|Year : 2021 | Volume
| Issue : 3 | Page : 210-215
Evaluation of pediatric prescriptions using WHO indicators in a tertiary care hospital in Pune city, India
Alitta Prasad, Apoorv Johar, Prasanna R Deshpande
Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth Deemed University, Pune, Maharashtra, India
|Date of Submission||30-Apr-2021|
|Date of Acceptance||31-May-2021|
|Date of Web Publication||03-Sep-2021|
Dr. Prasanna R Deshpande
Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth Deemed University, Pune, Maharashtra.
Source of Support: None, Conflict of Interest: None
Context: The study provides comprehensive insight on the use of World Health Organization (WHO) prescribing indicators in the pediatric population in a tertiary care hospital. Aims: The aim was to evaluate pediatric prescriptions as per WHO prescribing indicators. Settings and Design: This study was a prospective observational study, conducted at Pediatrics Outpatient Department (OPD) of a tertiary care hospital for 6 months. Materials and Methods: This included consent form and data collection form. Statistical Analysis: Spearman’s rank correlation and Mann–Whitney U-test were performed to evaluate whether prescribing indicators are statistically dependent on age and gender, respectively. P-values less than 0.05 were considered to be statistically significant. Results: A total of 418 prescriptions were included in the study. The majority of the patients were female (70.09%). The mean age of the patients was 5.87 (SD±4.32) years, with a range from 3 days to 17 years. The average number of drugs per prescription was 2.4 (SD±1.022). Only 4.21% of medicines were prescribed by generic name. Antibiotics and injections were prescribed in 7.65% and 0.23% of prescriptions, respectively. Drugs prescribed from the essential drug list (EDL) were 60.45%. Conclusion: The study necessitates the need to follow the optimal values set by WHO prescribing indicators. The percentage of prescriptions with antibiotics and injections was in the optimal range as set by WHO. However, the average number of drugs/prescriptions, usage of generic names, and prescriptions using the EDL were not in the optimal range. The prescribing indicator did not statistically depend on age and gender.
Keywords: Pediatrics, prescription, WHO indicators
|How to cite this article:|
Prasad A, Johar A, Deshpande PR. Evaluation of pediatric prescriptions using WHO indicators in a tertiary care hospital in Pune city, India. MGM J Med Sci 2021;8:210-5
|How to cite this URL:|
Prasad A, Johar A, Deshpande PR. Evaluation of pediatric prescriptions using WHO indicators in a tertiary care hospital in Pune city, India. MGM J Med Sci [serial online] 2021 [cited 2021 Dec 2];8:210-5. Available from: http://www.mgmjms.com/text.asp?2021/8/3/210/325533
| Key Messages:|| |
The majority of the prescriptions did not comply with WHO prescribing indicators in our study. Therefore, more studies are recommended in this area.
| Introduction|| |
Children get affected by a wider variety of diseases when compared with adults. This can be due to various factors including poor development of the immune system but most importantly, unlike adults, they are both unaware of risks and unable to make choices to protect their health. This population group is most vulnerable to communicable diseases such as cough and common cold as well as other severe medical conditions. Furthermore, pediatrics differs from adult medicine in several areas, the most notable of which is the dose differential. Body surface area, fat content, total body water, and other factors all contribute to dosage differences, making it difficult to determine the optimum dosage. To ensure the safe and judicious use of drugs in children, a regular audit by trained experts with rational and judicious prescribing practices necessary will help toward standardizing pediatric therapeutic interventions while promoting a better and safe future for children. So, monitoring of prescriptions is necessary with the main focus on the rational use of drugs in this populace. Hence, the prescribing of medicine is an integral part of the provision of health and represents a relatively safe and effective way for quality patient care. To ensure effectiveness in prescribing, the World Health Organization (WHO) in collaboration with the International Network for Rational Use of Drugs (INRUD) has developed a set of indicators to measure the performance of healthcare facilities related to the utilization of drugs.
The following are the basic drug use indicators developed by WHO: (a) an 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, and (e) percentage of drugs prescribed from the essential drug list (EDL).
| Materials and methods|| |
The study population includes children attending pediatric OPD of the hospital.
This study is a prospective observational study.
This study was conducted for 6 months (September 2019–February 2020).
The inclusion criterion is patients ≤18 years from OPD of any medical illness, and the exclusion criteria are medico-legal cases and referred prescriptions.
The sampling method used was convenience sampling.
The Mann–Whitney U-test was performed to analyze whether gender affects the five prescribing indicators (the result is not significant at P < 0.05).
The Spearman rank correlation coefficient was performed to analyze whether age affects the five prescribing indicators (the result is not significant at P < 0.05).
Ethical approval was obtained for the study from the Ethics Committee of the hospital (Approval Number: REF: BVDUMC/IEC/107E), dated September 18, 2019.
| Results|| |
A total of 450 prescriptions were collected. Age, gender, and diagnosis were the three parameters targeted for evaluating prescriptions. Complete data were available only in 418 prescriptions; therefore, the remaining prescriptions (32) were not evaluated. According to the Raosoft calculator, the margin of error for 418 prescriptions was 4.74%. Among 418 patients, 293 (70.09%) patients were female and 125 (29.90%) patients were male. The mean age of the patients was 5.87 (SD±4.32) years, with a range from 3 days to 17 years.
According to the current study, common prevalent conditions in children were infectious diseases (24.40%), which included fever, dengue, cough, etc., followed by respiratory disorders (22.96%), which included asthma, chronic obstructive pulmonary disease, bronchitis, etc., and neurological disorders (19.13%), which included epilepsy. The other conditions were gastrointestinal (9.09%) which included nausea, vomiting, constipation, diarrhea, etc.; hematological (5.02%) which included anemia; hormonal imbalance (3.82%) which included global development delay, autism, acute deficit hyperactive disorder, etc.; skin-related (3.34%) which included itching, skin rash, diaper rash, insect bite, etc.; nephron-related (2.15%) which included nephrotic syndrome, nephritis, etc.; musculoskeletal (1.19%) which included rickets, arthralgia, etc.; autoimmune disorder such as Guillain–Barré syndrome (0.95%); hepatic and cardiac-related disorders constitute 0.23% each; eye-related which included conjunctivitis and ear-related which included otitis media (1.67%); endocrine-related (0.47%); follow-up prescriptions included follow-up for systemic lupus erythematosus and regular follow-up (2.15%); and other conditions (3.58%) which included normal child, well-child, short stature, etc. [Table 1].
The most common dosage form prescribed was syrup (56.82%), followed by tablets (25.22%), drops (6.86%), granules (4.71%), inhalers (1.66%), spray (1.07%), cream (0.39%), ointments (0.58%), suspension (0.88%), capsules (0.78%), lotion (0.68%), suppositories (0.19%), and injection (0.09%) [Figure 1].
A total of 1019 drugs were prescribed in 418 prescriptions. The number of drugs per encounter ranged from one to seven [Figure 2].
Among the prescribing indicators, we found that the average number of drugs per prescription was 2.43 (SD±1.022887). Only 43 (4.21%) drugs were prescribed by generic name. Antibiotics and injections were prescribed in 32 (7.65%) and 1 (0.23%) prescriptions, respectively. Drugs that were prescribed from the EDL were only 616 (60.45%) drugs [Table 2].
Statistical analysis was performed to obtain P-values. Spearman’s rank correlation coefficient and the Mann–Whitney U-test were performed to obtain P-value and to check whether age and gender, respectively, are statistically dependent on WHO prescribing indicators. The P-values are mentioned in [Table 3].
| Discussion|| |
Our study provides a current scenario of the WHO prescribing indicators in the pediatric population in a tertiary care hospital. The mean age of the patients in our study was 5.87 years. In a similar study conducted by Jose and Devassykutty, the mean age was 6.1. Pise et al. had more patients from the age group >1 month to ≤ 1 year. Thiruthopu et al. had more patients in the age group 14–18 years, and Cole et al. had 1–2 years dominated.
The present study had female predominance (70.09%) which was similar to the study conducted by Pise et al. (56%). In contrast, male predominance was observed in Bansal et al. (68.3%), Jose and Devassykutty (55%), Sharma and Shweta (56.7%), and Nduka et al. (54.0%).
Infectious diseases dominated our study (25.75%). The same was observed in a study conducted by Nduka et al. (45%) and Cole et al. (41%). Respiratory infections were dominant in studies conducted by Bansal et al. (36.6%) and Sharma and Shweta (20.7%). Hussain et al. had gastrointestinal diseases dominant (26.38%). The syrup was the commonly prescribed dosage form in our study (56.82%). The same was observed in studies conducted by Bansal et al. (60.6%), Jose and Devassykutty (62.73%), and Sharma and Shweta (34.8%). Pise et al. calculated all the oral forms together, which include syrups, tablets, drops, etc., and reported 74%, which was the most commonly used dosage form in their study as well. The other authors did not provide percentages for the common dosage form in their studies.
By assessing each of the indicators, it has been found that the average number of drugs per prescription was 2.43. The optimal value set by WHO is less than 2. The study conducted by Sharma and Shweta (1.9 drugs) and Desalegn (1.9 drugs) fulfilled the criteria. In contrast, the criteria were not met in the studies conducted by Bansal et al. (2.15), Hussain et al. (2.9), Jose and Devassykutty (2.29), Pandey et al. (2.5), Berha and Seyoum (2.84), Irunde et al. (2.3), Pise et al. (3.4), Cole et al. (3.77), and Thiruthopu et al. (4.56). Few reasons for which the number of drugs per prescription should be as low as possible are because as the number of drugs increases, the chances of adverse drug interactions will also increase, then leading to adverse effects which in turn increase the hospital charges., There are chances when the number of drug increases, pediatric patients refuse to take all medicines together.
As per WHO standards, ideally, all the drugs should be prescribed by generic name and should be selected from the EDL. However, in our study, only 4.21% of the drugs were prescribed using generic names. This could be mainly because brand names are easier to recall, easily available, frequent visits by particular pharmaceutical representatives, etc. A lower value, in comparison to the WHO value, was observed in Bansal et al. (2.4%), Hussain et al. (10.05%), Pandey et al. (7.4%), Thiruthopu et al. (19.16%), Pise et al. (50.4%), Sharma and Shweta (60.2%), Nduka et al. (62.3%), and Cole et al. (71.0%). One of the reasons for poor prescribing by generic name is the non-availability of pediatric formulations in the hospital pharmacy., A 100% generic prescribing was not observed in any studies. However, much closer values were observed in studies conducted by Jose and Devassykutty (98.4%), Desalegn (98.7%), Irunde et al. (95.7%), and Berha and Seyoum (97.9%).
The drugs prescribed using EDL [WHO Model List of Essential Medicines for Children 5th List (April 2015)] in our study were only 60.45%. This could be due to a lack of availability of EDL to the prescriber. There were other similar studies conducted by Pandey et al. (38.9%), Hussain et al. (22.57%), and Thiruthopu et al. (49.78%), in which the rate of prescribing using EDL was comparatively very less. The use of essential drugs offers many advantages including cost, safety, and effectiveness. Therefore, the practice of prescribing from the essential medicine list has to be improved. A good rate was observed in studies conducted by Jose and Devassykutty (98.44%%), Bansal et al. (96.5%), Berha and Seyoum (99.3%), Desalegn (96.6%), Irunde et al. (96.7%), and El Mahalli (99.2%). Most of the authors have referred to the different editions of the WHO Model List of Essential Medicines for Children. For example, Pandey et al. referred 1st List 2007, Sharma and Shweta referred 4th List 2013, etc.
Antibiotics were prescribed only in 7.65% of the prescriptions in our study, which were mostly for upper respiratory tract infections. According to the WHO, the value should be less than 30%. Reduction in antibiotic prescribing is a very good step to prevent overuse and therefore prevent antibiotic resistance. It also reduces the cost of treatment. The study by Berha and Seyoum (6.6%), Bansal et al. (18.8%), Hussain et al. (19.70%), and Sharma and Shweta (25.3%) also had a lesser rate. However, higher antibiotic prescribing was seen in studies conducted by Thiruthopu et al. (33.33%), Pandey et al. (79%), Nduka et al. (72.3%), Jose and Devassykutty (73.18%), Pise et al. (60.6%), Cole et al. (74.8%), Desalegn (58%), and Irunde et al. (67.7%). As antibiotics are most commonly involved in adverse drug reactions,, initiatives such as spreading awareness and strict adherence to antibiotic policies have to be taken to curb antibiotic use.Adverse reactions due to antibiotics are often observed in patients due to hypersensitivity reactions.
The injection was prescribed only in one (0.23%) patient, which was leuprolide acetate for precocious puberty. Desalegn in his study mentioned that unhygienic use of injections can increase the risk of transmission of potentially serious pathogens, such as hepatitis, HIV/AIDS, and blood-borne diseases. The optimal value set by WHO is less than 20%. Studies conducted by Irunde et al. (0.23%), Jose and Devassykutty (0.006%), Bansal et al. (0.9%), Hussain et al. (2.20%), Pandey et al. (1.6%), Pise et al. (0.8%), Sharma and Shweta (4.1%), Berha and Seyoum (8.4%), El Mahalli (2.0%), etc. also had a low rate of injection use when compared with the optimal value. However, studies conducted by Thiruthopu et al. (21.80%), Cole et al. (21.1%), Nduka et al. (25.3%), and Desalegn (38.1%) had a higher rate of injections prescribed.
Based on the P-values obtained after using the Mann–Whitney U-test (gender versus prescribing indicators), we concluded that gender does not statistically influence the five prescribing indicators. The P-values obtained for each of the indicators are mentioned in [Table 3]. Based on the P-values obtained after using Spearman’s rank correlation test (age versus prescribing indicators), we concluded that there is no significant positive correlation between age and the prescribing indicators. The P-values obtained for each of the indicators are mentioned in [Table 3].
The study had few limitations as it was conducted in the outpatient department of a single hospital and was carried out only for a short duration of time with limited sample size. Furthermore, the pediatric population usually depicts the variation in diseases with season change in India. The WHO prescribing indicators are used to record the data that are prescribed to the patients but do not accomplish the assertion behind prescribing. The study did not conduct an extensive analysis of the correlation between the prescribed medicines and the medical condition of the patients. The rationality and accuracy of diagnosis or adequacy of drug choices could not be determined.
| Conclusion|| |
Our study provides a current scenario of the WHO prescribing indicators in the pediatric population in a tertiary care hospital. The average number of drugs per prescription (2.43) was slightly higher than the optimal range set by the WHO. The percentage of drugs prescribed by generic names (4.21%) and from the EDL (60.45%) has to be improved. The percentage of prescriptions with antibiotics (7.65%) and injections (0.23%) was in the optimal range as set by the WHO. In our study, age and gender did not statistically depend on the prescribing indicators.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethical approval has been obtained for the study from the Ethics Committee of the hospital (approval number: REF: BVDUMC/IEC/107E), dated September 18, 2019.
| References|| |
World Health Organization. How to Investigate Drug Use in Health Facilities: Selected Drug Use Indicators. Geneva: WHO; 1993. Available from: http://apps.who.int/medicinedocs/en/d/Js2289e/ [last accessed May 10, 2021].
Raosoft I. Raosoft sample size calculator. Available from: http://www.raosoft.com/samplesize.html [last accessed April 18, 2020].
Jose J, Devassykutty D. Paediatric prescription analysis in a primary health care institution. J Clin Diagn Res 2016;10:FC05-8.
Pise HN, Padwal SL, Jadhav RR, Deshmukh VS, Jadhav AD, Kolhe AM. Drug prescribing and dispensing pattern in pediatrics outpatient clinic of a rural tertiary-care teaching hospital. Natl J Physiol Pharm Pharmacol 2015;5:313-7.
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;5:178-83.
] [Full text]
Cole CP, James PB, Kargbo AT. An evaluation of the prescribing patterns for under-five patients at a tertiary paediatric hospital in Sierra Leone. J Basic Clin Pharm 2015;6:109-14.
Bansal A, Jain C, Advani U, Sharma N, Kakkar S, Sharma L, et al
. Current scenario of common diseases and their management using who drug use indicators in paediatric outdoor patients in Jaipur. World J Pharm Res 2017;6:929-35.
Sharma A, Shweta O. Assessment of drug prescription pattern in children: A descriptive study. Natl J Physiol Pharm Pharmacol 2016;6:74-80.
Nduka SO, Edebeatu C, Isidienu CP, Amorha KC. Prescribing practices for pediatric out-patients: A case study of two teaching hospitals in Nigeria. Trop J Pharm Res 2017;16:705-11.
Hussain S, Yadav SS, Sawlani KK, Khattri S. Assessment of drug prescribing pattern using World Health Organization indicators in a tertiary care teaching hospital. Indian J Public Health 2018;62:156-8.
] [Full text]
Desalegn AA. Assessment of drug use pattern using WHO prescribing indicators at Hawassa University teaching and referral hospital, south Ethiopia: A cross-sectional study. BMC Health Serv Res 2013;13:170.
Pandey AA, Thakre SB, Bhatkule PR. Prescription analysis of pediatric outpatient practice in Nagpur city. Indian J Community Med 2010;35:70-3.
] [Full text]
Berha AB, Seyoum N. Evaluation of drug prescription pattern using World Health Organization prescribing indicators in Tikuranbessa specialized hospital: A cross-sectional study. J Drug Deliv Ther 2018;8:74-80.
Irunde H, Minzi O, Moshiro C. Assessment of rational medicines prescribing in healthcare facilities in four regions of Tanzania. J Pharm Pract Community Med 2017;3:225-31.
Pramil T, Rajiv A, Gaurav G. Pattern of prescribing at a pediatric outpatient setting in Northern India. Indian J Pharm Pract 2012;5:40-4.
Nazima YM, Sagun D, Barna G. Prescribing pattern in a pediatric out-patient department in Gujarat. Bangladesh J Pharmacol 2009;4:39-42.
World Health Organization. The Use of Essential Drugs. Third Report of the WHO Expert Committee. WHO Technical Report Series, No. 770. Geneva: WHO; 1988. p. 64.
World Health Organization. WHO Model List of Essential Medicine for Children, 5th List. Geneva: WHO; 2015. Available from: http://www.who.int/medicines/publications/essentialmedicines/en/.
El Mahalli AA. WHO/INRUD drug prescribing indicators at primary health care centres in Eastern Province, Saudi Arabia. East Mediterr Health J 2012;18:1091-6.
Shamna M, Dilip C, Ajmal M, Linu Mohan P, Shinu C, Jafer CP, et al
. A prospective study on adverse drug reactions of antibiotics in a tertiary care hospital. Saudi Pharm J 2014;22:303-8.
Haggard M. Poor adherence to antibiotic prescribing guidelines in acute otitis media—Obstacles, implications, and possible solutions. Eur J Pediatr 2011;170:323-32.
Jourdan A, Sangha B, Kim E, Nawaz S, Malik V, Vij R, et al
. Antibiotic hypersensitivity and adverse reactions: Management and implications in clinical practice. Allergy Asthma Clin Immunol 2020;16:6.
Social Science Statistics: Mann–Whitney U Test Calculator. Available from: https://www.socscistatistics.com/tests/mannwhitney/default.aspx [last accessed May 10, 2021].
Ramsey Philip H.. Critical values for Spearman’s rank order correlation. J Educ Stat Fall 1989;14:245-53.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]