Evaluation of Drug Prescribing Habits in a Postgraduate Teaching Set-up in Saudi Arabia.

The objective of this retrospective study was to assess the rationale behind the practices of drug use in a teaching hospital that provides primary health care. A total of 500 prescriptions issued 6y faculty and post-graduate fellowship residents in the Department of Family and Community Medicine were collected. An evaluation of these prescriptions was carried out using the INRUD indicators of drug prescribing. The results of this study showed that apart from the low percentage (43.2%) of drugs prescribed generically, the application of INRUD indicators of drug prescribing appeared satisfactory when compared to similar studies from local and other developing countries. This study recommends a review of the current teaching of Pharmacology and Therapeutics to undergraduates in general & in particular to postgraduates specializing in Family & Community Medicine. Quality assurance systems on drug prescribing at primary health care centers should be established and implemented. Large scale studies similar to that under discussion should be encouraged.

INTRODUCTION

Inspite of their lengthy training in therapeutics, there is evidence that the prescribing habits of doctors is sometimes irrational1–8. The consequences of this are obvious. They include discomfort to patients, poor patient-doctor relationship, prolongation or exacerbation of illness, admission to or longer stay in hospital as well as an increase in the cost of health care9–15.

Several studies on this subject carried out in Saudi Arabia showed that the situation in this country is fairly similar to those of other countries16–19. The introduction in 1989 of the proposal of specific indicators for rational drug use by the International Network for Rational Use of Drugs (INRUD) has made it possible to objectively quantify and compare the basis of drug usage in different parts of the world.20–21

The objective of this study was to assess the rationale underlying drug use in a teaching hospital primary health care unit using the INRUD indicators of prescribing. The study was also designed to compare the patterns of prescribing by faculty and residents at two levels of the post graduate fellowship program in Family & Community Medicine, using INRUD indicators of prescribing practices.

METHODOLOGY

The study was retrospective. A total of 500 prescriptions were collected during a period of 3 months (January 1st 1991 - March 31st 1991). These prescriptions represented all the prescriptions issued by 20 postgraduate fellowship residents and 8 faculty members in the Department of Family & Community Medicine. The prescriptions were issued following regular attendance of patients at the primary health care clinics. Patients are usually seen without appointment by residents during the four years of post-graduate training in Family & Community Medicine. Clinical exposure for residents during the 2nd & 4th levels is more than other years.22 Those at the second level attend a minimum of 8 half-day clinics per week and those in the 4th level attend 5 clinics per week. Faculty attend two half-day clinics weekly.

The components of each prescription were recorded according to a checklist, which included seven of the nine INRUD indicators of drug prescribing21 . Two INRUD indicators were not evaluated because of inadequate resources. Drug choice, dosage schedule and suitability of drug duration (appropriateness of drugs prescribed to diagnosis) were assessed according to a standard reference23. The data were collected and entered in a personal computer. Data analysis was carried out using EPI-INFO statistical package. The analysis included descriptive statistics and chi-square test. Multiple comparisons were made across physician categories (faculty, 2nd and 4th level residents).

RESULTS

INRUD Indicators of Drug Prescribing

The results of this section is summarized in table 1. The overall results of similar studies using INRUD indicators24–26 compared to this study are summarized in table 2.

Table 1

INRUD indicators of drug prescribing

Table 2

INRUD Prescribing indicators ln this study compared to some selected studies in developing countries PHC centers

The results of other components of the prescrip-tions evaluated are summarized in table 3.

Table 3

Other components of the prescription

Drug Prescribing Practices Comparison

Eight faculty members and 20 residents participated in the study. Nine of the 20 residents were at the fourth level and the rest a the second level.

Ninety prescriptions (18%) were written by faculty, while 225 (45%) and 185 prescriptions (37%) were written by the residents in the 2nd and 4th levels, respectively.

Faculty compared to Residents

Faculty members prescribed fewer drugs per consultation (P<0.02). They also wrote fewer drugs by their generic names as compared to the residents (P<0.01). In general, residents prescribed more antibiotics than faculty but the difference was not statistically significant. However, the 2nd level residents were found to be significantly more inclined towards prescribing antibiotics than faculty (P< 0.01). There were no statistically significant differences between the faculty and the residents with regard to the rest of the INRUD indicators or the other components of the prescription.

Residents’ Comparison

Residents at the fourth level prescribed fewer drugs per consultation in comparison to those in the 2nd level (P<0.04). There were no significant differences between the 2 groups in relation to the usage of generic names of the drugs. More antibiotics were prescribed by the 2nd level residents as compared to the senior residents (P<0.02). There were also no statistically significant differences between the residents in the 2 levels with respect to the rest of the INRUD indicators or the other components of the prescription.

DISCUSSION

The objective of this study was to assess the prescribing practices at this particular teaching institution. The results of this study may not apply to other institutions or other study populations.

Examining the results of table 2, it is possible to compare the range of experience in different countries. Apart from two countries which re-ported high figures, the mean number of drugs prescribed per consultation ranged from 1.3 to 2.2.

Other local studies reported relatively higher figures (2.11, 2.1) than was found in this study1719. This may be due to polypharmacy which is still practiced world wide27–30. Prescription of antibiotics ranged from 22.7% to 56%, as compared to only 15.6% in our study. Although there is a considerable variation between studies in the use of injectables (0% to 48%), our findings are similar to the lowest figures reported. The figures of percentage of injections reported from Nigeria and Indonesia24 are considered to be an underestimation, since the data were collected prospectively rather than in retrospect.

Unfortunately, our study indicates that a rather high percentage of drugs are not prescribed by their generic names. Although this is comparable to the 41% reported from England31, it is however, much higher than the 21.9% reported by AI-Asmari in a similar but bigger study done in this country17. Our study also showed that while all children under five with diarrhoea received ORS, a comparatively high percentage of patients were prescribed no drugs. Studies from developing countries however, reported that up to a third of patients’ visits ended without prescriptions.32–34

In general, apart from the unexpected low percentage in two of the other components of the prescriptions examined (No. 2 & 7 in Table no 2), our results are better than other reported local studies1617193536 With the exception of the fact that faculty wrote statistically fewer drugs by their generic names than residents, experience and period of training among the groups could explain the significant differences in the rest of the INRUD indicators.

In general the low percentage of drugs prescribed in generic form as well as the relatively low percentages in the best drug choice, correct dosage schedule, and suitability of duration, among faculty and residents reflect a universal weakness in professional skills.

Despite advances in knowledge and the numerous studies done on drug utilization, prescribing practice and local or national formularies, there are still reports of a lack of professional application of skills37. One reason for this may be that the curriculum in pharmacology training during pre-clinical years may have consisted mainly of theoretical knowledge38. This type of training which is called “drug-centered” differs greatly from what the physician encounters in real clinical practice39. Disparity between one fewer hours spent on teaching therapeutics during medical training and the hours spent on the teaching of pharmacology was reported4041 Different investigators have shown that the results of teaching one traditional curriculum are not optimal3641–43. Though the level of pharmacological knowledge increases during medical training, the skills in rational selection and prescription of drugs remain poor.44

The results of this study suggest that there is a need for the review of the undergraduate teaching in pharmacology and therapeutics in our medical schools. Recommendations made by different investigators on the inclusion of a variety of skills and areas of knowledge and how these might be taught in existing undergraduate education programs should be considered45–49.

Based on the findings of this study, it is recommended that a well designed post graduate course which aims at improving diagnostic skills and drug use has to be offered by clinical pharmacologists to all the participants in this study. This has been shown to improve appreciably, both knowledge and expertise of drug prescribing50–52. Special courses in therapeutics tailored to the needs of the specialty should be incorporated in the curricula of post-graduate training programs in Family and Community Medicine. An efficient drug prescribing quality assurance system at primary health care centers should be implemented. Large scale studies similar to this one using INRUD indicators should be encouraged. This will assist in quantifying and comparing objectively the rational approach to drug use and prescribing practices in Saudi Arabia with other countries.