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Abstract
Objective Inappropriate use of medicine is a global challenge with greater impact on developing countries. Assessment of drug use pattern is used to identify gaps in medicine utilisation to implement strategies for promoting rational drug use. This study aimed to assess drug use pattern using the WHO drug use indicators in selected general hospitals in Tigray region, Ethiopia.
Design A cross-sectional study was conducted using WHO drug use indicators in two public hospitals located in Tigray.
Setting Prescriptions recorded from 1 January 2017 to 1 June 2019 were randomly selected, and participants who visited the public hospitals from 1 March 2019 to 30 August 2019 and hospital pharmacies were interviewed.
Participants 100 patients who visited both outpatient clinics and hospital pharmacy departments of the public hospitals.
Results The average number of medicines per prescription was 1.69 (±0.81). Prescriptions containing antibiotics and injectables were 58.2% and 15.9%, respectively. The percentages of medicines prescribed with a generic name from essential medicines list of Ethiopia were 97.5% (974) and 88.1% (970) in Mekelle Hospital and Quiha Hospital, respectively. The patients spent an average of 6.6(±3.5) min with their general practitioners, while only 22.8 (±21.7) s with their pharmacists. Of the patients interviewed, 56.9% knew their dosing regimen and 32.7% of them had their medication labelled.
Conclusion The finding of the present study revealed deviation of drug use pattern from the WHO optimal levels suggesting the hospitals had limitations in appropriate utilisation of medicines. Understanding the factors attributed to the observed gaps and implementing corrective measures are required to conform with the recommended standards of appropriate drug utilisation.
- quality in healthcare
- public health
- clinical pharmacology
Data availability statement
Data are available upon reasonable request. The data of this study are available from the corresponding author upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
The study used all three of the WHO core drug use indicators to assess quality of patient care in a hospital setting.
Evidence about rational drug use has been provided in an area rarely assessed.
The study did not try to identify the factors that contributed to the observed gaps making it difficult to propose improvement strategies.
As diagnosis was missing in considerable number of prescriptions, we did not confirm that the drugs were prescribed for right diagnoses.
Introduction
The rational use of drugs depends on rational prescribing, correct dispensing and adherence to treatment by patients.1 According to the WHO, a medicine is used rationally if patients received appropriate medicines, in doses that meet their individual requirements, for an adequate period of time and with an affordable cost.2 The concept of rational drug use can be summarised as the right medicine at the right dose by the right route at the right time for the right patient (‘five rights’).3 Conversely, irrational use of medicines is termed to have occurred when one or more of the above-mentioned conditions are not met.2 Irrational use of medicine is a global challenge with the highest prevalence in developing countries. Multiple stakeholders including patients, prescribers, workplace and supply system may be attributed for irrational drug use4 due to many reasons such as limited knowledge about medicines, unethical medicine promotions and improper prescribing habits of clinicians.5 6
WHO drug use indicators are used to evaluate rational drug use at all levels in the chain of medicine utilisation (facility, clinician, pharmacist and patient) using highly standardised indicators developed by WHO Action Program on Essential Drugs and International Network for Rational Use of Drugs to be used for drug use evaluations without further national validation.7 8 Prescribing indicators include average number of medicines prescribed per encounter, percentage of those prescribed by generic name and those from national essential medicines list, percentage of encounters with antibiotics and those with injections prescribed. Patient care indicators are used to evaluate the interaction between the patients with their clinicians and pharmacists, and include average consultation and dispensing times, percentage of medicines dispensed and those adequately labelled, as well as patients’ knowledge of correct dosage. The availability of the copy of essential medicines list and key medicines is assessed using facility indicators.9
Ethiopia has introduced a national drug policy in 1993 with the aim of meeting the demand for essential medicines together with appropriate use, making them affordable to the public as well as ensuring their safety, efficacy and quality. The policy also encourages domestic manufacturing, enhancing manpower training and research and development of medicines as well as devising ways to integrate traditional medicines into conventional medicine as objectives.10 Despite these policy directions, studies conducted so far reported gaps in rational medicine use.11 12 Considering the very large population size of Ethiopia and the diversity of geographical areas, there are very few studies on medicine use conducted so far. Therefore, this study was conducted to evaluate drug use and contribute to addressing the information gap in drug use pattern in Ethiopia, specifically Tigray region.
Methods and materials
Study setting and period
The study was conducted in Mekelle and Quiha General Hospitals between 1 March 2019 and 30 August 2019. Both hospitals are located in Mekelle, the capital city of Tigray regional state, Ethiopia.
Study design and population
All prescriptions recorded from 1 January 2017 to 1 June 2019 were considered. Of which, randomly selected prescriptions were retrospectively assessed using WHO prescribing indicators during the study period (1 March 2019 and 30 August 2019). All patients who visited outpatient departments of Mekelle and Quiha Hospitals during the study period were used as a target population. Of note, patients aged less than 18 years or not willing to participate in the study were excluded.
Sampling technique and procedure
The WHO recommends assessments of at least 600 prescriptions and 100 patients per each hospital for drug use evaluation. Accordingly, 600 randomly selected prescriptions recorded from 1 January 2017 to 1 June 2019 from each hospital were included. Twenty key drugs were also selected from each hospital as per WHO recommendation which is a minimum of 15 essential drugs for each health facility.9
Data collection instruments and process
Three well-trained pharmacists were recruited and deployed to assess the prescriptions identified using prescription registration books, interview patients, and evaluate availability of copy of essential medicines list and key medicines in the hospitals. Data on quality of prescribing were collected by using WHO’s prescribing indicators. In assessing patient care indicators, the average number of medicines prescribed per encounter, the percentage of medicines prescribed with generic names and those prescribed from essential medicines list, the percentage of prescription encounters which ended up with antibiotics and those with injections prescribed were collected. However, immunisations of children were not considered as injections. In measuring the proportion of medicines prescribed with generic names, the essential medicines list of Ethiopia was used as a source for generic names.13
For assessment of patient care indicators, consultation time and dispensing time were obtained by recording the time that the patients spent with their physicians and pharmacists, respectively. The knowledge of the patients on their dosage regimen was assessed by asking the patients to explain whether they knew about the medicine dispensed to them. Availability of formulary, essential drugs, standard treatment guidelines, and key drugs at the time of the visit were assessed to confirm whether the hospitals comply with WHO standards.
Operational definitions
Drug use evaluation is a systematic approach that assesses the appropriateness, safety and effectiveness of a medication to improve patient care.
Percentage of drugs prescribed by generic name
It measures the tendency to prescribe by generic name.
Percentage of drugs prescribed from a list of essential drugs
It measures the degree to which practices conform to a national drug policy.
Average number of drugs per encounter
Average number of drugs per encounter measures the degree of polypharmacy.
Average consultation time
The average time that physicians spend with patients. It does not include waiting time.
Average dispensing time
The average time that pharmacists spend with patients while dispensing the medications.
Data analysis procedure
The data collected were entered and analysed using SPSS V.20. The data on prescribing indicators as well as patient care indicators were described using frequency, percentage, mean and SD.
Patient and public involvement
Patients and/or the public were not directly involved in this study.
Results
Prescribing indicators
A total of 1200 prescriptions, 600 from each hospital, were evaluated using WHO prescribing indicators. On average, 1.69 (±0.81) drugs were prescribed and 44.7% of the prescriptions contain one or two drugs (table 1).
Number of drugs per prescribing encounter in the selected general hospitals
A total of 2028 drugs were prescribed, of which 1944 (92.8%) were prescribed in generic name. More than 50% (58.2%) of the prescriptions contained antibiotics and 191 (15.9%) include at least one injectable medication (table 2). Amoxicillin was the most frequently prescribed antibiotic in both hospitals (table 3).
Percentages of encounters with generic drugs, antibiotics and injections in the selected general hospitals
Antimicrobial/antibiotics prescribed in the selected general hospitals
Patient care indicators
On average, each patient spent approximately 7 min with his/her general practitioner and 22 s with his/her pharmacist. A total of 81.2% of the prescribed drugs were dispensed. Of which, 32.7% of them were adequately labelled. A total of 56.9% of patients knew about the dosage regimen of their medications (table 4).
Assessment of patient care using WHO patient care indicators in selected general hospitals
Health facility indicators
Both Quiha and Mekelle Hospitals had their own formulary, essential drugs list and standard treatment guidelines. From the list of key drugs of the hospitals, on average, 77.5% of them were available in stock (table 5).
Availability of key drugs in selected general hospitals
Discussion
In this study, the average number of drugs per prescription was within the WHO acceptable standard. The finding was comparable with studies done in different parts of Ethiopia including Jimma (1.59),14 Hawassa University Teaching Referral (1.9)11 and Bahir Dar Hospital (1.8).12 However, studies in Debre Tabor (2.2),12 Felege Hiwot Referral Hospital (2.49)15 and Karamara Public General Hospital in Ethiopia (2.46)16 reported higher average number of drugs per prescription. Such discrepancy may be attributable to differences in the level of awareness among clinicians working in different parts of the country and lack of harmonised national prescribing guidelines.
In terms of percentage of medicines prescribed by generic name, our finding is lower than the WHO’s recommended standard value. Similar results were reported in Hawassa University Hospital (98.7%),11 Felege Hiwot Specialized University Hospital (97.4%)15 and selected health centres in eastern Ethiopia (97%).17 This may be attributable to increasing promotion of brand drugs names influencing clinicians to prescribe drugs in their brand names. Of note, Workneh et al18 have shown the prescribing decisions of clinicians working in Mekelle were influenced by promotion of medical representatives. This suggests that there is a gap in ensuring patients to get cost-effective medicines on the side of prescribers and the health institution, which in turn reduces health-seeking behaviour of the community.19
The percentage of encounters with antibiotics, which is 58.2% in the present study, is comparable with a study conducted in public hospitals in eastern Ethiopia (57.9%)16 and Hawassa Teaching Referral Hospital (58.1%).11 As high as 85.5% were also reported in selected health centres in eastern Ethiopia.17 However, our finding is higher than the WHO recommended standard (20%–26.8%). This finding should be interpreted cautiously as high prevalence of infectious diseases in developing countries may partly contribute to such high antibiotic prescribing. However, overprescribing of antibiotics is a problem that needs to be carefully monitored as it is associated with antimicrobial resistance which is a threat to global health.20 The percentage of prescription encounters with injections was within the WHO standard level.
The WHO recommends healthcare professionals to adhere to national essential medicines list for drug prescribing. To this end, a deficiency was noted in terms of prescribing according to essential medicines list of Ethiopia compared with the WHO standard of a 100%8 and to that of the national assessment results of 2003 (99%).21 This may be attributable to patient preference, clinician decision and availability of the medications.
In this study, the average consultation time that the patients spent with clinicians was approximately 7 min, which is higher compared with studies conducted in public hospitals in eastern Ethiopia (4.6 min).16 The duration, however, does not seem to be sufficient to make physical examination and select the best available treatment choices. High patient load could have contributed to such below optimal duration of consultation time. The average dispensing time recorded in the present study was approximately 23 s. This is significantly lower than the WHO recommendation of 180 s.8 The lower the dispensing time, the poorer the understanding of the patients would be about their medications, which may lead to frequent encounters of drug therapy problems. The percentage of drugs actually dispensed out of the total drugs prescribed to the patients stood at 80% compared with the recommended 100%.6 Frequent stock out of medicines may account for this finding. Regarding the adequacy of labelling of medicines dispensed, slightly over one-third of medicines were appropriately labelled, which is far from the recommended level of 100%.8 High patient load encountered at an outpatient pharmacy department and negligence of the pharmacists together with poor concern and follow-up from the hospital side could be implicated for such low level of performance in this indicator. Of note, only about half of the patients knew the dosage schedules of medicines prescribed to them, which is far below the expected level of 100%.
Both Quiha and Mekelle Hospitals had their own essential drugs list and standard treatment guidelines. Only 7.5% of key drugs were in stock and this is lower than the 100% of the WHO recommendation. Absence of key drugs may impair patient care and compromise patient quality of life.
Conclusion
The findings of the present study showed prescribing practices of antibiotics, prescribing from essential drugs list and injections were not within the acceptable WHO recommendations. Overuse of antibiotics facilitates the emergence of antimicrobial resistance which is a threat to global health. There was a little deviation in terms of generic prescribing, whereas the average number of drugs per encounter was within the acceptable standard. Poor generic prescribing coupled with shorter consultation and dispensing time may lead to frequent encounters of drug therapy problems. Future studies should investigate underlying factors that contributed to the observed gaps to improve patient care in those hospitals.
Data availability statement
Data are available upon reasonable request. The data of this study are available from the corresponding author upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The study was approved by the Institutional Review Board of Mekelle University (reference number: ERC/224/2019). Based on this, a letter of support was written from Tigray regional health bureau. During data collection on patient care indicators, a written consent was obtained from each participant after provision of all the necessary information. In addition, the data collected in the study did not use patient identifiers and were kept strictly confidential and were only used for the purpose of the study.
Acknowledgments
The authors wish to thank all the staff members of Mekelle and Quiha Hospitals for their sincere cooperation and support.
Footnotes
Contributors SGT and AKG designed the study, obtained the fund, supervised data collection, conducted data analysis and wrote the first draft of the manuscript. SGT, KG, AKG and HNA provided critical comments, revised and finalised the manuscript. All authors read and approved the final manuscript.
Funding This study was funded by College of Health Sciences, Mekelle University small scale grant with registration number of CRPO/CHS/Young/Recurrent/ 008/2011.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.