Indian Journal of Pharmacology 1998; 30: 43-46 RESEARCH PAPER

EVALUATION OF PRESCRIBING PATTERN OF DOCTORS FOR RATIONAL

DRUG THERAPY

K.U. ANSARI, S. SINGH, R.C. PANDEY ’

Department of Pharmacology and *Department of Microbiology,

M.L.N. Medical College, Allahabad - 221 001.

Manuscript Received: 25.61997 Revised: 22.10.1997 Accepted: 18.11 .1997

SUMMARY Objective: To study the prescribing patterns of doctors in Allahabad district for evaluation of their
rationality.
Methods: Prescriptions written by the consultants in Private (P.S.) and Service Sectors (S.S.) were
collected and studied retrospectively under two heads: (a) whether the prescriptions written by the
Doctors are in conformity with the general format (b) whether the drugs prescribed by them are
rational. The study was conducted on the 200 prescriptions comprising of 92 prescriptions of PS
and 108 prescriptions of SS.
Results: Audit of the prescription pattern revealed that most of the prescriptions did not conform
to the pattern of a typical prescription. Eighty five percent of them were without the age of the patient,
which includes 30% of the paediatric prescriptions. Superscription was not mentioned in 71% of the
prescriptions. Inscription, subscription and signature were inadequate in 50%, 18% and 35% of the
prescriptions, respectively. In these 200 prescriptions drugs were inappropriately administered in more
than half (52 %) and it was more common among the consultants in P.S. (65%) than in S.S. (41%).
Forty percent of the prescriptions showed overprescribing. The tendency of polypharmacy was more
in P.S. (5.05 medications per prescription) than S.S. (3.52). Interacting drugs were prescribed in 10%
cases and banned drug formulations were prescribed in 3% cases.
Conclusion: Large number of prescriptions do not conform to ideal pattern and lack in their rationality.

KEY WORDS Prescription audit rational drug therapy

INTRODUCTION It was, therefore, thought pertinent to study the pre-

sent prescribing pattern adopted by doctors working
Prescription order is an important transaction be-
as consultants in Private and Service Sectors. The
tween the physician and the patient’. It is an order said audit was carried out at two levels:
for a scientific medication for a person at a particular
time2. It brings into focus the diagnostic acumen (1) whether the prescriptions written by doctors were
and therapeutic proficiency of the physician with in conformity with typical prescription, and (2)
instructions for palliation or restoration of the pa- whether drugs prescribed were rational.
tient’s health’. Now-a-days the prescribing pattern
is changing and it has become just an indication MATERIALS AND METHODS
of medicine with some instructions of doses without
A retrospective study was carried out from May
considering its rationality2.
1996 to January 1997 by collecting prescriptions
It has been frequently observed that doctors are written by consultants working in private and service
adopting polypharmacy, promoting unnecessary use sector to assess the prescribing pattern of the doc-
of tonics and other drugs under the sales influence tors and to evaluate the prescriptions for their rational
of drug companies and overlooking drug interac- approach. Only precompounded prescription orders
tions. This has resulted in increased side effects, that call for a drug or mixture of drugs supplied
adverse drug reactions and the cost of treatment. by the pharmaceutical company by its official or
However, irrational prescribing can be avoided by proprietary name and in a form that the pharmacist
sticking to the ideal prescription writingsId, following dispenses without pharmaceutical alterations were
the P-drug and P-treatment concep@, and by con- included in the study. The qualifications of all the
sulting the WHO / or National essential drug list. prescribers were M.B.B.S. and above.
44 K.U. ANSARI, S. SINGH AND R.C. PANDEY

Mode of Collection of Prescriptions tions containing formulations and drugs banned by

The patients attending the clinics of the consultants Drug Controller General of India.
working at various levels of the health care were The different categories were designed to describe
approached either at the clinic or at pharmacy shop our judgement on the use of drugs. The evaluation
with a request to have their prescriptions xeroxed. criteria was designed on the basis of categories
The patients were also interviewed to have nec- suggested by Kunin et a/ 7 and WHO guide to good
essary information. The format consists of infor- prescribing6. Criteria III, IV and V mentioned below
mations given below: (1) Patient’s Demographics: show inappropriate use:
Name/Age/Sex/Address/Profession. (2) Patient’s
medical history; if any. (3) Sign and symptoms or (1) Agree with therapy prescribed. It is appropriate
complaints for which the consultation was sought. in terms of efficacy, safety, suitability6 and cost ef-
(4) Provisional/confirmed diagnosis. (5) Medication fectiveness8. (2) Agree with therapy prescribed. It
therapy: Number and names of drugs/dose/dosage is efficacious, safe and cost effective but advantage
regimen/duration of therapy/use of corrective meas- derived remain controversial. (3) Agree with therapy
ures. (6) Investigations. (7) Drug interactions/aller- prescribed but the number of drugs can be reduced
gies. (8) Instructions for diet. (9) Refill instructions. or a different (usually less expensive and/ or toxic)
(10) Any other remarks. drug is prescribed. The therapy is efficacious but
not cost effective and/or safe. (4) Agree with the
Prescriptions were studied to observe whether they therapy but a modified dose, dosage regimen and/or
conform to the following parameters of a typical duration should be recommended. The drug is safe,
prescription3v4: suitable and cost effective but not efficacious in
the already recommended dosages. (5) Disagree
Parameters of Audit with therapy prescribed, either the administration
(A) For format of the prescription of the drug prescribed is unjustified or unnecessary
(1) Patient identity: Name and address of the patient. use of drug.
Also age and weight in case of paediatric patients.
(2) Date on which the prescription was issued. (3) RESULTS
Superscription symbol: Rx meaning “take thou” or A. Evaluation for format of prescription
“recipe”. (4) Inscription: which includes the name
of drugs, dose, dosage forms, total amount of medi- Patient’s identity: Name and age of patients were
cation prescribed. (5) Subscription: the dispensing not found in 6% and 85% of the prescriptions, re-
and compounding instructions to the pharmacist as spectively. Thirty percent of the paediatric prescrip-
regards to form and quantities to be dispensed or tions were without their ages and/or weight
supplied. (6) Transcription or Signa: the direction recorded. Address of the patient was not mentioned
to the patient for use of drugs. (7) Prescriber’s iden- in any of the prescriptions collected. Date was not
tity: Name, address and qualification. found in 10% of the prescriptions.

(B) For Rationality of the Prescription: Superscription: Superscription (Rx) was not found
in 71% prescriptions. In many prescriptions it was
Rational therapy is an outcome of rational prescrip- replaced by the word ‘Adv’ indicating advice. In-
tier? . WHO guidelines were taken into consideration scription was inadequate in 50% prescriptions.
for evaluating the rationality of the prescriptions6.
Subscription: 18.5% prescriptions were found to be
The parameters for evaluation are: with inadequate subscription. In all prescriptions
(1) Dose strength and dosage schedule: whether collected in this study there were no explicit di-
the strength of drug, its dosage form and schedules rections to the pharmacist regarding the dosage
are correct. Different dosages forms usually lead form and total amount to be dispensed. However,
to different dosing schedule. (2) Duration of therapy: in our study, only those prescriptions were identified
under or over duration or not mentioned. (3) Over- as having inadequate subscription in which it was
prescribing: unnecessary use or duplication of drugs very difficult for the pharmacist to ascertain the total
and dosage form as far as therapeutic or phar- amount of medication to be dispensed with.
macologic effect is concerned. (4) Interactions: in- Transcription or Signature: It was not adequate in
cludes drug-drug, drug-disease, food-drug 35% prescriptions. The prescription in which dosage
interactions. (5) Banned drug formulations: prescrip- schedule was indicated in any form that is under-
 RATIONAL DRUG THERAPY 45

Table 1. Retrospective analysis of prescriptions by using Kunin’s criteria7.

Therapy
Category of Total
consultants Appropriate Inappropriate prescription

Sub Total III Sub Total

(NA.%, (Ni.%, (No.%) (No.%) (N!!%) (N:.%) (No.%)

Private
sector (n=92) (ii, & (E, (E, (::, & (Z, (19020,

Service 108
sector (n=108) (1Y, (Z, (& (E, (:A, (:A, (t:, (100)

Sub total 104 200

(ET, (52) (100)

n = Total prescription collected.

Figure 1. Pie chart showing the number of medications per fever, ciprofloxacin was given 250 mg b.i.d. for 5
prescriptions. days which was inadequate for an adult person.

ervice Sector
Duration of therapy: Duration of therapy was irra-
3.52 tional in 35% prescriptions i.e. short in 15%, pro-
longed in 9% and not mentioned in 11% of the
prescriptions. For example, vitamins and iron tonics
were continued for excessively longer period of time
without proper and careful monitoring.
Over prescribing: Forty percent of the prescriptions
showed over prescribing. For example, in case of
bronchitis both Theo-asthalin (Theophylline + Sal-
butamol) and Asthalin (salbutamol) were recom-
Private Secto mended; in another prescription both otrivin
5.05
(xylometazoline) and dristan (phenylephrine) were
recommended; anaflam (a combination of ibuprofen
and paracetamol) and piroxicam were prescribed
together.
standable to the patients other than the usual latin Interactions: Ten percent of the prescriptions showed
words like b.i.d., t.i.d, o.d. etc were treated as pre- various types of interactions viz. drug-drug(5%),
scription with adequate signa. In these prescriptions, drug-disease(3%) and drug-food interaction (2%)
instructions about the refilling of the prescription, eg. Fesovit, an iron supplement is given along with
substitution of the products, precautions or warning Aciloc (H2 receptor blocker that decreases gastric
regarding drugs or therapy were verbal and not acidity). This will decrease the absorption of iron.
recorded.
Banned drug formulation: Three percent of the pre-
Prescriber’s identity: Eight percent of the prescription scriptions contained drugs banned by Drug Con-
were not signed by the doctors. Name, address troller of India like diiodohydroxyquinolone (in
and qualifications were not found in 6.5% of the combination with other drug), combination of an an-
prescriptions as these were written on plain papers. tispasmodic with analgin.
Only 2% of the drugs were prescribed with generic The Table 1 shows that 52% of the total prescriptions
names. collected were inappropriate. The inappropriate pre-
B. Evaluation for Rational Drug Therapy scriptions were more in Private Sector (65%) than
in Service Sector (41%). The number of medications
Dose strength and dosage schedule: Of all the pre- per prescription is more in private sector (5.05) than
scriptions, 25 % showed incorrect dosage. In typhoid service sector (3.52) (Figure 1).
46 K.U. ANSARI, S. SINGH AND R.C. PANDEY

DISCUSSION Nies AS, Taylor P, (eds). Goodman and Gilman’s The phar-
macological basis of therapeutics. 8th ed. New York: Per-
The results obtained after auditing of the prescrip- gamon Press Inc. 1991:1640.
tions indicate that majority of the prescribers do
not adhere to the ideal pattern of the prescription 2. Gaud RS, Jain DK, Kaskhedikar SG, Chaturvedi SC. Critical
evaluation of present prescribing pattern. Indian J Hosp
writing314 and these prescriptions are not explicit Pharm 1989:26:70-72.
in their contents. Replacement of Rx sign with the
word ‘Advice’ in large number of prescriptions is 3. Puthawala AK, Mansuri SM. Pharmacy practicals for medi-
indicative of changing pattern of the prescriptions. cal students. 2nd ed. Ahmedabad: 1986:13-5.
Overprescribing in 40% of the prescriptions indicates
4. Budhiraja RD. Manual of Practical Pharmacy. 2nd ed. Bom-
the increasing tendency of polypharmacy. This ten- bay: Popular Prakashan, 1993:6.
dency is more prevalent in private sector which is
evident from greater number of medications per pre- 5. Kohli K, Kela AK, Mehta VL. Rational drug therapy as
scription (Figure 1). The trend of the polypharmacy evaluated from students clinical case reports. lndian J
may be due to the patient’s expectations and de- Physiol Pharmacol 1995:98:400-2.
mand of quick relief, the incorrect diagnosis, and
the influence of the lucrative promotional pro- 6. de Vries TPGM, Henning RH, Hogerzeil HV, Fresle DA.
grammes of the drug companies. More than 50% Guide to good prescribing: a practical mannual. Geneva;
World health Organization, Action Programme on Essential
of the inappropriate therapy shows that prescribers Drugs, 1995:14-31.
are not uptodate with the progress in medical field
and should be more responsible. These results 7. Kunin CM, Tupasi T, Craig WA. Use of antibiotics : a
justify the apprehension reported earliergplO. brief exposition of the problem and some tentative solutions.
Ann Inter Med 1973;79:555-60.
Within the limited scope of this study, it can be
concluded that a serious health hazard can be 8. Karki RG, Goyal RK. Pharmacoeconomics. A new concept
minimised by educating the erring doctors for a more in pharmacy. Eastern Pharmacist 1996;39:43-5.
rational use of drugs.
9. Ansari KU. Health for all by 2000 AD- Do we achieve
REFERENCES it? Therapeutic and Drugs 1987;3:8-10.

1. Benet LZ. Principles of prescription order writing and pa- 10. Ansari KU. Rational drug therapy- Do we achieve it?
tients compliance instructions. In: Goodman AG, Rall TW, Antiseptic 1987;84:357-60.

“ADRENALINE IS NOT MANUFACTURED NOW-A-DAYS”

General practitioners, as also some of the specialists have forgotten the role of adrenaline
in the management of anaphylactic reactions. If we ask any medical practitioner the treatment
of acute anaphylaxis we are bound to get the answer as steroides and antihistaminics
combination, although this is never taught this way.
I have tried to find an answer to the question as about who has spread this misinformation.
And the answer is readily available. The pharmaceutical industry is not interested in selling
lnj. Adrenaline as it sells for only Re.1, and who will be interested in selling so cheap
a drug. When once I went to buy Inj. adrenaline for my own emergency kit the chemist
said: “Sir this is a very old drug, my father used to sell it. It is not manufactured these
days”!
And he was right in that for his scientific knowledge he is dependent on medical representatives.
In fact that is true for most of the practitioners at the periphery. Most of the doctors also
are dependent on medical representatives for their updating. And which company is interested
in promoting a cheap injection like adrenaline?
Dr. Prakash C. Malshe,
B-73; Shivalik Nagar,
Hardwar - 249 403.,
c -