because of the reason; as most of the patients are unaware / ill-informed about the quality drug and drug companies, brand name will be chosen by the pharmacist/ chemist rather than the patient where their choice is the company which provides higher rate of profit rather than a company which provides a quality drug. Percentage of drugs prescribed from EDL is 11.05%, which is too less to the standard given by WHO model prescribing indicator, it is similar with the studies done by Vineeta D et al⁹ and Mohamed Saleem T K¹⁵. This could be due to 1) essential drugs list contain a very few drugs of dermatological importance. 2) Some physicians are not adhering to implication of EDL. 3) As a result of rampant clinical trials especially in this specialty; made the availability of newer improved drugs in the market every year.

 

CONCLUSION

In our study Poly pharmacy was very high, the average number of drugs per encounter was more, Percentage of drugs prescribed from EDL and Percentage of drugs prescribed in generic name is very less when compare to WHO standards. EDL should be revised and include newer improved drugs every year. Prescribe in generic name is questionable in India a country of villages. Implementation of WHO prescribing indicator is not feasible in the dermatology outpatient unit.

 

REFERENCES