Prospective cross-sectional study in evaluation of prescribing pattern of doctors for oncology treatment

 

Amit Boralkar*, Prashant Bobhate and Avinash Khairnar

University Department of Interpathy Research and Technology, Maharashtra University of Health Science, Nashik (MS) 422 004

*Corresponding Author E-mail: amitpboralkar@rediffmail.com

 

ABSTRACT:

The word medical audit focuses on evaluation of health care in a health care setting. It has been frequently observed that doctors are adopting poly pharmacy, promoting unnecessary use of tonics and other drugs under the sales influence of drug companies and overlooking drug interactions. This has resulted in increased side effects, adverse drug reactions and the cost of treatment. So doctors should write every prescription with utmost care and responsibility. The primary objective of the study is to evaluate prescribing writing error and to evaluate relative use of Anti-cancer drug. Present prospective cross-sectional study is done for 3 months in a Tertiary care and Private cancer Hospitals of Nasik city in Maharashtra state.

In first visit total 100 prescriptions are collected and then compare with the 100 prescriptions obtained after giving the instructions to doctors for prescribing errors they committed and for proper prescribing practices. Statistical ‘Z’ test is used to evaluate the significance.

 

Sr no.

Parts of prescription

First audit % prior instruction

Second audit % after instruction

Significant improvement %

01

Superscription

80.92%

91.07%

10.15%

02

Inscription

62.9%

79.9%

17%

03

Subscription

9.5%

26.5%

17%

04

Transcription

79.25%

85.75%

6.5%

05

Extra points (Legibility of prescription, Follow up visit of patient)

40.83%

61.5%

20.67%

 

In the second prescription audit significant improvement was found. In both Hospital relative use of Anti-cancer drug in total 1st and 2nd 200 prescription audit was found to be Injection-Graniset 3gm47.61%, Injection-Cisplat 500MG 22.38%, Injection Paclitaxol 500MG 17.14% and Injection 5FU 500MG 12.85%.

 

KEYWORDS: prescription audit, cancer, oncology.

 

 


 

 

INTRODUCTION:

This study is to analyze, as a part of a continuous quality improvement program, the quality of prescriptions writing for Oncology department, in the Hospitals of Nasik district as a risk factor for prescription errors.

 

The Prescription is order for medication issued by a physician, dentist or other properly licensed medical practitioner (1). Also it is important transaction between the physician and the patient’. It is an order for a scientific medication for a person at a particular time.

 

It brings into focus the diagnostic acumen and therapeutic proficiency of the physician with instructions for palliation or restoration of the patient’s Health (2). Prescribing drugs is an important skill which needs to be continuously assessed and refined accordingly. It not only reflects the physician's knowledge of pharmacology and path physiology but also his/her skill in diagnosis and attitude towards selecting the most appropriate cost-effective treatment  (3) Many factors are known to adversely affect prescribing behaviour such as unethical drug promotion, direct to consumer advertising, lack of knowledge and non-availability of drugs (4) This could be countered to a great extent by drawing up an essential drugs list, preparation of treatment guidelines, conducting periodic prescription Audits and continuing medical education (5) Prescription audit is far more important than the financial audit because it deals with human beings. Financial deficiency can eventually be met but medical deficiency may cost lives and loss of health which cannot be reverse. Prescription audit therefore should become an article of faith for all concerned. Now-a-days the prescribing pattern is changing and it has become just an indication of medicine with some instructions of doses without considering its rationality. It has been frequently observed that doctors are adopting poly pharmacy, promoting unnecessary use of tonics and other drugs under the sales influence of drug companies and overlooking drug interactions(6). This has resulted in increased side effects, adverse drug reactions and the cost of treatment. However, irrational prescribing can be avoided by sticking to the ideal prescription writings, following the P-drug and P-treatment concept, and by consulting the (7) it was, therefore, thought pertinent to study the present prescribing pattern adopted by doctors working as consultants in Tertiary care and Private Sectors. The rational prescribing skills of clinicians can be assessed by conducting periodic prescription audits. In a teaching hospital as the medical teachers are the role models for the students, the prescribing behaviour of the teachers can affect the students. These audits and studies can also influence the policy makers by informing them about the quality of drug use in the health facility  There is an urgent need to ensure that patients are always given evidence-based, cost-effective and rational treatments(8). Medication orders were either handwritten by the prescriber on standard blank physician order sheets or pre-printed forms requiring partial completion and signature. Potential prescribing problems were defined as medication orders that involved the wrong patient, drug, dose, dosing frequency, route, or dosage form; an inappropriate indication for use; inappropriate combinations of drugs; documented patient allergies to ordered medications (contraindicated therapy); missing critical information; and other miscellaneous problems.

 

The importance was also based on the potential of the error, if carried out as ordered, to result in adverse consequences an increased risk of adverse effects or an inadequate therapeutic response based on drug dosage or incorrect route. The potential significance of errant orders was evaluated using a previously described rating scale (9). Seven thousand deaths have been attributed annually to medication errors.  Distractions account for a large portion of errors in all professional fields, including health care. Distortion errors are often caused by illegibility and misunderstood translations of symbols or abbreviations The Institute of Medicine’s 1999 report, To Err Is Human: Building a Safer Health System, and the 2001 follow-up report, Crossing the Quality Chasm: A New Health System for the 21st Century, have appropriately provoked interest and debate regarding the scope, severity and detrimental impact of medication errors on individual patients and health care systems. Though some have disputed the reported 7,000 deaths annually attributed to medication errors and the $37.6 billion price tag for adverse medical events, it Prescription Writing to Maximize Patient Safety These tips can help you avoid two important causes of prescription error(10).

 

Objective of the Study:

Primary:

1) To evaluate prescription writing error.

Secondary:

2) To identify relative usages of Anticancer drugs in the hospital under study.

 

Methodology:

Present prospective cross-sectional study is done for 3 months in a Tertiary care and Private Hospital in Nasik city. In first visit total 100 prescriptions are collected and then compare with the 100 prescriptions obtained after giving the instructions to doctors for prescribing errors they committed and for proper prescribing practices. Statistical ‘Z’ test is used for evaluation of significance.

 

A cross sectional study was conducted in the tertiary care hospital and Private cancer Hospitals in Nasik city Institutional Ethical Committee permission was taken before the start of the study. A informed   consent to note down the drugs prescribed to patients was taken from each patient before collecting the data. The names of the patients and prescribing doctors were kept confidential throughout the study. Prescriptions were collected and the data was recorded from new patients of either sex coming to hospital. Firstly Audit of 100 consecutive original prescriptions was used to record or copy of all those things on prescription. Prescriptions the prescription was analyzed for evaluation of writing errors and legibility concerned as per standard prescription format. Second Audit of 100 original prescriptions was carried out after the giving Verbal suggestion and instructions to respective practitioner in hospital about their error in writing and prescribing therapy of anticancer drugs. Statistical prospective cross sectional analysis by comparing both prescription audit data whether any significant difference in prescribing pattern of Anticancer drugs after awaring to the practitioner through the Verbal suggestion and instructions to respective practitioner in hospital. Following tables used as case record form for each prescription. In which each prescription has assessed for 23 elements in 5 different categories.

 

Each element has maximum 2 points and minimum 0 point. 2 points indicates- Full and adequate information. 1 point indicates- Inadequate information. 0 point indicates- No information.

 

All collected data has to be tabulated in below mentioned table.

PARTS OF PRESCRIPTION

POINTS (0/1/2)

COMMENTS

1) SUPERSCRIPTION

 

 

1.Name and Address of Doctor/ Hospital

 

 

2. Name of Patient.

 

 

3. Date

 

 

4. Sex

 

 

5 Age

 

 

6. Diagnosis(Final or Provisional )

 

 

7. Prefix Rx

 

 

Total (14)

2)INSCRIPTION

 

 

1.Basic active drugs

 

 

2. Adjuvant Drug

 

 

3. Drug used when not indicated (over- prescribing)

 

 

4. drug not used when indicated (under prescribing)

 

 

5. Dose proper

 

 

6. Route (Safety and convenience)

 

 

7. Frequency

 

 

8. Duration

 

 

9. Proper Sequence

 

 

10. Proper combination of drug

 

 

Total (20)

 

 

3) SUBSCRIPTION

 

 

1.Direction to pharmacist

 

 

Total(2)

 

 

4) TRANSCRIPTION OR SIGNA

 

 

1.Direction to the Patient

 

 

2. Prescriber Identity (Name, Reg. No., Signature)

 

 

(Total 4)

 

 

5)EXTRA POINTS

 

 

1.Legibility of prescription

 

 

2. Whether or not explained in local language

 

 

3. Follow up visit

 

 

Total(6)

 

 

 

RESULT AND DISCUSSION:

Statistical ‘Z’ Test For Calculation:-

Audit of prescription pattern for assessment of writing error and relative used  revealed that most of prescription was  did not confirm to ideal pattern of prescription writing but there were significant improvement in prescription writing  status after giving  suggestion to the respective  doctor or prescriber. Calculated Mean (1 ) for first prescription audit is 594.4 and S.D. (σ) 1 is 2430.04% and for second prescription audit Mean (2 ) is 727.6 where S.D. (σ)is 2971.22 %.The S.E. (12) is 1716.58, so by applying Z-test. For two mean calculated Z-values was 0.38798 at p=0.05 level of significance. We can say, calculated Z=0.38798<critical value Zα=1.96.

 

So, Null hypothesis (Ho: Doctor or prescriber will improve in quality of prescription writing pattern for anti-cancer drug after receiving instruction) is accepted Vs. alternative hypothesis (H1: Doctor or prescriber will not improve in quality of prescription writing pattern for anti-cancer drug after receiving instruction.)

 

Graph No.1: Effectiveness of Audit

 

The results obtained after auditing of the prescriptions indicate that majority of the prescribers do not adhere to the ideal pattern of the prescription writing and these prescriptions are not explicit in their contents. Replacement of Rx sign with the word ‘Advice’ in large number of prescriptions is indicative of changing pattern of the prescriptions.

 

Graph No.2: Relative Used Of Drug for Treatment in Cancer Hospital

 

DISCUSSION:

The results obtained after auditing of the prescriptions indicate that majority of the prescribers do not adhere to the ideal pattern of the prescription writing and these prescriptions are not explicit in their contents. Replacement of Rx sign with the word ‘Advice’ in large number of prescriptions is indicative of changing pattern of the prescriptions. The trend of the poly pharmacy may be due to the patient’s expectations and demand of quick relief, the incorrect diagnosis, and the influence of the lucrative promotional programs of the drug companies. Within the limited scope of this study, it can be concluded that a serious health hazard can be minimized by educating the erring doctors for a more rational use of drugs.

CONCLUSION:

Large numbers of prescriptions do not conform to ideal pattern and lack in their rationality there is also an increasing concern about prescribing unnecessary, inappropriate, or irrational drugs. in these circumstances it is important that we critically examine what drugs are prescribed, how much is prescribed, by whom, for what reasons, and evaluate resulting benefits or possibly ill effects. proper attention should be paid while mentioning various parameters such as dose, duration, direction to the pharmacist, legibility, explanation in language and follow up visits. this study indicates that there is scope for improving the prescribing habits of doctors in the present study by educational intervention. it is also important to form drug and therapeutic committees to formulate and standardize drug policy, conduct regular audits and to keep a check on the undue influence of high power salesmanship. also in this study there is lots of use of  injection granisetron on anticancer prescription this indicates anticancer treatment requires antiemetic drugs.

 

REFERENCES:

1.       Remington the science and practice of pharmacy, 2005;6th ed: pp. 1836-1840.

2.       Ansari KU, Singh S, and Pandey RC Evaluation of Prescribing Pattern of Doctors for Rational Drug Therapy. Indian Journal of Pharmacology.1998 vol 30, pp 43-46.

3.       Benet LZ. Principles of prescription order writing and patients compliance instructions. In: Goodman AG, Rall TW. Nies AS Taylor P, (Eds). Goodman and Gilman's The pharmacological basis of therapeutics. 8th Ed New York: Pergamon Press Inc. 1991: pp 1640.

4.       Soumerai SB, Mclarghllin TJ, Avron J. Improving drug prescribing in primary care; A critical analysis of experimental literature. The Milbank quarterly 1989:67:2.

5.       Drug prescribing pattern in a tertiary care teaching hospital in madurai (Tamilnadu) Indian Journal of Pharmacology 2001; 33: pp 223 .

6.       Patel V, Vaidya R, Naik D, Borker P. Irrational drug use in India: A prescription survey from Goa. J Postgrad Med 2005;51(1): pp 9-12.

7.       Kunin et a/ 7 and WHO guide to good prescribing.

8.       Mohanty BK Aswini M et al , Prescription pattern in Rajahmundry, Indian Journal of Clinical and Diagnostic Research 2010 feb ; (4), pp 2047-2051.

9.       Timothy S. Lesar, Pharm D; Laurie Briceland, Pharm D; Daniel S. Stein, MD ;Factor related to error in medication  prescribing. Jama January 1997-vol 277 no.4, PP 312-17.

10.     Peter G, Teichman MD, MPA, and Anne E. Caffee, Pharm D, BCPS family practice management:  a study available from: URL: http:/www.aafp.org / fpm July/August 2002 pp 27-30.

 

 

 

 

 

Received on 20.01.2011       Modified on 09.02.2011

Accepted on 28.02.2011      © RJPT All right reserved

Research J. Pharm. and Tech. 4(4): April 2011; Page 634-637