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Abstract
Pattern of medicine use among in-patients in a tertiary health care setting using the WHO prescribing indicators
Ehizokhale Peter Akhideno, Department Of Medicine ,Irrua specialist Teaching Hospital, Irrua; Ambrose O Isah
Clinical Pharmacology and Therapeutics Unit, Department Of Medicine, University of Benin Teaching Hospital;
Keywords: Indicators, in-patients, rational drug use.
Problem statement: Irrational use of medicines exemplified by polypharmacy, overuse of injections and antimicrobials have
resulted in increased morbidity, mortality and cost burden for patients. This is especially more so in developing countries where inpatient medicines use are poorly characterized. This study evaluates the use of medicines among in-patients in a tertiary health care
setting using the WHO drug use indicators.
Objectives: To outline the pattern of use of medicines using the WHO prescribing indicators among in-patients in a tertiary health
care setting with a view to attain a rational and safer pharmacotherapy.
Design: A descriptive prospective study of patients admitted into the adult medical wards of a tertiary health care setting in Nigeria.
Setting: This study was conducted at the University of Benin Teaching Hospital, a 620-bed tertiary health care setting.
Study population: All patients admitted into the adult medical wards over a period of 9 months, numbering 507 were included in
the study. Males were 269 and females 238. The mean age of participants was 48.9±17.8 years ranging from 17- 89 years.
Policies: The WHO indicator was designed for out-patient encounters. Some studies including this, have modified the indicators
for use in in-patient setting. Admitted patients were evaluated on days 0, (day of admission), 1, 3, 7, 10, 14 and weekly thereafter
and at discharge. All medicines prescribed for patients were noted. Doses, frequency, and route of administration were recorded.
Outcome measures: The WHO drug use indicator values.
Results: The most frequent diagnoses were malaria, HIV/AIDS, diabetes and hypertension (18.9, 17.2, 17.0 and 16.8% of patients
respectively). The mean duration of hospital stay was 11.9±11.3. The average number of medicines used per patient during
admission was 9.1±3.8 (median 8); The number of drugs rose from 4.2 on admission to 8.3 on day 28, reducing to 6.3 on discharge.
Prescription from essential medicines list and generic prescribing were 88.1% and 85.6% respectively. The percentage of
admissions with injectables prescribed was 89.3%, decreasing from 75.1% on admission day to 48.7% on discharge, while those
with antimicrobials prescribed was 61.9%, rising from 41.2% on admission to 68.4% on day 28, reducing at discharge to 49.3%.
The percentage of admissions with antimalarials prescribed was 18.9%. STG was at developmental stage thus unavailable as at
study.
Conclusion: The WHO indicators would serve usefully perhaps with some modification in the study of drug use among in-patients.
The rates of prescriptions of medicines on the EM list and use of generic names were fairly high, however the WHO
recommendation is 100% leaving room for improvement. The rates of use of antimicrobials and injectables were high, suggesting
overuse among in-patients. There is however a need to develop standard values for the basis of comparison as in-patients and outpatients differ in profile and severity of illness.
Introduction
Use of medicines is considered to be an important step in patient care.
However, irrational use of medicines exemplified by polypharmacy,
overuse of injections and antimicrobials have resulted in increased
morbidity, mortality and cost burden for patients.
Tackling problems associated with rational medicine use and its
monitoring has been a priority issue of the WHO. The development of
standard indicators for such monitoring may be regarded as one of the
most notable achievements in the efforts aimed at promoting rational
use of medicines, especially since the WHO sponsored Nairobi
conference of 1985 on rational medicine use. The indicators enable the
characterisation of medicine use pattern, identification of inappropriate
use and evaluation of interventional strategies.
Introduction
These indicators were developed for out-patients and they have been
used extensively for out-patients’ rational medicine use evaluation
and monitoring. From available literature, rational use of medicines
is poorly characterised among in-patients. This is even more so in
developing countries. In-patient medicine use patterns are likely to
differ from out-patients since they are usually more ill and likely to
require more concomitant medicines. There are also some medicines
which may only be administered among in-patients.
In this study, an attempt is made to evaluate the use of medicines
among in-patients using the WHO drug use prescribing indicators,
with some modification to suit this purpose.
Objective
To outline the pattern of medicine use, using the WHO
prescribing indicators among in-patients in a tertiary
health care setting with a view to attain a rational and safer
pharmacotherapy.
Methods
Study location: The University of Benin Teaching Hospital, Benin
City, located in Southern Nigeria on longitude 5.6145⁰E and latitude
6.3176⁰N. It is a Federal government owned tertiary health care
institution with 620 bed spaces including an 84-bed space medical
wards.
Inclusion criteria:
All consecutive patients admitted to the medical wards.
Exclusion criteria:
1. Patients that were wrongly diagnosed with medical illness and
initially admitted into medical wards.
2. Patients referred from other wards after initial management for
non-medical reasons.
3. Patients who could not or who declined to give consent.
Methods
Conduct:
The study is a descriptive prospective study. Information concerning
all admitted patients were entered into a data collection form, modified
from the WHO prescribing indicator form.
Patients were evaluated on days 0 (admission day), 1, 3, 7, 10, 14, 21
and weekly thereafter till discharge and at discharge or death. Sociodemographic parameters including age, sex, religion, occupation
amongst others were recorded at admission.
Records were made of all medicines prescribed during admission,
including dates, route, doses and frequency of administration. The
hospital’s Essential Medicines List which was largely derived from the
WHO Essential Medicines List was used to assess medicines
prescribed.
Patients’ morbidities were recorded at admission (initial diagnoses) and
at discharge (final diagnoses). The final diagnoses were used in the
evaluation of morbidity patterns and classified using the ICD-10
classification of diseases.
Data was entered for statistical analyses using SPSS version 13.
Results
Total number of patients evaluated = 507
Number of males
= 269 (53.1%)
Number of females
= 238 (46.9%)
Table 1: Age and duration of hospital stay (in days) of medical
patients admitted into UBTH Benin City
Age (years)
Duration of hosp. stay
All patients
Mean ± SD
48.9±17.8
Males
Females
48.3±17.9
49.5±17.7
45
46
All patients
11.9±11.3
9
Males
Females
10.9±10.2
12.9±12.3
7
10
median
46
Results
Table 2: Morbidity pattern of medical patients admitted in UBTH Benin City
using the ICD-10 classification
S/N ICD-10
classification
1 A00 – B99
2 I00 – I99
3 N00 – N99
4 G00 – G99
5 E00 – E90
6 K00 – K93
7 T36 – T50
Title
Number of
patients (%)
290 (57.2)
125 (24.7)
117 (23.1)
105 (20.7)
92 (18.1)
58 (11.4)
52 (10.3)
8 J00 – J99
9 D50 – D89
10 M00 – M99
Certain infectious and parasitic diseases
Diseases of the circulatory system
Diseases of the genitourinary system
Diseases of the nervous system
Endocrine, nutritional and metabolic diseases
Diseases of the digestive system
Drugs, medicaments and biological substances
poisoning
Diseases of the respiratory system
38 (7.5)
Disease of blood and blood forming organs
12 (2.4)
Musculoskeletal system and connective tissue disease 6 (1.2)
11 X20 – X29
Contact with venomous animals and plants
4 (0.8)
Results
Table 3: Most frequent disease entities (top 10) diagnosed among patients
admitted in UBTH Benin City
S/N
Morbidity
(%)
1.
2.
3.
4.
5.
Malaria
HIV/AIDS
Diabetes mellitus
Hypertension
Chronic renal failure
18.9
17.2
17.0
16.8
13.8
6.
Cerebrovascular accident
12.4
7.
Adverse drug reaction
10.1
8.
9.
10.
Tuberculosis
Heart Failure
Sepsis
9.7
7.9
5.3
Results
Table 4: Major classes of medicines used for medical in-patients in UBTH
using the anatomic therapeutic chemical classification
S/
N
1
2
3
4
5
6
7
8
9
10
11
ATC main group
Alimentary tract and metabolism
Blood and blood forming organs
Cardiovascular system
Antiinfectives for systemic use
Nervous system
Antiparasitic products
Musculoskeletal system
Systemic hormonal preparation
Dermatologicals
Respiratory system
Antineoplastic and immunomodulating agents
12 General nutrients
TOTAL
Frequency
1167
914
878
868
343
182
55
52
49
37
4
% of all
prescriptions
25.6
20.1
19.3
19.1
7.5
4.0
1.2
1.1
1.1
0.8
0.08
2
4551
0.04
100
Results
Table 5: Observed values for WHO indicators for medical in-patients
in UBTH Benin City
INDICATOR
Average no of medicines per
admission
% of medicines prescribed by generic
name
% of drugs prescribed from essential
medicines list
% of admissions with injections
prescribed
% of admissions with antimicrobials
prescribed
% of admissions with antimalarials
prescribed
VALUE
9.1 ±3.8 (median=8)
Females:9.5±3.7(median=9)
Males : 8.7±3.8 (median=8)
85.6%
88.1%
89.3%
61.9%
18.9%
Results
90
80
70
60
50
40
30
20
10
0
% pts on
antimicrobials
% pts on
injections
1 5 9 13 17 21 25 29
admission day
average number of drugs
percentage of patients
Figure 1: WHO indicators for specific evaluated days of in-patient
stay in the medical wards in UBTH Benin City
9
8
7
6
5
4
3
2
1
0
avr. no of
drugs
1 5 9 13 17 21 25 29
admission day
Conclusions/Implications
The most frequent medicines used were mainly in the ATC classes
‘Alimentary tract and metabolism’ and ‘Blood and blood forming
organs’, classes that include haematinics and antiemetics. Use of
analgesics was also prevalent, all suggesting that symptomatic
treatment is widely prevalent.
When compared with the WHO recommended values, modest values
were obtained for medicines prescribed in generic names (85.6%) and
those prescribed from Essential Medicines List (88.1%).
Admissions with injections and antimicrobials prescribed were 89.3%
and 61.9% respectively. These high values may suggest an overuse of
injections and perhaps antimicrobials. However, no reference values
exist for in-patient care for comparisons. While there is need to
develop such values, the impact of an interventional programme will
be most revealing.
In all, the WHO prescribing indicators with modifications, used in
this study have highlighted areas for further research.