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Photo: QBOF Baqui

Prescribing pattern of graduate and non-graduate medical prescribers in rural Bangladesh

Baqui QBOF, Chowdhury SAR

 

 

Problem statement: Irrational and inappropriate prescribing were observed in both graduate (GP) and non-graduate (NGP) medical prescribers in rural Bangladesh. The extent of such irrational prescribing and underlying cause were studied.

Objectives: The prime objective of this study was to describe the prescribing patterns of both graduate medical prescribers and non graduate medical prescribers for five common diseases - watery diarrhoea, dysentery, acute respiratory infection (<5 yrs), urinary tract infection and enteric fever.

Design and setting: A cross sectional study was carried out from June 1995 to July 1996 at Sonargaon, Arihazar and Trishal Thana in rural Bangladesh. 840 prescriptions were collected, audited, and analysed using INRUD prescribing indicators from Thana Health Complexes (THCs) and private practices (PP) of GPs and NGPs. In THCs data were collected from hospital records and by exit interviews of the patients of the GPs. In PP data were collected for both GPs and NGPs by photocopying the prescriptions from 50 drug selling shops by shop attendants.

Outcome measures: Average number of drugs per encounter, % of drugs in generic name, % of drugs from the essential drugs list (EDL), % of drugs having antibiotics prescribed, % of drugs with an injection prescribed and % of patients treated according to standard treatment guidelines (STG).

Results: Drugs prescribed from EDL & in generic name occurred more frequently in THCs than PP due to the implementation of the 1982 Bangladesh national drug policy.

Average no. of drugs and % of antibiotics prescribed per encounter were higher in PP of both GPs & NGPs than in THCs by GPs. Patients treated according to STG was lower in PP of NGPs than that of GPs in THCs & PP. Injection prescribed by NGPs were higher than that of GPs in PP.

Conclusion: The most urgent need is to improve the NGPs practice of ensuring improvement in case management for the diagnosis and treatment of common health problems in rural Bangladesh.

 

Introduction and background

In a developing country like Bangladesh with 120 million people and limited financial resources in the health sector, the rational treatment of most common diseases is essential. 85% of the population live in rural communities; poor social economic conditions, demographic structure, system of sanitation, water supply and food are the reasons for the common prevailing diseases.

The concept of essential drugs in Bangladesh was introduced in 1982 after the implementation of the national drug policy and drug ordinance (Drug Control Ordinance, 1982). The impact of the national drug policy on actual drug use with regard to disease patterns and drug utilization patterns, compounding, dispensing and consumption, etc. have not been properly assessed either at macro or micro levels. Similarly, no comprehensive study has been conducted to assess the extent of rational prescribing and dispensing, except a few works which were carried out on these aspects at micro level (Azad et al.,1992). Inappropriate drug use has been identified as an important health and economic problems in primary health care and such prescribers should explore practical ways to promote rational drug use (Reimann, 1992).

Five common diseases have been selected for this study:

  1. watery diarrhoea - "commonest childhood disease;
  2. acute respiratory infection;
  3. bloody dysentery ;
  4. urinary tract infection (UTI) - if not treated properly, it may cause chronic pyelonephrities and renal failure;
  5. enteric fever - "multi drug resistant (MDR) enteric fever cases are being seen in alarmingly high numbers in Bangladesh and its neighbouring countries" (Alam et al., 1995 ).

The five common diseases are initially treated by non-graduate medical prescribers and then, or secondly, treated by graduate medical prescribers in the Thana Health Complexes (THCs) and private practices (PP) in rural Bangladesh.

Graduate medical prescribers (MBBS) - are those who have a 5 year graduate course in medical science with 1 year in service training.

Non-graduate medical prescribers - There are three types:

Medical assistant (MA) - have 3 years organised training from the medical assistant training schools (MATS) and 1 year practical training after passing secondary school.

Palli Chikitshaks (PC) - prescribers at village level with 6 - 18 months’ training obtained from THC.

Rural medical practitioners (RMP) - prescribers at village levels with no training (Quack).

THCs are 31 bed hospitals with indoor and outdoor facilities. Nine graduate doctors are posted, including a dental surgeon and a graded specialist in medicine, surgery and gynea & obstretics with graduate nurses & diploma pharmacists. The Thana Health and Family Planning Officer (TH & FPO) is the Chief. Irrational drug use and inappropriate prescribing is a global phenomenon which also exists within Bangladesh. A study has been undertaken to collect baseline information in 3 selected thanas in Dhaka division about irrational prescribing habits of graduate and non-graduate medical prescribers for the 5 most common diseases and to recommend measures on these issues.

 

Objectives

General

To find out the pattern of prescribing habits of both graduate and non-graduate medical prescribers in rural areas.

Specific

To find out the prescribing pattern of graduate medical prescribers at THCs for five common diseases in retrospective and prospective studies.
To examine the adequacy of retrospective data in THCs for studying prescribing practices.
To compare the prescribing patterns of graduate prescribers in THCs and private practices.
To compare the prescribing pattern of non-graduate prescribers and graduate prescribers in private practices.
To compare the inappropriate dosages and duration of antibiotics prescribed by graduate prescribers in THCs and private practices and non-graduate prescribers in private practices.

 

Methods

Cross sectional descriptive study. Retrospective and prospective data were collected to assess the prescribing practices of both GPs and NGPs at THCs, and private practices in 3 selected thanas. This study was carried out from July 1995 to June 1996.

Three THCs were selected by randomly from the Dhaka Division. 50 drug selling shops and NGPs were identified in 3 thanas with the help of community leaders.

Five common diseases (watery diarrhoea, blood dysentery, ARI (< 5 years), UTI and enteric fever) were studied.

Study population: The total study sample size was 840 prescriptions. For GPs 240 retrospective prescriptions and 120 prospective prescriptions were sampled in THCs. In private practices, 120 prescriptions were sampled from GPs and 360 from NGPs.

The retrospective data were collected from medical records at THCs. The prospective data were sampled by intercepting the patients of the THCs as they exited. In private practices prospective data for both GPs and NGPs were sampled by photocopying the prescriptions from drug shops.

All data were equally distributed among the 5 important diseases (see Tables 1 & 2).

Table 1: Prescriptions for the five common diseases collected from GPs at each THC

Type of

Prescription

Diseases

 

Watery dia.

ARI (<5yrs)

Blood dys.

UTI

Enteric fever

Total

no.

Retrospective

(16)*

(16)

(16)

(16)

(16)

(80)

Prospective

(8)

(8)

(8)

(8)

(8)

(40)

Grand Total

120

Table 2: Prescriptions for the five common diseases collected from GPs and NGPs at private practice level at each Thana

Prospective

Prescriptions

Diseases

 

Watery dia.

ARI

(<5 yrs)

Blood dys.

UTI

Enteric fever

Total no.

A. MBBS

(8)

(8)

(8)

(8)

(8)

(40)

B. MA

(8)

(8)

(8)

(8)

(8)

(40)

C. PC

(8)

(8)

(8)

(8)

(8)

(40)

D. RMP

(8)

(8)

(8)

(8)

(8)

(40)

Grand Total

160

 

8 GPs from each THC, 8 MAs, 8 Palli Chikitshak and 8 RMPs from private practice level of each thana were selected purposively.

Prescriptions were evaluated using INRUD indicators (WHO/DAP 1993).

Parameters studied:

[1] Average number of drugs prescribed per encounter

[2] % of encounters with antibiotic prescribed

[3] % of drugs prescribed from essential drug list

[4] % of drugs prescribed in generic name

[5] % of encounters with an injection prescribed

[6] % of patients treated with standard treatment guideline

[7] % of inappropriate dosage of antibiotics prescribed

[8] % of inappropriate duration of antibiotics prescribed

 

Prescribing pattern of graduate and non graduate prescribers

(average result of 3 thanas)

Prescribing Indicators

In Thana health complexes (THCs) by Graduate Medical Prescribers

(Retrospective)

In Thana health complexes (THCs) by Graduate Medical Prescribers

(Prospective )

In private practics Level (PPL) by Graduate Medical Prescribers

(Prospective )

In private practics Level (PPL) by non Graduate Medical Prescribers

(Prospective )

1. Average number of of drugs per encounter

1.6

2.4

3.41

4.17

2. Percentage of encounters with an antibiotic prescribed

40%

50%

73.33%

85.55%

3. Percentage of drugs prescribed from essential drug list or formulary

88.33%

75%

49.00%

39.70%

4. Percentage of drugs prescribed by generic namel

84.58%

80%

4.10%

2.90%

5. Percentage of encounters with an injection prescribed

4.16%

6%

9.70%

17.37%

6. Percentage of patient treated with standard treatment guideline

74.16%

60%

52.50%

24.90%

7. Percentage of encounter having metronidazole prescribed

18.00%

30%

40%

56%

8. Percentage of antibiotic with an appropriate dosage

24.17%`

32%

65.30%

43.60%

9. Percentage of antibiotic with an appropriate duration

17.50%

20%

73.90%

45.27%

 

Analysis

Data were subjected to statistical analysis appropriate Z tests.

 

Results

Figure 1: comparison of retrospective with prospective p. data in TCHs by GP

Figure 1: Results showed that the average number of drugs prescribed per encounter by graduate prescribers at THCs were 1.6 and 2.4 from retrospective and prospective data respectively. The percent of encounters with antibiotics prescribed were 40% and 60%, while others were prescribed from the EDL at 88.33% and 75%, with generic name at 84.58% and 56% and with injections prescribed per encounter at 4.16% and 6%. Prescriptions given from the STG were at 74.16% and 60% in retrospective and prospective levels respectively. % of antibiotics used were significantly higher in prospective studies than that of the retrospective ones in THCs. (P<0.01). % of drugs prescribed from EDL and by generic name were significantly lower in prospective studies than that of the retrospective one. (P<0.001).

 

Figure 2: comparison of public sector THCs and private sector PP prescribing of GP using prospective data

Figure 2: The average number of drugs prescribed per encounter of GPs were 2.4 and 3.41 in THCs and PP respectively in prospective studies. The percent of encounters with antibiotics prescribed were 60% and 73.33%, while others were prescribed from EDL at 75% and 49% and drugs prescribed with generic name at 56% and 4.10%, injections used per encounter at 6% and 9.7%, and lastly drugs prescribed according to STG were at 60% and 52.50% by GPs in THCs and PP respectively at prospective levels. Generic prescribing and drugs used from the EDL in PP were significantly lower than that of THCs (P<001). Antibiotics prescribed in PP were significantly higher than that of the THCs (P<01).

 

Figure 3: comparison of private practice graduate and non graduate medical prescribers

Figure 3: The average number of drugs prescribed by GPs were 3.41 against 4.17 of the NGPs in private sector. 73.33% of GPs prescribed antibiotics against 85.55% of NGPs. 49% of GPs prescribed drugs from the EDL against 39.70% of NGPs and 4.10% of GPs prescribed drugs against 2.90% of NGPs in generic name. 9.70% of GPs having injections prescribed as against 17.37% of NGPs. Lastly, 52.50% of GPs prescribed drugs according to STG as against 24.90% of NGPs. The percent of antibiotics and injections prescribed in PP by NGPs significantly higher than that of GPs (P<01). The percent of drugs prescribed according to the STG by NGPs was highly significant than that of GPs in PP (P<001).

 

Figure 4: comparison of inappropriate dosage and duration of antibiotics precribed of 3 groups of prospective data

Figure 4: Result showed that 68% and 34.70% of GPs prescribed antibiotics in THCs and PP respectively against 56.40% of NGPs in appropriate dosages in PP. Similarly 80% and 26.10% of GPs prescribed antibiotics in THCs and in PP respectively as against 54.73% of NGPs inappropriate duration in PP. Inappropriate dosages and duration of antibiotics prescribed by GPs in PP were significantly higher than that of THCs (P<.001). Inappropriate dosages and duration of antibiotics prescribed by NGPs were significantly higher than that of Gps in PP (P<001).

 

Implications/conclusions

Retrospective data are inadequate in THCs to study prescribing because they underestimate key variables like the number of drugs, percentage of dosage and duration of antibiotics prescribed.

Poor prescribing practices in THCs for 5 common diseases:

  1. Over use of antibiotics, metronidazoles and anti diarrhoeals;
  2. Indiscriminate use of injections;
  3. Prescribing of tab iron and vitamin B complexes randomly; and
  4. Inappropriate dosages and duration of antibiotics.

Key reasons for this include:

  1. Inadequate education and training of prescribers;
  2. Misleading promotional activities by pharmaceutical companies;
  3. Uncertain diagnosis;
  4. Patients desire;
  5. Prescribers relying on their clinical experiences;
  6. Irrational prescribing by peers;
  7. Lack of monitoring system.

Private practice graduate prescribers are worse than THCs, with almost no generic prescribing, higher use of antibiotics, polypharmacy, etc…

Greater economic capacity of the private patient.

Different expectation about what drugs they are given.

Belief that brand name drugs are higher quality.

Non-graduate prescribers are even worse than graduate prescribers in private practices at prescribing because:

  1. Most of the PPs have their own drug shops.
  2. Lack of knowledge for proper diagnosis and treatment.
  3. Modelling behaviour on private practice of GPs.

 

Conclusion

The most urgent need is to improve the practice of non-graduate prescribers to ensure basic knowledge about diagnosis and treatment of common health problems in rural Bangladesh.

Photographs:

NGP is prescribing in his own drug shop
GP is prescribing in THC
Model of THC
Picture shows patients seated in NGP's private chamber
Open latrines are seen in rural Bangladesh
Picture shows NGPs pushing IV fluids and vitamins in private chambers