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Muhammad Ndeem et al. World Journal of Pharmaceutical Research

PRESCRIBING PRACTICES OF GENERAL PRACTITONARS OF

PUBLIC HOSPITALS OF PAKISTAN

Ayaz Ali Khan, Marvi, Javeid Iqbal, Muhammad Nadeem*

Department of Pharmacology, Faculty of Pharmacy, Hamdard University, Karachi, Pakistan.

ABSTRACT

Prescribing is not easy. It requires a thoroughly understanding and

knowledge of the path physiology of disease. The appropriate use of

prescription drug by physician should be a key element of high quality

of primary care. The process of prescription is very much influence by

social system and structure in which these operate. Consequently the

process will tend to be slightly different from different health

provision. To improve prescribing practice we need methodologically

to evaluate strategy to change prescribing behavior, various

interventions to promote rational prescribing are not classified as

educational immaterial and regulatory. From the study which we have

conducted based upon the behavior of the prescriber regarding

prescription writing from all area which have been covered like private

or public hospitals, private clinics, and even the prescriber who practice in an area where the

patient do not have awareness regarding the prescription writing pattern The study comprises

on a small number of area, we cannot suggest any recommendation on government level

however for the knowledge of further researcher this work would be very much beneficial for

the conclusion of ultimate reasons of irrational prescribing that some time produce undesirable

effects and could be lethal for the patients.

KEY WORDS: Prescription, prescription lay out, Prescriber, Rational use of drugs,

Prescription Indicators.

1. INTRODUCTION

Prescription is combination of two words pre means before and script means written, that

means, the prescription looks like an order that ought to be printed on the paper of the

World Journal of Pharmaceutical research

Volume 2, Issue 2, 285-296. Research Article ISSN 2277 – 7105

Article Received on 06 January 2013, Revised on 28 January 2013,

Accepted on 28 February 2013

*Correspondence for Author: * Muhammad Nadeem

Department of Pharmacology,

Faculty of Pharmacy, Hamdard

University, Karachi, Pakistan

[email protected],

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prescription. Prescription is written and also followed by the doctor because it is the variety

of commands which direct the care arrangement of a patient. The prescriptions carried the

information which is to be obeyed either by a patient care taker, pharmacist and nurse. The

word “prescription” means, a sort of instructions to take certain medications. It has certain

officially permitted implication, which shows that prescriber is responsible for medical care

of the patient and mainly monitoring the usefulness and wellbeing.

Most medicines are becoming already packaged manufactured goods and the medical

practice has developed into multifaceted. Thus meaning of the word prescription has

broadened and it also covers up clinical assessment, lab tests and imaging study related to

optimizing the protection or effectiveness of medical management. "According to WHO

relational uses of medicines demanded that the appropriate drug to be prescribed; and it

should be in use with the right dose on right interval of time and technique. Suitable medicine

should be effective and should be of acceptable in all senses [1]. The concept about rational

drug usage in old age, as an evident by the statement made by Alexander physician

Herophilus 300B.C. that is medicines are nothing but very hand of GOD if employed with

reason and prudence [2]. Rational use of drug depends on many activities such as making the

correct diagnosis and prescribing the appropriate drug in correct doses. Reports on drug

prescriptions from developing countries like Pakistan and India indicate the general pattern of

poly pharmacy, misuse of antibiotics. Injectable, frequent use of multivitamins, wrong

medications and inappropriate treatment is common in GP's practice. General Private

Practitioner is the most sought out healthcare provide [3]. The services of the private sector are

perceived to be far better than the public sector in most developing as well as nation [4] The

extent of drug use is directly affected by prescribing behavior of physicians, especially in

primary care [5] The Inappropriate usage of medicines is a most important challenging task for

the national health & medicine rule maker in any country. The misuse of drug is depletion,

costly and hazardous both for the health of patient as well as community [6]. The

inappropriate drug usage problem is multifaceted. Its seriousness is difficult to summarize in

a single statistic [7]

There is certain concern regarding the irrational prescription which is also used in Pakistan.

The intend of study is to describe the superiority of prescriptions by private general medical

practitioner which including both the layout of the prescription and the type and number of

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drugs which are prescribed using standard methodology for selected drugs use indicator

developed by WHO and INRUD.

The Core indicators are used for the measurement for the presentation in 3 following areas;

1. Medicines prescribed by doctors and MS etc,

2. patient care consisting conference, dispensing, and

3. Services which specifically measures to support rational drug usage.

These indicators have highly standard with a distinct sample range and don’t involve

national adaptation and all these indicators are suggested for insertion during the drug

usage in the study conducted. Whereas, opposite indicators have not holded the good

applications and standards due to local variables [8].

2. METHODOLOGIES

2.1 Study Design

It was a descriptive quantitative study conducted in urban areas of Sindh during the month of

March and April 2011, in GPs clinic.

2.2 Sample Size

The study was carried out by collecting the data from 20 GP’s practicing in different area of

Sindh and 10 cases from each GP were observed.

2.3 Tool Development

Two tools were developed to collect the data one was the structured observation form and

other was prescribing indicator form. The structured observation form was used to observe

the standard prescriber patient interaction while examining the patient whereas prescribing

indicator form was used to document the parts of prescription to asses either the prescriptions

follow the standard prescription format or not and also prescribing core indicators by WHO

to investigate rationale drug used in private clinics. These tools were selected on the bases of

their proved effectiveness in previously conducted studies. The structured observation form

was consisted mainly of two parts one was comprised of general demographics including

patient name, age, sex and name of prescriber. The part of required information is to observe

prescriber patient interaction. A standard patient prescriber interaction scale was developed

with a sore ranging from o to 27 and comprising of four subscales. Subscale one was

introduction consisting of four items with the which score ranging from 0 to 4 subscale two

was history taking having 5 items with the score ranging from the 0 to 5. Third subscale was

of diagnostic procedure with five items having score ranging from the 0 to 5 and the last

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subscale was patient counseling comprising of about twelve items with the score ranging 0 to

12. Consultation time was also noted. Another scale of the structured observation form was to

observe the timing at which the prescribers started to write drugs on prescriptions and having

score ranging from 0 to 1. The other tool was prescribing indicators and other was of standard

prescription format scale was develop with nine subscales with score ranging from 0 to 9.

Prescription layout was also observed to assess that how much prescriptions follow standard

prescription pattern and contains all the eight parts of prescription as mentioned in the

literature.

2.4 Tool Validation

The tool was developed by inputs from focused group discussion and validation for face and

content validation. The face validation easy done by panel of experts which includes

academic researches and prescribers whereas content validation was done by focused group

discussions and pilot testing.

2.5 Data Collecting Plan

After tool validation field visits were conducted to collect data. For the purpose of data

collection a team of two data collectors worked. The sampling units were located and

permissions had been taken by GPs supervising those clinics. To follow the ethical criteria

only those GPs were included who were willing. Confidentially approval was given to them

that their personal information will not be disclosed. After data collection we maintained the

data in files on completion of field visit that was coded to enter in the SPSS (17.0 version)

statistical package for social science software was used for data entry and analysis.

2.6 Data Analysis

After coding the data was entered in SPPSS for analysis. Data screening was done by running

frequencies. After performing the statistical analysis it was found that our data was skewed so

non parametric tests, Spearman s test was applied to find the correlation between patient

prescriber interaction and prescription pattern, patient prescriber interaction and consultation

time and patient age on consultation time. Mann Whitney test was also applied to check

effect of patient gender on consultation time and patient prescriber interaction. Then obtained

results were recorded

For the purpose of this descriptive quantitative study data from a non probability sample of

200 patients, 10 patients from each, was collected, coded, and analyze by SPSS as shown in

table.

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3. RESULT

prescription of 200 patients were observed to investigate the WHO middle prescribe indicator

that were, the usual numbers of medications prescribed in an encounter , average

consultation time , %age of prescribed medicine via their generics , the percentage of

encounter by way of approved antibiotics, %age of encounters with prescribed injections,

%age of medications agreed commencing EDL results were found.

3.1 Prescribing indicators

Table 3.1 Prescribing Indicator

Count Mean +S.D Minimum Maximum

Average numbers of

medications per

encounter

200 +3.04 1.41 1 7

Average consultation

time 200 +5.02min 2.97 1 21

%age of drug agreed by

their generics 607 0 0 0 0

%age of encounter

through prescribed

antibiotic

200 37% 0.48 0 1

%age of encounter by

the prescribed

injectables

200 17.5% 0.38 0 1

%age of the drug

prescribed from the

EDL

607 39.5% 1.13 0 6

%age antibiotics

prescribed 607 13% 5.3 0 2

% of injectables

prescribed 607 8.4% 5.9 0 3

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3.2 Pattern of Prescription

Prescription pattern was also observed to investigate how many prescriber follow standard

prescription patterns. The prescription pattern scale was developed with score from 0_8, with

the mean results obtained 5.21 (range 3_7, SD + 1.02). Prescription pattern was observed to

have all eight parts of prescription. The results obtained are given below in graph 1.

0

20

40

60

80

100

120

patient information

Rx

diagnosis

inscription

signa

subscription

signature

prescriber information

Graph.1 Pattern of Prescription

3.3 Patient and Prescriber Interaction

A standard patient – prescriber interaction scale was developed having 26 items with 4

subscales, consisted of four items with the score ranging 0 to 4. The mean score obtained

were 2.43 (range: 0-4, SD + O.95) as shown in table 3.2.

Table 3.2 Patient and Prescriber Interaction

S.NO Subscales Items Response

N ( % )

1 Introduction Prescribers greets patients 38 ( 19% )

Friendly conversation 100 ( 50 % )

Encouraged to describe problem 169 ( 84.5 % )

Prescribers listened to patients carefully 179 ( 89.5 % )

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3.4 Taking of History

Second subscale was history taking having 5 items with score 0_5 and the mean score

obtained 2.11 (range 0-5, SD + 1.34) as shown in table 3.3.

Table 3.3 Taking history

S.NO Subscale Items Response

2

History taking

Prescribers asked for chief complaints 175 ( 87.5 % )

Prescriber asked duration of current

problem

109 ( 54.5 % )

Ever experienced this condition before 28 ( 14 % )

Taking any drugs 63 ( 31.5 % )

Name of drugs 48 ( 24 % )

3.5 Diagnostics Technique

Third scale was use of diagnostic procedure with 5 items having score from 0-5 with the

mean result 2.28 (range 0-5, SD + 1.05) as shown in table.

Table 3.4 Diagnostics Technique


N ( % )

3

Diagnostic

Technique

Temperature measured 75 ( 37.5 % )

Patient touched for fever 30 ( 15 % )

Pulse felt 64 ( 32 % )

B.P measured 128 ( 64 % )

Other diagnostic problems 159 ( 79.5 % )

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3.6 Patient’s counseling

The fourth scale was patient counseling comprising of 12 items with score ranging from 0-12

and the mean score obtained was 4.54 (range 0-10, SD + 2.42) as shown in table.

Table 3.5 Patient’s counseling


4 Patient

Counseling

Explained patient about disease 93 ( 46.5 % )

Prescriber told patient how to take

medication

133 ( 66.5 % )

Prescriber told patient about dose 88 ( 44 % )

Prescriber told patient about frequency 119 ( 59.5 % )

Prescriber told patient the duration of

therapy

110 ( 55 % )

Prescriber told the patient about the

side effects

2 ( 1 % )

Prescriber listen to responses 88 ( 44 % )

Patient satisfied 172 ( 86 % )

Patient call for follow up 42 ( 21 % )

Prescribers end conversation 86 ( 43 % )

Prescribers reassured the patients

understanding

10 ( 5 % )

3.7 Statistical Analysis

The overall patient prescriber interaction with a score ranging from 0-26 mean score found

were 11.37 (range 4-21 SD + 4.0). Another observation was made that is the time at which

the prescriber started to write drugs at the beginning or after listening the patient properly the

result was found that 99.5 % prescription drugs were written by prescriber and properly

listening the patients whereas o.5 % was written before properly listening the patient

problems .

On further analysis we found that our data was asked so spearman’s test was applied to check

association between different scales i.e. . . .

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patient prescriber interaction and prescription pattern,

patient prescriber interaction and patient age,

patient prescriber interaction and consultation time,

patient prescriber interaction and consultation fee,

consultation and consultation fee,

consultation and patient age, and

Prescription pattern and consultation fee.

The result showed that patient-prescriber interaction was correlated with prescription pattern

and consultation time at the significance level of o.o1 with the value r = 0.316 and r = 0.32

respectively. Showing that where the patient-prescriber interaction is better the prescription

lay out is also better and those prescriber are given more consultation time. Whereas patient-

prescriber interaction was not associated with patient age and consultation fee presenting that

patient-prescriber interaction is not effected by patient age or consultation fee. Consultation

time was correlated with consultation fee at significance level of 0.01 with the r value 0.28

which can be interpreted as the prescribers charging more consultation fee are giving more

consultation time to patients.

Prescription pattern was also associated with consultation fee and consultation time at

significance level of 0.01 with the value of r =0.32 and o.28 respectively. This means that

prescribers charging more consultation fee and giving more consultation time have better

prescription patterns.

By applying Mann Whitney test it was found that patient’s gender does not significantly

affect the prescription pattern, patient-patient interaction and consultation time.

4. DISCUSSION

The general practitioner or GP is medical practitioner who can provides primary cares and

specialize in family medications. The general practitioner treating acute as well as continual

ill health and also provides preventive cares & health education for the all ages and for both

sexes. They have unique skills in the treating of peoples with multi-health issue commodities [9]. To assess the prescriptions’ qualities by the medical practitioners , consisting both the

layout of prescription & types, also numbers of medicines prescribed , thus a sample of

twenty health facilities ( GPs ) clinics were selected to represents large groups of the

facilities [10] The intend of this study is to describe prescribing behavior of doctors in urban

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areas of the Sindh , Pakistan . Our focus was not on whether the drugs were indicated for the

patient’s illness, but on the lay out and content of the prescription. In particular, we wished to

assess the extent of polypharmacy, The 200 patients were observed out of which 52 % were

females and 48 % were male. A study from Pakistan indicated 56 % females and 44 % were

male. This gender difference could be because of fact that female in our country have poor

diet habits so they are more prone to disease among the clinics selected for data collection 85

% of the clinics were located in the main area and only 15 % were located in small area. It

may also be because of reason that clinics in the markets are more facilities and may have

laboratories nearby reduce the cost of traveling. And among the GPs practicing in those

clinics 95 % were male and only 5 % were female. This may be due to the fact that there is

generally a lesser trend of female doctors in Pakistan, Our results showed that GPs in urban

areas of Sindh were charging consultation fee 100-600 excluding the course of drugs.

Poly pharmacy was the norm, with 24 % of prescriptions having more than one medicine,

with a significant proportion of patients receiving 3 0r more prescriptions. The average

number of drugs was found to be +0.34. Other studies also shows almost the same results like

study in from Pakistan showed average number of drugs was +3.5 [11] . When the reason for

prescribing more drugs for same condition was asked by prescribers they said in some

situation it is needed but mostly we prescribe more number of drugs to satisfy the patients. A

study from Pakistan including all 4 provinces of Pakistan showed Injectable use 15 % and

Punjab being showing significantly higher percentage [10]. Private practitioners usually

prescribed costly medications because most of the times our patients feel that as much as the

cost is the medication are that much effective. This study highlighted the presence of severe

deficiencies in the layout of a significant proportion of prescriptions. Not a single prescription

was according to the standard layout. Subscription was found to be 0% which showed that

not a single prescriber was giving instructions to pharmacist or the dispenser. As the selected

clinics were not dispensing clinics this could be reason for the absence of such instructions. A

study from Goa, India showed a lesser number of prescriptions with this significant part. 15%

of prescriptions were had proper patient information whereas remaining were not contained

the complete information. The reason behind this is that there is no trend to tell the complete

address to prescriber in Pakistan because patient thought that if they are living in an

established area or high class locality the prescriber will charge more consultation fee of they

might be of theft while telling their address. Patient prescriber interaction scale resulted with

mean score of 11.3. It was found that prescribers having better interaction, better prescription

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layout, giving more consultation time, prescribing more Injectable, charging more

consultation fee and are more experienced. Whereas another study from the attack district

indicated deficiencies in prescription practices among all health care providers however the

problem is extremely serious among the more qualified general practitioners.

5. CONCLUSION

Generic prescribing is found to be 0 % in the region and antibiotic use is higher. Consultation

time is very less. Money and prescriber the drugs of their choice either they comply with the

national polices or not. Standard prescription layout is not being followed even by a single

prescriber. There is not check point for the prescription standard. Directions for the

pharmacist or dispenses or not present even a single prescription.

6. ACKNOWLEDGEMEMT

The authors are very thankful to Faculty of Pharmacy, Hamdard University Karachi, Pakistan

for providing the research conveniences. Authors are also thankful to all head of departments

of different public and private sectors hospitals and clinics who gave us much help during the

data collection

7. REFERENCES

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developing countries." The Lancet 342(8884): 1408-1410.

2. Le Grand, A., H. V. Hogerzeil, et al. (1999). "Intervention research in rational use of

drugs: a review." Health policy and planning 14(2): 89-102.

3. Duggal, R. and S. Amin (1989). Cost of health care: a household survey in an Indian

district, Foundation for Research in Community Health Bombay.

4. Rohde, J. E. and H. Viswanathan (1995). The rural private practitioner, Oxford University

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5. Laing, R., H. Hogerzeil, et al. (2001). "Ten recommendations to improve use of

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6. Organization, W. H. (2002). "WHO policy perspectives on medicines." Promoting

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7. Laing, R., H. Hogerzeil, et al. (2001). "Ten recommendations to improve use of

medicines in developing countries." Health policy and planning 16(1): 13-20.

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8. Quick, J. D., H. V. Hogerzeil, et al. (1997). "Managing drug supply: the selection,

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in collaboration with the World Health Organization; editors: Jonathan D. Quick

9. Kraigher, A. (2003). "Pogledi na cepljenje." Zdrav Var 42: 127-128.

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