|Year : 2012 | Volume
| Issue : 3 | Page : 202-206
Medicine utilization review at a university teaching hospital in New Delhi
M Aqil, V Bhadana, MS Alam, KK Pillai, P Kapur
Department of Pharmaceutics, Faculty of Pharmacy, Majeedia Hospital, Jamia Hamdard, New Delhi, India
|Date of Submission||21-Mar-2011|
|Date of Decision||20-Apr-2011|
|Date of Acceptance||23-May-2011|
|Date of Web Publication||26-Jul-2012|
Department of Pharmaceutics, Faculty of Pharmacy, Majeedia Hospital, Jamia Hamdard, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: A prospective medicine usage evaluation based on prescription monitoring was conducted in the medicine OPD of our university teaching hospital to know prescribing trends of different categories of medicines. Materials and Methods: A total of 600 patients were included in the study comprising of 339 (56.5%) males and 261 (43.5%) females. The data were recorded within the OPD by a registered pharmacist on a medicine usage evaluation form, approved by The University Institutional Review Board (IRB). Results: A total of 2365 medicines were prescribed to 600 patients during the 3 months study period. The mean number of medicines per prescription were found to be 3.94. Medicines were most frequently prescribed as solid dosage forms (85.62%), especially tablets (70.82%), and liquid formulations (14.12%). Oral route (96.17%) was the most preferred mode of administration, followed by topical (2.11%) and parenteral (1.60%) routes. Combination therapy (94.33%) was more prevalent than monotherapy (5.66%). An overwhelming tendency for prescribing medicines by brand names (99%) was observed by the physicians. The most frequently prescribed class of medicines were antimicrobials > analgesics > cardiovascular > gastrointestinal agents. The most prescribed individual medicines among various therapeutic classes included isoniazid (antimicrobial), amlodipine (cardiovascular), metformin (hypoglycemic), cetirizine (antiallergic), rabeprazole (GI medicine), atorvastatin (hypolipidemic), dextromethorphan (respiratory medicine), alprazolam (sedative-hypnotic), paracetamol (analgesic). Conclusions: There is a considerable scope of improvement in the existing prescribing practice, especially prescribing by generic names, needs to be encouraged and a hospital formulary has to be developed for the purpose. The number of medicines to be included per prescription should be judged rationally and polypharmacy ought to be curbed. Use of antimicrobial also needs to be rationalized as over usage of antibiotics may lead to the problems such as medicine resistance and noncompliance.
Keywords: Medicine usage evaluation, prescribing pattern, prescription monitoring, teaching hospital
|How to cite this article:|
Aqil M, Bhadana V, Alam M S, Pillai K K, Kapur P. Medicine utilization review at a university teaching hospital in New Delhi. J Pharm Bioall Sci 2012;4:202-6
|How to cite this URL:|
Aqil M, Bhadana V, Alam M S, Pillai K K, Kapur P. Medicine utilization review at a university teaching hospital in New Delhi. J Pharm Bioall Sci [serial online] 2012 [cited 2021 Sep 19];4:202-6. Available from: https://www.jpbsonline.org/text.asp?2012/4/3/202/99026
The appropriate use and cost of pharmaceuticals are important issue in health care systems worldwide. Advances in medical technology are likely to attract more debates over the use and prescribing of medications. The rational use of medicines was the theme of a major World Health Organization (WHO) conference held in 1985, and the appropriateness of pharmacotherapy has since been the subject of many investigations within individual facilities and across all countries.
Unfortunately, irrational prescribing is a global problem. In the majority of developing countries, the quality of health services at peripheral health centers is considered to be unsatisfactory. Patients prefer to visit referral hospitals even for minor ailments which could be easily treated at a primary health center (PHC).  At PHC 80% of the expenditure is incurred on medicines. Because of the limited overall health budget for medicines, it is vital that medicines are prescribed rationally. Studies on medicine prescribing in India have concluded that much of it is irrational. ,
Making a prescribing decision is vital in the prevention of morbidity and mortality. The physician's prescribing decision is the result of input from patients, commercial sources, professional colleagues, academic literature, and government regulations. ,, Ineffective use of these sources of information can result in a wide variety of prescribing errors.  Medicine utilization review is the most common and structured approach used to examine patterns of medicine use and to determine levels of appropriateness in prescribing.  Medicine usage reviews are essential in order to establish the extent of rational and irrational prescribing and to deliver better healthcare services.
A concurrent medicine usage evaluation was carried out in the medicine OPD of a 150-bed teaching hospital in New Delhi over a period of 3 months. This is the first local study for evaluation of prescribing and medicine use patterns in our university hospital. These data may vary from hospital to hospital, depending on the patient population. They do provide some useful base line data and will provide a basis for further investigational studies and advanced medicine policies aimed at rational medicine prescribing, improved patient compliance leading to safe and efficient medicine use.
| Materials and Methods|| |
A concurrent medicine usage review was conducted in the Department of Medicine of a 150-bed Majeedia Hospital, New Delhi. The study was carried out for duration of 3 months between the periods of January to March 2004. All patients who were prescribed at least one medicine were included in the study irrespective of age and sex. All mentally retarded, drug addicts, and unconscious patients were excluded. Informed consent was taken from the patients prior to inclusion in the study. The patient demographics are given in [Table 1]. The study protocol was previously approved by Jamia Hamdard Institutional Review Board (IRB). The data were recorded within the OPD by a registered pharmacist on completion of patient's encounter with the physician; the medicines prescribed were documented on a medicine utilization review form [Figure 1].
| Results|| |
Total number of medicines consumed by 600 patients during the study was 2365. The mean number of medicines per prescription was 3.94. The most frequently prescribed dosage forms are solids (85.62%) in which tablets were prescribed 70.82%, and capsules were 14.79%. The liquid dosage forms (14.12%) were second in number amongst the formulations prescribed in which syrups were 10.65%, injections were 1.56%, and inhalers were 1.14%. Least prescribed were semisolid dosage forms, 0.25%. The main route of administration was oral (96.27%), topical (2.11%), and parenteral (1.60%). The doctors mainly used combination therapy (94.33%) for their patients. Monotherapy was not so common (5.66%). A total of 116 (19.33%) prescriptions with fixed dose combination were prescribed. Inclination to brand name prescribing (99%) was overwhelmingly more than prescribing by generic name (1%). It was observed that only 1.56% injections were prescribed with only 4% of total prescriptions carrying at least one injection. The most frequently prescribed classes of medicines in the Majeedia Hospital were in order of antimicrobials (16.49%) > vitamins and minerals (14.92%) > respiratory medications (13.91%) > analgesics (13.15%) > cardiovascular medications (10.99%) > gastrointestinal medications (9.09%).
Medicine utilization trend among various therapeutic classes
The prescribing pattern of various categories of drugs in Majeedia Hospital is discussed hereunder and the overall data is presented in [Figure 2].
The antimicrobials prescribed most frequently are isoniazid (8.20%), rifampicin (7.94%), and azithromycin (7.17%). The antimicrobials were used by 22.5% of male and 14.83% of female patients. Rifampicin, isoniazid, pyrazinamide, and ethambutol combination (Brand : Akurit 4) was more preferred for tuberculosis therapy. Study population (5.33%) used combination therapy for tuberculosis, 3.5% of prescriptions are prescribed with amoxycillin cloxacillin combinations.
The most frequently prescribed cardiovascular medicines are amlodipine (15.38%), atenolol (11.15%), and losartan (8.84%). Major classes of this group are antiadrenergics (29.61%), especially atenolol (11.15%), and propranolol (4.60%); diuretics (22.30%), especially hydrochlorthiazide (6.53%) and frusemide (5.76%); calcium channel blockers (16.92%), especially amlodipine (15.38%); angiotensin converting enzyme inhibitors (12.69%), especially ramipril (10.00%) and angiotensin I receptor inhibitors-losartan (8.84%). A total of 12.66% males and 10.83% females used cardiovascular medicine(s). Non steroidal anti inflammatory drugs (NSAIDs) prescribed to hypertensive patients were 1.16%.
hypoglycemics prescribed most frequently are metformin (37.59%), pioglitazone (15.03%), and glimipiride (12.03%). Major parts of this medicine group are biguanides (37.59%), thiozolidenedione (21.05%), and sulfonylureas (27.06%). Hypoglycemics used by males were 5.66% and 5.83% by females.
most frequently prescribed antiallergics are cetirizine (41.11%), fexofenadine (24.44%), and levocetirizine (22.22%). Antiallergics are mainly prescribed from antihistaminic group, whose consumption account for 3.80% from the total pool of medicines prescribed. Antiallergics used by males were 8% and by females 5.83%.
antiulcers (66.04%) are the most frequently prescribed class among the GIT medicines. Other classes are antiemetics (13.95%), especially domperidone (8.83%) and laxatives (10.23%), especially Ispaghula (5.11%). The most frequently prescribed GIT medicines are rabeprazole (13.95%), lansoprazole (12.09%) and omeprazole (10.69%), which are mainly used as antiulcers. Among GI medicines antiulcers consumption in male population was 12.33%, laxatives 3.66%, antiemetics 1.83% and gastroprokinetics 1.33%. Among females atleast one antiulcer is used by 11.66% study population laxatives by 1.83%, antiemetics by 2% and gastroprokinetics by 1.33%.
most frequently prescribed hypolipidemic is atorvastatin (62.50%). The major class of this group is HMG Co-reductase inhibitor whose overall consumption is 1.01%. Hypolipidemics were used by males 1.83% and by females 1.16%.
frequently prescribed nasal decongestant was phenylpropanaline (80.30%). Major class of this group is alpha agonists whose overall consumption is 2.79%. Nasal decongestants were used by males and females (0.66% each).
Vitamins and minerals
consumption is about 75.35% and minerals are consumed by 24.89% of the patient population. Overall vitamins and minerals consumption was 14.92%. About one-fourth (25.33%) of males and one-fifth (20.5%) of females used vitamins. Minerals were used by 10.33% males and 6.66% females.
most prescribed respiratory medications are dextromethorphan (20.36%), chlorpheniramine (16.41%), theophylline (8.2%), and terbutaline (8.20%). Among this group, major class are the antitussives (41.33%), especially dextromethorphan and chlorpheniramine, bronchodilators (34.65%), especially theophylline and terbutaline, expectorants (14.28%), especially bromhexine and guaifenesin (5.77% each) and corticosteroids (9.72%), especially fluticasone (3.64%). Bronchodilators were used by 7.33%, corticosteroids by 2.33%, expectorants by 4.16%, and antitussives by 9.16% of male population. While in female population; bronchodilators, corticosteroids, expectorants, and antitussives are used by 4.83%, 1.83%, 2.66%, and 6.33% patients, respectively.
most prescribed medicine amongst sedatives-hypnotics is alprazolam (74.57%). The major class is anxiolytics (84.74%). Sedatives are used by 4.5% of male population and 4.66% of female population.
most frequently prescribed medicine is dotheipin (29.72%) and sertraline (27.02%). They are seldom prescribed (only in 1.56% of all reviewed prescriptions). Only 3.83% of antidepressants were used by males and 3% by females.
most frequently prescribed analgesics are paracetamol (31.51%), nimesulide (20.90%), valdecoxib (11.57%), and aceclofenac (9.00%). They are used by 21.33% of males and 18.33% of females. As expected, opiates (1.92%) are given less frequently than nonopioid analgesics (98.07%).
classes of medicine are less frequently prescribed like muscle relaxants (1.05%): used by 3.16% of males and 1.5% of females, proteolytics (0.33%) used by 0.66% of males and 0.83% of females, antispasmodics (0.04%), enzymes (1.05%) used by 3.16% of males and 0.83% of females, thyroid acting medicines (0.38%) used by 0.16% of males and 1.5% of females, whereas coenzymes (0.25%), local anesthetics (0.04%), antipsychotics (0.16%), anti-Parkinson agents (0.04%), anticonvulsants (0.16%), and herbal medicines (0.59%) are used almost equally in both genders.
| Discussion|| |
The average number of drugs per prescription in our study was higher when compared to previous reports from various specialty clinics in India ,, and a study in Hongkong,  but lower than in Yamen, Sudan, Malawi, Bangladesh, and several other developing countries.  Such prescribing behavior may lead to polypharmacy, which in turn leads to the increased cost in medicine therapy, unwanted adverse effects, increased risk of medicine interactions, development of bacterial resistance in case of antimicrobials and affects patient compliance.
Combination therapy was widely prevalent in our therapy. The use of combination therapy may escalate the unwanted side effects and harmful sometimes fatal medicine-medicine interactions. Such kind of prescribing may be discouraged. Prescribing by brand names might be due to the absence of the hospital formulary system and biased promotion of selected brands by the medical representatives of pharmaceutical manufacturers. It is a common practice in Indian hospitals. In a recent study from Allahabad, it was reported that only 2% of the medicines were prescribed by the generic names.  In health settings in Nepal, an average of 44% medicines were prescribed by generic names, which was found to be far less in our study (1%).  Prescribing by generic name should be promoted as it could help in cheaper treatment to the patients.
The under utilization of antitubercular combination therapy reflects a major deviation from the standard course of treatment for tuberculosis, which recommends the use of some standard combinations of major antitubercular drugs, the most prescribed among them is rifampin, isoniazid, pyrazinamide, and ethambutol combination.  This might be due to the absence of any hospital formulary system in Majeedia Hospital and there is an urgent need to implement one.
NSAIDs are among the most commonly used medicines in the world. They have been reported to account for almost a quarter of all reported adverse medicine reactions, primarily related to gastrointestinal (GI) toxicity. It has been estimated that 10-20% of patients receiving NSAIDs will develop dyspepsia and 5-15% will discontinue treatment within 6 months, primarily due to GI adverse reactions. In addition, population studies have estimated that there is an annual incidence of 1-4% of significant GI complications, such as bleeding, perforation, or gastric outlet obstruction. Several risk factors for the development of GI adverse reactions have been identified. These include use of high dose NSAIDs, advanced age, prior history of peptic ulcer disease and concomitant use of certain medications, including anticoagulants and corticosteroids. 
In our study total prescriptions in which NSAIDs were given to hypertensive patients were 1.16% which is lower in comparison to 41% NSAIDs reported by Gurwitz et al.  In hypertensive patients, NSAIDs are known to raise the blood pressure. Indomethacin and naproxen appeared to be associated with the largest increase in blood pressure. Among the antidiabetic agents, metformin consumption was comparatively higher in our study in comparison to the data of Masoudi et al.  However it was lower than reported by Baccuzi et al.  Metformin is contraindicated in all patients with heart failure requiring the pharmacological treatment because of the increased risk of potentially lethal lactic acidosis. Metformin also decreases the risk of macrovascular events in overweight patients with newly diagnosed diabetes. Because of fluid retention with thiozolidinediones, patients are also treated with insulin.  ACE inhibitors, calcium antagonists, and thiazide diuretics, in small doses, are recommended for diabetic patients with hypertension, while beta blockers, and potassium sparing diuretics are used with caution, in spite of the fact that beta blockers have shown a beneficial effect after acute myocardial infarction, especially in diabetic patients. 
Vitamins are used not only for medically acceptable purposes, but also in order to maximize athletic performances, to prevent the body from aging, and as a panacea to prevent or cure almost every known disease.  Vitamins were prescribed frequently in our study. However, neither anemia nor vitamin deficiency was among the common diagnosis. Similar observations are reported from different healthcare settings and hospitals in India, Sri Lanka and Nepal. ,, The high use of vitamins may be due to their use as placebo. They are amongst the cheapest medicines and their use cannot be considered irrational although it is unnecessary and could be best avoided. This would help reduce the medicine cost to the patient. This correlates with the findings of a study at a primary health centre in Bangladesh. 
Prescribing of sedatives was not excessive. In fact these were infrequently prescribed. It appears that doctors in the hospital were not inclined to give sedatives to outpatients. This is a good clinical practice because long-term use of sedatives is likely to lead to dependence. In the treatment of depression, the use of tricyclic antidepressants (TCAs) is questionable in view of unwanted adverse effects. In some countries, the selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors have superseded the TCA, although data on their efficacy or adverse effects is in short supply. 
| Conclusion|| |
The study presents the medicine usage pattern based on prescribing trends of physicians in the medicine OPD of our University Teaching Hospital. These findings will help as a guideline for policymaking decision in the health care system and also will be helpful in drug evaluation process. There is a considerable scope of improvement in the existing prescribing practice, especially prescribing by generic names, needs to be encouraged and a hospital formulary has to be developed for the purpose. Prescribing medicines by generic names would help in less expensive treatment. The number of medicines to be included per prescription should be judged rationally and polypharmacy ought to be curbed to minimize adverse drug reactions and drug interactions.
| Acknowledgements|| |
This work was funded by the University Grants Commission, New Delhi (Grant no 7. F-28/2003). The authors would like to express their gratitude to all of the patients who participated in the study.
| References|| |
|1.||Beghin D, Dujardin B, Wollast E. A versatile approach to health system evaluation. World Health Form 1989;10:37-40. |
|2.||Krishnaswamy K, Kumar BD, Radhaiah G. A medicine survey-precepts and practices. Eur J Clin Pharmacol 1985;29:263-70. |
|3.||Nahar S, Uppal R, Mehta S, Sharma PL. Prescribing for diarrheal diseases. Indian Pediatr 1988;25:754-6. |
|4.||Comaroff J. A bitter pill to swallow: Placebo therapy in general practice. Sociol Rev 1976;24:79-96. |
|5.||Avorn J, Chen M, Hartley R. Scientific versus commercial sources of influence on the prescribing behavior of physicians. Am J Med 1982;73:4-8. |
|6.||Soumerai SB, Avorn J, Ross-Degnan D, Gortmaker S. Payment restrictions for prescription medicines under Medicaid: Effects on therapy, cost, and equity. N Engl J Med 1987;317:550-6. |
|7.||Soumerai SB, McLaughlin TJ, Avorn JL. Improving medicine prescribing in primary care: A critical analysis of the experimental literature. Milbank Q 1989;67:268-317. |
|8.||Mack SD, Demsey JW. Medicine usage: A regional approach. Leadersh Health Surv 1995;4:34-7. |
|9.||Maini R, Verma KK, Biswas NR, Agrawal SS. Medicine usage study in dermatology in a tertiary hospital in Delhi. Indian J Physiol Pharmacol 2002;46:107-10. |
|10.||Biswas NR, Biswas RS, Pal PS, Jain SK, Malhotra SP, Gupta A, et al. Patterns of prescriptions and medicine use in two tertiary hospitals in Delhi. Indian J Physiol Pharmacol 2000;44:109-12. |
|11.||Biswas NR, Jindal S, Siddiquei MM, Maini R. Patterns of prescription and medicine use in ophthalmology in a tertiary hospital in Delhi. Br J Clin Pharmacol 2001;51:267-9. |
|12.||Lau GS, Chan JC, Chu PL, Tse DC, Critchely JA. Use of antidiabetic and antihypertensive medicines in hospital and outpatients settings in Hongkong. Ann Pharmacother 1996;30:232-7. |
|13.||Hogerzeil HV, Walder GJ, Sellanic AO, Gernoado G. Impact of essential medicine programe on availability and rational use of medicines. Lancet 1989;1:141-2. |
|14.||Ansari KU, Singh S, Pandey RC. Evaluation of prescribing pattern of doctors for rational medicine therapy. Indian J Pharmacol 1998;30:43-6. |
|15.||WHO. How to investigate medicine use in health facilities: Selected medicine use indicators. Vol. 1 Geneva: World Health Organization; WHO/DAP/93. 1993. p. 1-87. |
|16.||Sharma S, Sethi GR, Gulati RK. Standard treatment guidelines. Delhi Society for Promotion of Rational Use of Drugs. New Delhi: 2002. p. 14-21. |
|17.||Bennett K, Teeling M, Feely J. Selective switching from non-selective to selective non-steroidal anti-inflammatory medicines. Eur J Clin Pharmacol 2003;59:645-9. |
|18.||Gurwitz JH, Soumerai SB, Avorn J. Improving medication prescribing and usage in the nursing home. J Am Geriatr Soc 1990;38:542-52. |
|19.||Masoudi FA, Wang Y, Inzucchi SE, Setaro JF, Havranek EP, Foody JM, et al. Metformin and thiazolidinedione use in Medicare patients with heart failure. JAMA 2003;290:81-5. |
|20.||Boccuzzi SJ, Wogen J, Fox J, Sung JC, Shah AB, Kim J. Usage of oral hypoglycemic agents in a medicine-insured U.S population. Diabetes Care 2001;24:1411-5. |
|21.||Wandell PE, Brorsson B, Aberg H. Medicine prescription in diabetic patients in Stockholm in 1992 and 1995-change over time. Eur J Clin Pharmacol 1997;52:249-54. |
|22.||Klaukka T, Riska E, Kimmel UM. Use of vitamin supplements in Finland. Eur J Clin Pharmacol 1985;29:355-61. |
|23.||Bapn JS, Tekur U, Gitanjali B. Medicine usage at primary health care levels in Southern India. Eur J Clin Pharmacol 1982;43:413-5. |
|24.||Tomson G, Angunawela I. Patients, doctors, and their medicines-Astudy at four levels of health care in an area of Sri Lanka. Eur J Clin Pharmacol 1990;39:463-7. |
|25.||Rehan HS, Nagarani MA, Rehan M. A study on the medicine prescribing pattern and use of antimicrobial agents at tertiary care teaching hospital in eastern Nepal. Indian J Pharmacol 1998;30:175-80. |
|26.||Gurgon AB, Barman A, Ahmed JU, Ahmed AU, Alam MS. A baseline survey on use of medicines at primary health care level in Bangladesh. Bull World Health Organ 1994;72:265-71. |
|27.||van Dijk KN, de Vries CS, van den Berg PB, Brouwers JR, de Jong-van den Berg LT. Medicine usage in Dutch nursing homes. Eur J Clin Pharmacol 2000;55:765-71. |
[Figure 1], [Figure 2]