A Retrospective Analysis of the Drug Prescribing Pattern in the Emergency … · 2018. 12. 27. · ASIA Journal of Management (AJM) Vol 1 No 10 November 2018 A Retrospective Analysis

ASIA Journal of Management (AJM) Vol 1 No 10 November 2018

A Retrospective Analysis of the Drug Prescribing Pattern in

the Emergency Department of a Tertiary Care Hospital

Mei Ji Chong1,*

, Nurulumi Ahmad1, Hariana Haris

1, Nur Liana Md Nasir

1

1Faculty of Pharmacy, Asia Metropolitan University, Selangor, Malaysia

*Corresponding author: [email protected]

ABSTRACT

Introduction:Emergency department (ED) is characterised by concurrent treatment

of multiple patients with a variety of acute and complicated medical conditions,

which leads to complex and extensive drug use. Therefore, it represents an

important healthcare facility to conduct drug utilisation studies. This is helpful in

improving the drug prescribing practices in the emergency settings, ultimately

resulting in better patient outcomes and decreased morbidity and mortality.

Objective: This study aims to evaluate the drug prescribing pattern in ED in

Malaysia by employing the WHO/INRUD core drug prescribing indicators.

Methods: A retrospective cross-sectional study was conducted among 404 patients

attended the ED of the study hospital from 1st

January to 31st December 2017.

Medical records of the patients were selected randomly from the hospital

information system. In this study, a total of 1518 drugs were prescribed among the

patients, with an average of 3.76 ± 2.65 drugs per patient.

Results:Generic prescribing rate and antibiotic prescribing rate were found to be

72.93% and 29.21%, respectively. More than half (53.96%) of the encounters had an

injection prescribed. Majority (71.60%) of the prescribed drugs were available in the

Malaysia National Essential Medicines List. The index of rational drug prescribing

(IRDP) obtained in this study was 3.3. Most prevalent morbidities encountered in ED

were diseases of the respiratory system (21.78%), circulatory system (18.07%) and

digestive system (14.60%). This study exhibited a high utilisation of

paracetamol(9.42%), tramadol (4.94%) and metoclopramide (4.87%).

Conclusion:According to the study findings, the values of WHO core prescribing


indicators and IRDP showed deviations from the recommended standards, indicating

that irrational prescribing practices exist in the ED of the study hospital.

Polypharmacy and high usage of injectable medicines were the two major problems

identified in the ED. Irrational drug use could lead to various undesirable medical,

social and economic consequences. In view of this, there is a need for rationalising

the drug therapy in ED by using the study findings as an evidence-based guidance for

implementing appropriate interventions to achieve quality medical care for the

patients.

Keywords: Emergency department, prescribing pattern, prescribing indicator

1. INTRODUCTION

Medicines play a pivotal role in healthcare delivery and they are responsible for

protecting, maintaining and restoring health. The availability of appropriate

medicines of high quality, in sufficient quantities and at affordable prices as well

as their rational use have been the major concerns of various healthcare systems

across the world [1]

. The appropriate use of medicines represents a significant

aspect for ensuring safe and effective drug therapy outcomes. Nonetheless,

irrational use of medicines remains the leading problem in many health facilities,

especially in the developing countries due to a myriad of challenges such as

insufficient funds for drug procurement, insufficient training of prescribers,

attitudes of prescribers, and patients’ beliefs [2]

.

In fact, according to the World Health Organisation (WHO), over half of all

medicines worldwide are prescribed, dispensed, or sold inappropriately, while half

of the patients fail to take them correctly [3]

. Irrational use of medicines results in

serious consequences for patients in terms of poor health outcomes, increased

medication errors, increased adverse drug events (ADEs), increased morbidity and

mortality, accelerating rates of antimicrobial resistance, excessive wastage of

scarce recourses, and increased healthcare expenditures[2]

.

The fundamental step to reduce the irrational use of medicines is to investigate the

nature and extent of its occurrence in different healthcare settings through


appropriate and reliable methods such as drug utilisation studies. Drug utilisation

research (DUR) is a structured process which is used to describe several aspects of

drug use and drug prescribing, which include pattern, quality, determinants and

outcome of drug use [4]

. The ultimate goal of DUR is to facilitate the rational use

of drugs in populations. With an adequate knowledge of the usage patterns of

drugs, measures to improve prescribing habits can be implemented [4]

. Appropriate

use of medicines has a major contribution to the global reduction in the morbidity

and mortality, along with its subsequent medical, social and economic benefits [5]

.

In the early nineties, WHO collaborated with the International Network for

Rational Use of Drugs (INRUD) to develop a set of core drug use indicators,

which can be used to explore the prescribing patterns in developing and

transitional countries [6]

. These indicators are intended to serve as effective tools

for the policymakers and healthcare administrators to assess and monitor the

extent of rational medicine use. At the same time, they enable the comparison of

the differences in the drug use practices across facilities, districts or regions as

well as allowing the evaluation of changes over time [7]

. Prescribing practices,

patient care, and facility-specific factors represent the three main areas related to

the rational use of drugs that are assessed by using these indicators [8]

.

Emergency departments (EDs) are characterised by concurrent treatment of

multiple patients with a variety of complicated medical conditions, in which most

of them are acutely ill [9]

. Clinicians often experience difficulties in selecting,

initiating and individualizing optimal drug therapy for patients admitted to the

emergency room [10]

. Due to the need for correct and rapid diagnosis of a large

number of acute and unexpected cases of illness and injury, a high frequency of

drug prescription errors including medication errors and ADEs are encountered in

ED, which are associated with poor patient outcomes and increased cost of therapy

[1]. As a result of its complex and extensive drug use, ED represents an important

medical treatment facility to conduct drug utilisation studies [1]

. The evaluation of

drug prescribing behaviour and usage patterns in the emergency settings can

provide valuable insights into the rationality of the prescribed drug therapy [1]

.

This is likely helpful in improving the drug prescribing practices in the emergency

settings, ultimately resulting in better patient outcomes and decreased morbidity

and mortality [10]

.


Plentiful research studies have been conducted globally to determine the trends of

drug use in various healthcare facilities,with very few investigating the prescribing

trends specifically in the emergency units. Currently, there is no published

literature in Malaysia regarding the prescribing practices in ED. In view of this,

the main purpose of this study is to evaluate the drug prescribing patterns and the

rationality of drug use in the ED in Malaysia by employing the WHO/INRUD core

drug prescribing indicators.

2. METHODS

2.1. Study Design

A retrospective cross-sectional study was conducted among 404 patients attended the

ED of the study hospital from 1st January to 31

st December 2017. Medical records of

the patients were selected from the electronic hospital information system (e-HIS) by

systematic random sampling method.

Data obtained from all the patient encounters were recorded in a modified prescribing

indicator form. The WHO/INRUD core drug prescribing indicators were then

calculated based on the collected data to evaluate the level of appropriateness of the

prescriptions. These indicators included average number of drugs per encounter,

percentage of drugs prescribed by generic name, percentage of encounters with an

antibiotic prescribed, percentage of encounters with an injection prescribed and

percentage of drugs prescribed from essential drug list (EDL) or formulary. The core

prescribing indicators measure only the general prescribing tendencies at a particular

healthcare setting which is independent of the specific diagnoses. Therefore, the

collection of information on the patients’ signs and symptoms was not required during

the study [8]

.

On the other hand, the morbidity pattern and drug utilisation pattern in ED were also

analysed. The diagnoses were classified using the International Classification of

Disease, Tenth Edition (ICD-10) coding system, while the Anatomical Therapeutic

Chemical (ATC) classification was used to classify all the medications prescribed to

the patients. Malaysia National Essential Medicines List (NEML) 4th Edition, 2014

was used to access the number of medicines prescribed from the EDL/ formulary. For


the purpose of this study, intravenous fluids and blood transfusions were not

considered as prescribed medications.

2.2. Study Setting

This study was conducted in the ED of a tertiary care hospital in Selangor, Malaysia.

2.3. Study Population

Inclusion criteria: All patients attending the ED of the study hospital from 1st

January

to 31st

December 2017 irrespective of age, gender, ethnicity, and nationality with at

least one prescribed medication during their stay at ED or at discharge.

Exclusion criteria: Patients who were not prescribed with any medication during

their stay at ED or at discharge.

2.4. Ethical Consideration

Registration of National Medical Research Register (NMRR) was done before

conducting the study. An ethical approval for this study was obtained from the Medical

Research and Ethics Committee (MREC) Ministry of Health Malaysia prior to data

collection. The approval to conduct the study was obtained with the guidance of the

Clinical Research Centre (CRC) of the study hospital to conduct the study.

2.5. Data Analysis


2.5.1. Calculation of WHO/INRUD Core Drug Prescribing Indicators

The WHO core drug prescribing indicators were calculated using the methods shown

in Table 1.

Table 1: Calculation of WHO/INRUD Core Drug Prescribing Indicators[8]

No. Prescribing Indicators Calculation

1 Average number of drugs per encounter Total number of drugs prescribed/ Total number of encounters surveyed

2 Percentage of drugs prescribed by generic name

(Number of drugs prescribed by generic name/ Total number of drugs

prescribed) × 100

3 Percentage of encounters with an antibiotic prescribed

(Number of patient encounters with an antibiotic prescribed/ Total number of

encounters surveyed) × 100

4 Percentage of encounters with an injection prescribed

(Number of patient encounters with an injection prescribed/ Total number of

encounters surveyed) × 100

5 Percentage of drugs prescribed from the EDL/ formulary

(Total number of drugs prescribed from the EDL or local formulary/ Total

number of drugs prescribed) × 100

2.5.2. Outcome Measures

Further assessment of the extent of rational drug prescribing was done by employing

the Index of Rational Drug Prescribing (IRDP) [11]

. The method consists of five

indices derived from the WHO/INRUD core prescribing indicators. The optimal

values and index scores for all the indicators are given in Table 2.

For the calculation of the index of non-polypharmacy, index of rational antibiotic

prescribing and index of rational injection prescribing, the following formula was

used;

𝐈𝐧𝐝𝐞𝐱 =Optimal value

Observed value

The index of generic prescribing and index of EDL were calculated by using the

following formula;

𝐈𝐧𝐝𝐞𝐱 =Observed value

Optimal value

The total index (IRDP) which has an optimal value of 5 was then calculated by adding

up all the five component indices [12]. The closer the value is to 5, the more rational

the drug prescribing practice in the ED of the study hospital.

Microsoft Excel 2016 was used for the statistical analysis of the collected data,

generation of graphs, tables and others. Descriptive statistics were used to describe the


data. Continuous variables were expressed as mean ± standard deviation (SD)

whereas categorical variables were expressed as frequencies and percentages.

Table 2: Optimal Values and Index Scores of WHO/INRUD Core Drug Prescribing Indicators [12]

No. Prescribing Indicators Optimal Value Optimal Index Score

1 Average number of drugs per encounter 1.6-1.8 1 2 Percentage of drugs prescribed by generic name 100% 1

3 Percentage of encounters with an antibiotic prescribed 20.0%-26.8% 1

4 Percentage of encounters with an injection prescribed 13.4%-24.1% 1

5 Percentage of drugs prescribed from the EDL/ formulary 100% 1

3. RESULTS

3.1. Demographic Characteristics

Among the 404 patients included in this study, 226 (55.94%) were males and 178

(44.06%) were females, with a male: female ratio of 1.27 : 1. All the patients were

categorised into seven age groups. The average age of patients admitted was 41 ± 24

years, ranging from 1 to 92 years. Majority of the patients (19.80%) presented to ED

were elderly, belonging to the age group of 65 years and above. This is followed by

younger patients aged less than 18 years (18.81%). Table 3 shows the age and gender

distribution of the patients (n=404).

Table 3: Demographic Characteristics of Patients

M= Male; F= Female

3.2. Patients’ Outcomes

Characteristics Gender Wise

Distribution

of Frequency

Frequency

(n)

Percentage

(%)

Gender Male - 226 55.94

Female - 178 44.06

Age

Range

(Years)


Out of 404 patients, almost half of them (45.3%) were admitted to the hospital as

inpatients. 36.14% of the patients were discharged whereas 18.56% of the patients

were referred to other departments of the hospital or other health facilities for further

management. The average duration of stay of the patients in ED was 8 ± 6.73 hours.

The outcomes of patients admitted to ED are illustrated in Figure 1.

Figure1: Patients' outcomes

3.3. Morbidity Pattern

3.3.1. Morbidity Pattern, Prescribing Trend and Duration of Stay of Patients

The morbidity pattern of patients admitted to ED is demonstrated in Table 4.

According to the ICD-10 coding system, there were 16 major categories of diseases

encountered in the ED. It was found most patients were presented with diseases of the

respiratory system (21.78%), circulatory system (18.07%) and digestive system

(13.60%). Average number of drugs per patient was the highest among patients

diagnosed with diseases of the circulatory system (5.77 ± 3.86), followed by

neoplasms (4.20 ± 4.09) and diseases of the respiratory system (4.07 ± 2.09). Out of

all morbidities, diagnoses that caused significantly longer duration of stay in ED (>10

hours) were diseases of the blood and blood-forming organs and certain disorders

involving the immune mechanism (11.28 ± 6.36 hours), diseases of the circulatory

system (10.66 ± 9.41 hours), nervous system (10.32 ± 2.93 hours), and genitourinary

system (10.31 ± 7.44 hours).

Table 4: Morbidity Pattern, Prescribing Trends and Duration of Stay of Patients in ED

ICD-10 Description Frequency Percentage Average No. Average


Class of Drugs/

Encounter

Duration of Stay

in ED (Hours)

J00–J99 Diseases of the respiratory system 88 21.78 4.07 ± 2.09 8.75 ± 6.10

I00–I99 Diseases of the circulatory system 73 18.07 5.77 ± 3.86 10.66 ± 9.41

K00–K93 Diseases of the digestive system 59 14.60 3.02 ± 1.72 4.53 ± 3.61

A00–B99 Certain infectious and parasitic diseases 38 9.41 2.18 ± 1.45 7.26 ± 6.40

N00–N99 Diseases of the genitourinary system 37 9.16 3.68 ± 2.51 10.31 ± 7.44

S00–T98 Injury, poisoning and certain other

consequences of external causes

21 5.20 3.81 ± 1.81 8.39 ± 5.92

R00–R99 Symptoms, signs and abnormal clinical

and laboratory findings, not elsewhere classified

19 4.70 2.95 ± 2.12 6.32 ± 4.70

L00–L99 Diseases of the skin and subcutaneous

tissue

17 4.21 2.65 ± 1.32 5.81 ± 5.83

M00–M99 Diseases of the musculoskeletal system and connective tissue

11 2.72 2.18 ± 1.94 6.51 ± 5.50

E00–E90 Endocrine, nutritional and metabolic

diseases

10 2.48 2.80 ± 1.75 8.49 ± 4.75

G00–G99 Diseases of the nervous system 10 2.48 3.2 ± 1.75 10.32 ± 2.93

D50–D89 Diseases of the blood and blood-forming

organs and certain disorders involving the

immune mechanism

6 1.49 3.83 ± 2.32 11.28 ± 6.36

O00–O99 Pregnancy, childbirth and the puerperium 6 1.49 1.33 ± 0.52 4.35 ± 1.35

C00–D48 Neoplasms 5 1.24 4.20 ± 4.09 6.07 ± 3.93

H60–H95 Diseases of the ear and mastoid process 3 0.74 1.67 ± 1.15 2.51 ± 1.08

F00–F99 Mental and behavioural disorders 1 0.25 2 6.75

Total 404 100 3.76 ± 2.65 8 ± 6.73

3.3.2. Ten Most Frequently Encountered Diagnoses in ED and Their Prescribing

Trends

Table 5 presents the ten most frequently encountered diagnoses in ED along with the

top three drugs prescribed for each of these diagnoses. Asthma (6.93%), pneumonia

(6.44%) and dengue fever (6.19%) were among the most prevalent diagnoses in ED.

Table 5: Ten Most Frequently Encountered Diagnoses in ED and Their Prescribing Trends

No. Diagnosis Frequency Percentage Most Commonly Prescribed Drugs (Percentage of Drug

Prescription)

1 Asthma 28 6.93 Salbutamol (26.71%), Ipratropium bromide (13.70%), Hydrocortisone (11.64 %)

2 Pneumonia 26 6.44 Salbutamol (15.05%), Amoxicillin/clavulanate (13.98%), Paracetamol (10.75%)

3 Dengue fever 25 6.19 Paracetamol (41.86%), Oral rehydration salts (23.26%), Metoclopramide (11.63%)

4 Ischemic heart disease 24 5.94 Aspirin (18.09%), Clopidogrel (12.77%), Glyceryltrinitrate (6.38%)

5 Gastritis 17 4.21 Magnesium trisilicate mixture (23.81%), Ranitidine (23.81%), Metoclopramide (19.05%)

6 Injuries 15 3.71 Tramadol (24.14%), Paracetamol (17.24%), Metoclopramide (12.07%)

7 Stroke 12 2.97 Aspirin (18.00%), Simvastatin (18.00%), Ranitidine (10.00%)

8 Acute heart failure 12 2.97 Frusemide (25.93%), Aspirin (7.41%), Bisoprololfumarate (7.41%), Clopidogrel (7.41%)

9 Acute tonsillitis 10 2.48 Paracetamol (45.45%), Amoxicillin/clavulanate (18.18%), Amoxicillin trihydrate (18.18%)

10 Urinary tract infection 9 2.23 Cephalexin (25.00 %), Paracetamol (17.86%), Ural sachet (17.86%)

11 Others 226 55.94

Total 404 100

3.4. Drug Prescribing Pattern


3.4.1. Distribution of Drugs among the Patients Presented to ED

The distribution of drugs among the patients presented to ED is depicted in Figure 2.

Most of the patients (n=251, 62.13%) were prescribed with more than two drugs.

Figure2: Distribution of drugs among the patients presented to ED

3.4.2. Consumption of Drugs and Average Duration of Stay in ED by Different

Age Groups

Table 6 compares the average number of drugs per encounter and average duration of

stay in ED between the patients of different age groups. Among the seven age groups,

patients who were less than 18 years old had been prescribed with the lowest number

of drugs per encounter (2.59 ± 1.40) and their average duration of stay in ED (6.17 ±

5.11 hours) was the shortest as compared to other patients. In contrast, average

number of drugs prescribed to the older patients aged 45 years and above (4.49 ±

3.05) was higher than that of the younger patients. Besides, the patients within this

age range spent longer time in the ED (9.29 ± 7.64 hours) before being admitted as

inpatients or discharged.

Table 6: Consumption of Drugs and Average Duration of Stay in ED by Different Age Groups

3.4.3. Routes of Drug Administration

Age

(Years)

No. of

Patients

Percentage of

Patients

Average No. of

Drugs/ Encounter

Total No. of

Drugs Prescribed

Percentage of

Drugs Prescribed

Average Duration of

Stay in ED (Hours)


There were five main routes of administration for the prescribed drugs as presented in

Table 7. Out of 1518 drugs prescribed, majority of the drugs were administered

enterally (55.80%) and parenterally (32.87%).

Table 7: Routes of Drug Administration

Routes Subclass Frequency Percentage Total Frequency Total Percentage

Enteral Oral Solid 709 46.71 847 55.80

Liquid 120 7.91

Sublingual (SL) 18 1.19

Parenteral Intravenous (IV) 423 27.87 499 32.87

Intramuscular (IM) 14 0.92

Subcutaneous (SC) 62 4.08

Inhalation - 119 7.84 119 7.84

Topical - 33 2.17 33 2.17

Rectal - 20 1.32 20 1.32

3.4.4. Drug Classes and Prescribing Frequency

Table 8 summarises the major classes of drugs prescribed to the patients and their

relative frequency and percentage of prescription. The ATC classification was used to

divide all drugs into 14 main groups based on the organ or system on which they act.

Generally, drugs from the alimentary tract and metabolism class (23.32%) accounted

for the largest proportion of all the prescribed drugs, followed by drugs acting on the

nervous system (17.59%) and cardiovascular system (15.09%).

Table 8: Drug Classes and Prescribing Frequency

ATC Class ATC

Code

Frequency

of Class

Prescription

Percentage

of Class

Prescription

Most Frequently Prescribed Subclass

(Percentage of Subclass Prescription)

Alimentary tract and metabolism A 354 23.32 Drugs for acid related disorders (38.98%), Propulsives (20.90%), Antidiabetics

(12.15%)

Nervous system N 267 17.59 Analgesics (87.64%), Antiepileptics (4.49%), Anxiolytics (4.12%)

Cardiovascular system C 229 15.09 Diuretics (24.89%), Lipid modifying

agents (16.16%), Vasodilators used in

cardiac diseases (12.23%)

Blood and blood forming organs B 179 11.79 Antithrombotic agents (78.77%),

Antianemic preparations (11.73%),

Antihemorrhagics (6.15%)

Antiinfectives for systemic use J 168 11.07 Antibacterials for systemic use (94.05%),

Vaccines (3.57%), Antivirals for systemic

use (1.79%)

Respiratory system R 167 11.00 Drugs for obstructive airway diseases (78.44%), Antihistamines for systemic use

(16.77%), Mucolytics (4.79%)

Systemic hormonal preparations, excluding sex hormones and

insulins

H 76 5.01 Corticosteroids for systemic use (96.05 %)

Musculo-skeletal system M 47 3.10 Anti-inflammatory and antirheumatic

products (53.19%)

Dermatologicals D 14 0.92 Antipruritics (35.71%)


Various V 8 0.53 Drugs for treatment of hyperkalemia and

hyperphosphatemia (87.50%)

Sensory organs S 4 0.26 Ophthalmologicals (100%)

Genitourinary system and sex

hormones

G 2 0.13 Progestogens (100%)

Antiparasitic products,

insecticides and repellents

P 2 0.13 Antiprotozoals (100%)

Antineoplastic and

immunomodulating agents

L 1 0.07 Immunosuppressants (100%)

Total 1518 100

3.4.5. Top Ten Drugs Prescribed

Table 9 shows the top ten drugs prescribed in ED. This study demonstrates a high

utilisation of paracetamol (9.42%), followed by tramadol (4.94%), metoclopramide

(4.87%) and salbutamol (4.61%) in the ED.

Table 9: Top Ten Drugs Prescribed

No. Name of Drug ATC Code Frequency of Drug

Prescription

Percentage of Drug

Prescription

1 Paracetamol N02BE01 143 9.42 2 Tramadol N02AX02 75 4.94 3 Metoclopramide A03FA01 74 4.87 4 Salbutamol R03AC02 70 4.61 5 Aspirin B01AC06 62 4.08 6 Ranitidine A02BA02 61 4.02 7 Frusemide C03CA01 53 3.49 8 Amoxicillin/clavulanate J01CR02 36 2.37 9 Prednisolone H02AB06 36 2.37 10 Clopidogrel B01AC04 35 2.31 11 Others 873 57.51

Total 1518 100.00

3.4.6. Antibiotic Prescribing Pattern

Figure 3 outlines the prescribing pattern of antibiotics in ED. A total of 118 (29.21%)

patients admitted to the ED had at least one antibiotic prescribed. Out of 1518 drugs

prescribed, 159 (10.47%) were antibiotics. Some of the most frequently prescribed

antibiotics were amoxicillin/clavulanate (n=36, 22.64%), cefuroxime (n=23, 14.47%)

and cloxacillin (n=19,

11.95%). Most of the

antibiotics prescribed were

from the penicillin and

cephalosporin classes.


Figure3: Commonly prescribed antibiotics

3.4.7. Injection Prescribing Pattern

Figure 4 illustrates the prescribing pattern of injectable medicines in ED. Injections

were prescribed in over half (n=218, 53.96%) of the patients. 26.88% (n=408) of the

total number of drugs prescribed were in the injectable forms. Metoclopramide (n=47,

11.52%), tramadol (n=40, 9.8%) and ranitidine (n=40, 9.8%) were among the most

commonly prescribed injectable preparations in ED.

Figure 4: Commonly prescribed injections


3.5. WHO/INRUD Core Drug Prescribing Indicators

The core prescribing indicators were calculated according to WHO specifications.

Table 10 presents the results of the five prescribing indicators obtained in the ED in

this study, along with their respective optimal levels suggested by WHO.

Table 10: WHO/INRUD Core Drug Prescribing Indicators

No. Prescribing indicators Frequency Obtained Value WHO Optimal Value

1 Average number of drugs per encounter 1518 3.76 ± 2.65 1.6-1.8 2 Percentage of drugs prescribed by

generic name

1107 72.93 100%

3 Percentage of encounters with an antibiotic prescribed

118 29.21 20.0%-26.8%

4 Percentage of encounters with an injection prescribed

218 53.96 13.4%-24.1%

5 Percentage of drugs prescribed from the Malaysia NEML

1087 71.60 100%

3.6. Index of Rational Drug Prescribing (IRDP)

IRDP indicates the extent to which the prescribing practices meet the optimal level of

rational drug prescribing. The calculated indices of rational drug prescribing obtained

in the current study is shown in Table 11.

Table 11: Index of Rational Drug Prescribing (IRDP)

3.7. Comparison of the WHO/INRUD Core Drug Prescribing Indicators and

IRDP of the Current Study with Other Similar Studies

Table 12 compares the values of the WHO core prescribing indicators of this study

with the findings reported by other studies conducted in India and Arab. On the other

hand, Table 13 demonstrates the comparison of the calculated indices of rational drug

prescribing obtained in the current study with that reported by other studies. The EDs

in all these studies were ranked according to their respective IRDP, which enables the

rational drug use in all the EDs to be compared comprehensively.

Table 12: Comparison of the WHO/INRUD Core Drug Prescribing Indicators between the Current Study and Other

Studies

No. Index Obtained Value Optimal Index

1 Non-polypharmacy index 0.48 1 2 Generic prescribing index 0.73 1 3 Rational antibiotic prescribing index 0.92 1 4 Rational injection prescribing index 0.45 1 5 Essential drugs list index 0.72 1

IRDP 3.3 5


Studies on

Drug

Utilisation

Pattern in ED

Countries WHO Core Prescribing Indicators Average

Duration

of Stay in

ED

Average

number of

drugs per encounter

Percentage

of drugs

prescribed by generic

names

Percentage

of

encounters with an

antibiotic

prescribed

Percentage

of

encounters with an

injection

prescribed

Percentage

of drugs

prescribed from the

EDL/

formulary

Current Study Malaysia 3.76 ± 2.65 72.93 29.21 53.96 71.60 8 ± 6.73 hr Cheekavoluet

al., 2011 [13]

India 4.2 ± 1.2 5.00 21.78 79.96 63.45 2.8 ± 1.4 hr

Barotet al., 2013 [10]

India 9.99 ± 2.55 12 74 - 84.5 2 days

Pandey&

Khan, 2013 [5]

India 8.02 ± 1.94 18.86 93.6 97.6 52.14 3.03 ± 1.01

days Al Balushiet

al., 2014 [20]

Arab 3.16 ± 1.89 - 10 38 58 3.38 hr

Kauret al., 2014 [14]

India 4.9 29.27 14.89 75.17 64.94 2.23 ± 1.3 days

SulaimanSaite

t al., 2014 [15]

India 2.60 ± 1.41 37.63 15 67.5 16.94 -

Patidar&Pichh

oliya, 2016 [16]

India 2.4 20 23.11 67.49 92.6 -

Binuet al., 2017 [1]

India 6.4 20.9 78.84 87.88 83.88 -

Mamanthaet

al., 2017 [17]

India 6.76 41 76 100 64.8 2 days

Alkahtani,

2018 [21]

Arab 2.39 ± 0.55 - 23 33 65 2 ± 0.5 hr

WHO

Optimal

Value

1.6-1.8 1 20.0%-

26.8%

13.4%-

24.1%

1

Table 13: Comparison of the IRDP between the Current Study and Other Studies

Studies on

Drug

Utilisation

Pattern in ED

Countries Index IRDP Rank

Non-

polypharmacy index

Generic

prescribing index

Rational

antibiotic prescribing

index

Rational

injection prescribing

index

Essential

drugs list index

Current Study Malaysia 0.48 0.73 0.92 0.45 0.72 3.3 1

Cheekavoluet

al., 2011 [13]

India 0.43 0.05 1 0.3 0.63 2.41 7

Barotet al.,

2013 [10]

India 0.18 0.12 0.36 - 0.85 1.51 10

Pandey& Khan, 2013 [5]

India 0.23 0.19 0.29 0.25 0.52 1.48 11

Al Balushiet

al., 2014 [20]

Arab 0.57 - 1 0.63 0.58 2.78 4

Kauret al., 2014 [14]

India 0.37 0.29 1 0.32 0.65 2.63 5

SulaimanSaitet al., 2014 [15]

India 0.69 0.38 1 0.36 0.17 2.6 6

Patidar&Pichholiya, 2016 [16]

India 0.75 0.2 1 0.36 0.93 3.24 2

Binuet al., 2017 [1]

India 0.28 0.21 0.34 0.27 0.84 1.94 8

Mamanthaet

al., 2017 [17]

India 0.27 0.41 0.35 0.24 0.65 1.92 9

Alkahtani, 2018 [21]

Arab 0.75 - 1 0.73 0.65 3.13 3

Optimal Index 1 1 1 1 1 5

4. DISCUSSION


4.1. WHO/INRUD Core Drug Prescribing Indicators and IRDP

This study provides baseline information on the drug prescribing pattern in the ED of

the study hospital by employing the WHO/INRUD core drug prescribing indicators.

These indicators evaluate the performance of health care providers in five key aspects

related to the rational use of drugs [8]

. Therefore, the potential drug use problems that

require further improvement in the emergency care setting in Malaysia can be

identified, so that appropriate interventions can be implemented in order to optimise

the current prescribing practices.

The average duration of stay of patients in ED was 8 ± 6.73 hours, which is much

shorter as compared to the findings reported by Pandey& Khan (2013), 3.03 ± 1.01

days, Kauret al. (2014), 2.23 ± 1.3 days and Barotet al. (2013), 2 days. This indicates

a rapid and efficient management of patients admitted to ED. In spite of that, in two

studies conducted in Arab by Al Balushiet al. (2014) and Alkahtani (2018), the

patients had spent comparatively shorter time in ED, which were only 3.38 hours and

2 ± 0.5 hours, respectively. Therefore, the efficiency of working in ED and thus the

time of disposition of patients from the ED in this study can be further improved to

prevent the problem of overcrowding in ED.

Among the 404 patients, a total of 1518 drugs were prescribed. The mean number of

drugs per prescribing encounter, which reflects the standard of prescribing in ED, was

found to be 3.76 ± 2.65, with a significant percentage (62.13%) of patients prescribed

with more than 2 drugs. This value is considerably higher than the WHO

recommended standard range of 1.6-1.8 drugs per encounter, which indicates

tendency for polypharmacy in the prescribing practices. However, in the emergency

settings, most of the patients are presenting with acute life-threatening conditions or

multiple comorbidities and the diagnosis may not be confirmed at the time of initial

contact. Therefore, it is reasonable to prescribe higher number of drugs per encounter

for the effective management of acute conditions. Nevertheless, it is always advisable

to keep the mean number of drugs per prescription as low as possible, because

polypharmacy could potentially lead to higher risks of drug-drug interactions and

adverse drug reactions (ADRs) and increased cost of therapy. In comparison to the

present study, Barotet al. (2013), Pandey& Khan (2013), Mamantha,

Parashivamurthy&Suneetha (2017) and Binuet al. (2017) had reported markedly


higher incidence of polyparmacy in the EDs in India, in which the average number of

drugs per prescription were as high as 9.99 ± 2.55, 8.02 ± 1.94, 6.7 and 6.4,

respectively. This could be due to the longer duration of stay of the patients in ED as

compared to this study.

Out of all drugs prescribed, majority (72.93%) of the drugs were prescribed by

generic name. This finding portrays the highest rate of generic prescribing as

compared to the results obtained in the previous studies in India. which were

generally less than 45%[1,5,10,13-17]

. However, WHO recommended that all drugs

(100%) should be prescribed by generic name. Generic prescribing is greatly

encouraged because it is associated with lower healthcare costs as generic products

are often cheaper than their branded equivalents. Besides, prescribing generically may

also minimise the risks of medication errors during prescribing or dispensing due to

similar drug names and prevent the duplication of drug products [18]

.

In this study, the percentage of encounters with an antibiotic prescribed was 29.21%.

This is slightly higher than the ideal standard of 20.0%-26.8%. The problem of

overprescribing of antibiotics was found to be more prevalent in some of the EDs in

India, as reported by Pandey& Khan (2013), 93.6%, Binuet al. (2017), 78.84%,

Mamanthaet al. (2017), 76% and Barotet al. (2013), 74%. Acute tonsillitis, cellulitis,

pneumonia and urinary tract infections were the frequently encountered indications in

ED which were prescribed with at least one antibiotic. The major classes of antibiotics

prescribed were aminopenicillins (30.2%), second generation cephalosporins (14.5%)

and third generation cephalosporins (13.2%). Amoxicillin/clavulanate, cefuroxime

and ceftriaxone were the widely prescribed antibiotics from these classes,

respectively. The antibiotic prescribing pattern in this study was similar to that

observed in the EDs in Arab and India. For instance, according to Al Balushiet al.

(2014), Kauret al. (2014), Patidar&Pichholiya (2016) and Alkahtani (2018),

amoxicillin/clavulanate was the maximally prescribed antibiotic in ED whereas

Cheekavoluet al. (2011) and Barotet al. (2013) had revealed that a third generation

cephalosporin, namely ceftriaxone was the most frequently used antibiotic in ED.

From these findings, it can be inferred that broad-spectrum antibiotics are frequently

used for the empiric treatment of infections in the emergency set-ups before the

causative organism is known through the culture and sensitivity test.


More than half (53.96%) of the encounters had an injection prescribed. This shows

significant deviation from the WHO reference range of 13.4%-24.1%. Similarly, in

the EDs in other studies, the usage of injectable preparations was on the higher end,

which ranged from 67% to 100%[1,5,13-17]

. This indicates that parenteral administration

is preferred in the emergency management of patients due to its rapid onset of action

and high bioavailability. Furthermore, high injection prescribing rate in ED may be

attributed to patients’ conditions, such as in nauseous or unconscious cases, where

drugs cannot be administered orally. Nonetheless, excessive and indiscriminate use of

injectable medicines can increase the risk of transmitting blood borne diseases such as

hepatitis and HIV/AIDS, especially in the settings with high prevalence of infectious

diseases. In addition, the overuse of injections when oral formulations would be more

appropriate seems to be irrational because injectable preparations are often more

expensive than the oral medications. Consequently, there is a need to reduce

unnecessary injections as a way to reduce the risks associated with non-sterile

injections and to reduce healthcare costs associated with ED visits.

Drugs prescribed from the Malaysia NEML comprised 71.60% of the total number of

drugs prescribed. This finding is notably higher than that reported by other studies:

SulaimanSaitet al. (2014), 16.94%, Pandey& Khan (2013), 52.14% and Al Balushiet

al. (2014), 58%. Despite that, 100% of drugs should be prescribed from EDL or

formulary as recommended by WHO, because drugs listed in EDL or formulary have

assured safety and efficacy based on the clinical studies and are available in

affordable prices [19].

Taking all five prescribing indicators into consideration, the overall IRDP obtained in

the present study (3.3) was the highest, thus the ED in this study was ranked first

among all the 11 studies included in the comparison. As a whole, the prescribing

practices in this study are better than that observed in the EDs in India. However, both

reports from Arab had demonstrated more rational prescribing in terms of the average

number of drugs per prescription, antibiotic prescribing rate and injection prescribing

rate as compared to this study[20,21]

. Indeed, the IRDP of 3.3 was relatively lower than

the optimal value of 5, suggesting that there is still room for improvement in the drug

prescribing pattern in the ED in this study.


4.2. Morbidity Pattern and Drug Prescribing Pattern

Most prevalent categories of morbidities encountered in ED according to the ICD-10

classification were diseases of the respiratory system, constituting 21.78% of the 404

cases, followed by diseases of the circulatory system (18.07%) and digestive system

(14.60%). This is comparable to the results obtained by Pandey& Khan (2013) in a

tertiary care teaching hospital in India, in which these diseases were also found to be

the top morbidities among the patients admitted to ED. Besides, several studies on

drug utilisation pattern in ED [1,14,15,21,22]

had demonstrated similar morbidity pattern

among the admitted patients, in which respiratory system, cardiovascular system and

gastrointestinal system were among the principal organ systems involved.

In the present study, asthma (6.93%), and pneumonia (6.44%) represented the leading

diagnoses among the respiratory disorders and they were listed as the first and second

top reasons of admission to ED, respectively. Following next was dengue fever which

was diagnosed in 6.19% patients. Ischemic heart disease, comprising about 5.94% of

total encounters was the most frequently encountered circulatory system disorder and

it was ranked as the fourth most prevalent disease in ED. Besides, gastritis that

contributed to 4.21% of all cases was the most common complaint associated with the

gastrointestinal system.

Patients presented with diseases of the circulatory system had been prescribed with

the highest average number of drugs per encounter. Similarly, reports from studies

carried out by Cheekavolu et al. (2011), Barot et al. (2013) and Al Balushi et al.

(2014) had shown that the average number of drugs per prescription was the highest

in the cases of cardiovascular emergencies. Out of all morbidities, patients diagnosed

with diseases of the blood and blood-forming organs and certain disorders involving

the immune mechanism, diseases of the circulatory system, nervous system and

genitourinary system had spent significantly longer time in ED (>10 hours) as

compared to other patients. In contrast to these findings, Cheekavoluet al. (2011) had

demonstrated that traumatic disorders, respiratory disorders and cardiovascular

disorders were among the diagnoses that led to longer duration of stay in ED.

With regards to the prescribing pattern, drugs acting on the alimentary tract and

metabolism which comprised about 23.32% of all drugs prescribed were the most

frequently prescribed class of medications in ED. Examples of widely prescribed


drugs from this class were metoclopramide, ranitidine and oral rehydration salts. In

contrast, in the studies conducted in India by Barot et al. (2013), Pandey& Khan

(2013), SulaimanSait et al. (2014) and Mamantha et al. (2017), ondansetron and

pantoprazole were found to be the maximally prescribed drugs acting on the

gastrointestinal tract among the patients admitted to ED. Next, drugs classified under

the ATC classes of nervous system (17.59%) and cardiovascular system (15.09%)

represented the second and third most common groups of drugs prescribed in the ED

in this study.

This study exhibited a high utilisation of paracetamol in ED, constituting 9.42% of the

total drugs prescribed. Dengue fever, injuries and infections such as pneumonia, acute

tonsillitis and urinary tract infections were the common indications where

paracetamol was routinely being prescribed. Likewise, Al Balushi et al. (2014),

Patidar & Pichholiya (2016) and Alkahtani (2018) had reported high usage of

paracetamol in ED. Next in order were tramadol (4.94%), metoclopramide (4.87%)

and salbutamol (4.61%).

One pronounced difference in the drug prescribing trend observed in the current study

as compared to a number of studies conducted in India [16,22]

and Arab [20,[21]

was the

frequent utilisation of tramadol as analgesic in ED instead of NSAIDs, particularly

diclofenac. In terms of the prescribing pattern of antiemetics, metoclopramide was the

most common drug of choice in this study, while ondansetron was found to be the

first-line antiemetic agent prescribed in the ED according to the studies conducted in

India[1,5,10,13,15-17]

. On top of that, excessive and often inappropriate utilisation of

pantoprazole for gastrointestinal prophylaxis, which was found to be a common

irrational prescribing practice in the EDs in India[1,5,10,13,15,17]

was less frequently

encountered in the ED in this study.

5. LIMITATIONS

This study also had some limitations in addition to other limitations usually associated

with retrospective studies. Firstly, the information on the patients’ signs and

symptoms were not collected, so the adequacy of drug choices based on the patients’

underlying health problems cannot be determined. Secondly, the study was limited to

the ED of only one hospital, thus the prescribing practices in the EDs of different


hospitals cannot be compared. Besides, due to the differences in disease trends, the

results of this study cannot be generalised to other countries. Finally, the prescribing

pattern in the ED, particularly average number of drugs per encounter and injection

use rate was usually higher than that observed in other health facilities. Therefore, the

standard optimal values recommended by WHO for these prescribing indicators may

not be able to accurately assess the rationality of drug use in these areas in the ED.

6. CONCLUSION

In reference to the study findings, the values of WHO core drug prescribing indicators

and IRDP were not in accordance to the recommended standards, indicating that

irrational prescribing practices exist in the ED of the study hospital. Two priority drug

use problems identified in the ED in the present study were tendency for

polypharmacy and high usage of injectable medicines. Besides, generic prescribing,

antibiotic prescribing and prescribing from EDL were also found to be suboptimal but

to a lesser extent. These problems could potentially lead to various undesirable

medical, social and economic consequences. In view of this, there is a need for

rationalising the drug therapy in the emergency setting to ensure more cost-effective

treatment of the patients.

7. RECOMMENDATIONS

Physicians play a pivotal role in improving the prescribing practices, thus continuous

training and educational programs among the physicians are highly recommended in

order to promote rational drug prescribing in ED. These programs should focus on

encouraging the use of standard treatment guidelines, which help the prescribers to

make decisions about appropriate treatment choices for specific health problems.

Eventually, this could help to establish good prescribing habits, which lead to delivery

of better healthcare services in the ED through the safe and cost-effective use of

medicines.

A variation in the drug utilisation pattern may exist between different health facilities.

Therefore, further studies are required to compare the prescribing practices in the

emergency settings in different hospitals. Through better knowledge of the nature and

extent of irrational drug use, appropriate interventions and strategies to optimize the


use of medicines can be developed and implemented in order to achieve quality

medical care for the patients. Besides, future studies should focus on investigating the

factors contributing to the irrational prescribing practices as well as appropriate

interventions to improve the rational use of drugs in ED.

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