A cross sectional study on prescribing pattern for children at primary health care clinics

INTRODUCTION

The availability and affordability of good quality drugs and their rational use is needed for effective health care.¹ Rational prescribing is an essential component of health care system. Inappropriate prescribing negatively impacts the health of an individual and the economy of the society. Especially in children irrational prescribing may increase the risk of developing health complications in the later stages of their life. It was reported that the use of antibacterial at young age can develop respiratory problems, allergic manifestations and may increase the risk of obesity.^2,3 Thus medicine safety issues in children especially rational prescribing is an essential component of health care system. For the rational prescribing of medicines in children, the first model list of essential drugs for children (less than 12 years) was released in October 2007.⁴ It is aimed to serve as a guideline for rational prescribing in this age group. Now the 7th edition of list was released in 2019 by World Health Organization.⁵

Drug prescribing and utilization in children is of utmost concern worldwide.⁶ Information about prescribing practices and drug utilization in this population group is not up to the mark in developing and underdeveloped countries compared to western world so there is a need to carry out such studies by which rational prescribing can be promoted in this age group. Hence the present study aimed at studying the drug prescribing pattern and utilization in children in selected regions of Hyderabad city, India.

METHODS

A descriptive cross-sectional study was carried out in the primary health care pediatric clinics for evaluation of drug prescribing patterns starting from 20th January 2019 to 23rd March 2019. The study protocol was approved by RBVRR Women’s College of Pharmacy Institutional Research board (IRB). Only prescriptions with legible handwriting, demonstrating all the essential components of prescriptions were included. The data was collected from five private practitioners from chosen areas of Hyderabad. Five practitioners were randomly chosen each month from a pool of ten practitioners enrolled for the study. Prescriptions were selected by random sampling method. The study population included is under 13 years of age. Patients' demographic characters (age, gender), chief complaints and medicines prescribed were recorded. Class of medicines prescribed, dose, route of drug administration, frequency and duration of treatment was recorded in data collection form. WHO specifies drug use indicators for adoption in drug utilization studies.⁷

The sample size is calculated using following formula.⁸

N = Z² P (1-P) / d²

Where n is the sample size, Z is the statistic corresponding to level of confidence, P is expected prevalence (that can be obtained from same studies or a pilot study conducted by the researchers), and d is precision.

The following basic drug use indicators (core indicators) were used in the study to describe the prescribing pattern:

a) average number of drugs per encounter; b) percentage of drugs prescribed by a generic name; c) percentage of encounters with an antibiotic prescribed; d) percentage of encounters with an injection prescribed; e) percentage of drugs prescribed from the essential drug list. Based on this collected data, the WHO prescribing indicators were assessed.

Data collection was carried and supervised on daily basis by the investigators involved in the study. Completeness of data was checked every day during the data collection period. Data was analyzed descriptively and summarized using tables and charts.

RESULTS

Total 300 prescriptions were analyzed. 162 males and 138 females encountered the clinic during assessment period. Among 300 patients, 35% are below 4 years and 56% were of 4-10 years and 9% above 10 years. Major complaint was fever with or without upper respiratory tract infections. 32% of prescriptions found to be with one drug. 44% of prescriptions have two drugs. Only 22% of prescriptions with three drugs and 2% with more than three drugs (Table 1).

Average number of drugs prescribed is 1.92. NSAIDs occupied 30% of the total medications prescribed. 24% of the medications are mucolytics and antitussives (Figure 1). Most frequently prescribed drug was found to be paracetamol followed by mucolytic agents. Together they contributed to more than 50% of the prescribed drugs.

Only 10% patients received antibiotics and the overall percentage of antibiotics prescribed was also 10%. The most frequently prescribed antibiotics were fluoro-quinolones followed by macrolides (Figure 2). The Percentage of drugs prescribed from the essential drug list 67.3%. Out of 300 prescriptions, only five (1.67%) patients have been prescribed with injections. Percentage of drugs prescribed by a generic name is only 13%.

DISCUSSION

NSAIDs are the routinely prescribed drugs in children and paracetamol is the mostly prescribed drug among children.⁹ Antipyretics, cough and cold preparations and vitamins were the commonest category of drugs prescribed as reported in some similar studies.¹⁰ Fever and respiratory disorders are very common outpatient complaints in this age group.¹¹ The average number of drugs prescribed was comparatively less compared to the previous findings in a region of South India and is within the limits of WHO indicators. The percentage of antibiotics prescribed also less compared to the similar studies.^12,13 The total number of drugs from Essential list in this study was better compared to the studies at other cities.¹⁴

Percentage encounter with injection is only in 1.67% patients indicating a rational practice as previously reported.^12,15 Drugs prescribed from model EDL for children are relatively large compared to other studies.¹⁶ But Generics prescription was very poor which was in line with other reports, which needs to be improved.^15,16 There are only few published studies in India on prescribing practices for children to conclude about this practice. Especially there is a need to study prescribing practices in rural areas of India. However, findings of our study highlighted few areas of prescribing that should be intervened appropriately.

CONCLUSION

Hence, the present study concludes that the prescribing pattern in children in selected areas of Hyderabad city and found overall prescribing practices were found to be good and rational in most of the aspects WHO guidelines. We also found some areas of concerns regarding prescribing practices. Low usage of generic drugs in prescription writing was the main drawback. So, there is an immediate need of encouraging physicians towards generic prescriptions. The number of drugs prescribed from Model EDL list can also improve by continuing education on rational drug use and development of easy to use treatment guidelines by the physicians. The study has few limitations also. The time of sample collection is only two months which might miss the data of seasonal effects on prescribing patterns. The sampling distribution is also not even as it is only from few areas of urban Hyderabad. Despite of these limitations the study can help to create awareness in healthcare professionals.

ACKNOWLEDGEMENTS

Authors would like to thank the Principal and Management of RBVRR Women’s College of Pharmacy for supporting them to carry out this research.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Lalan BK, Hiray RS, Ghongane BB. Drug prescribing pattern of out-patient department ina tertiary care hospital in Maharastra. Int J Pharma Bio Sci. 2012;3:225-9.
2. 2. Foliaki S, Pearce N, Björkstén B, Mallol J, Montefort S, Mutius VE. Antibiotic use in infancy and symptoms of asthma, rhinoconjunctivitis, and eczema in children 6 and 7 years old: International study of asthma and allergies in childhood phase III. J Allergy Clin Immunol. 2009;124(5):982-9.
3. 3. WHO Model List of Essential Medicines for Children. First list, WHO. 2007
4. 4. Murphy R, Stewart AW, Braithwaite I, Beasley R, Hancox RJ, Mitchell EA. Antibiotic treatment during infancy and increased body mass index in boys: an international cross-sectional study. Int J Obes. 2014;38(8):1115-9.
5. 5. World Health Organization model list of essential medicines for children. 2019.
6. 6. Jasim AL. Parental self-medication of antibiotics for children in Baghdad city. Int J Pharm Pharm Sci. 2014;6:485-9.
7. 7. World Health Organization. How to investigate drug use in health facilities: selected drug use indicators. WHO/DAP. Geneva: World Health Organization. 1993: 1-87.
8. 8. Daniel WW. John Wiley and Sons; Biostatistics: a foundation for analysis in the health sciences; 7th edition. New York: 1999.
9. 9. Thiruthopu NS, Mateti UV, Bairi R, Sivva D, Martha S. Drug utilization pattern in South Indian pediatric population: a prospective study. Perspect Clin Res. 2014;5(4):178.
10. 10. Akhtar MS, Vohora D, Pillai K, Dubey K, Roy M, Najmi A, et al. Drug prescribing practices in paediatric department of a North Indian university teaching hospital. Asian J Pharm Clin Res. 2012;5(1):146-9.
11. 11. Malpani AK, Waggi M, Rajbhandari A, Kumar GA, Nikitha R, Chakravarthy AK. Study on prescribing pattern of antibiotics in a pediatric out-patient department in a tertiary care teaching and non-teaching hospital. IJOPP. 2016;9(4):253.
12. 12. Pradeepkumar B, Alameri T, Narayana G, Reddy YP, Ramaiah JD. Assessment of antibiotic prescribing pattern in pediatric patients: A cross-sectional hospital-based survey. Chrismed J Health Res. 2017;4(4):235.
13. 13. Senthilselvi R, Boopana M, Sthyan L. Drug utilization pattern in paediatric patients in a secondary care hospital. Int J Pharm Pharm Sci. 2019;11(4):69-74.
14. 14. Pandey AA, Thakre SB, Bhatkule PR. Prescription analysis of pediatric outpatient practice in Nagpur city. Indian J Community Med. 2010;35(1):70.
15. 15. Vallano A, Montane E, Arnau JM, Vidal X. Medical specialty and pattern of medicines prescription. Eur J Clin Pharmacol. 2004;60:725-30.
16. 16. Roy V, Gupta U, Gupta M, Agarwal AK. Prescribing practices in private health facilities in Delhi (India). Indian J Pharmacol. 2013;45(5):534.