|Year : 2014 | Volume
| Issue : 3 | Page : 153-157
Evaluation of knowledge, attitude and practice of rational use of medicines among clinicians in a tertiary care teaching hospital
Chaitali S. Bajait, Sonali A. Pimpalkhute, Smita D. Sontakke, Ganesh N. Dakhale, Kavita M. Jaiswal, Chetan S. Urade
Department of Pharmacology, Government Medical College, Nagpur, Maharashtra, India
|Date of Submission||13-Feb-2014|
|Date of Acceptance||05-Mar-2014|
|Date of Web Publication||16-May-2014|
Chaitali S. Bajait
1351, NIT Colony, Nandanwan, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Prescribing is a challenging task requiring knowledge of essential medicine (EM), rational use of medicines (RUM) and personal drugs (P-drug). Though the majority of clinicians recognize the importance of RUM, most of them have not been able to apply this knowledge in their medical practice. Aims: The aim of the following study is to assess knowledge, attitude and practice of clinicians about RUM, EM, P-drugs, and sources of drug information. Settings and Design: A cross-sectional, questionnaire based study . Subjects and Methods: Study was carried out in 100 respondents including faculty members and junior residents (JRs) in a tertiary-care teaching hospital. Statistical Analysis: Univariate analysis was carried out using fisher's exact test. Results: Nearly 93% respondents were aware about EM, but only 79% prescribe them. Percentage is significantly higher in respondents of age more than 30, having clinical experience <5 years and in faculty members as compared to residents. Nearly 87% respondents were aware about RUM, but only 83% practice it. Though 30% respondents practiced P-drug concept only 1% were aware about STEP criteria. Practicing P-drug concept was significantly more in JRs compared to faculty members (P < 0.0001). None of the respondents were aware about the number of drugs in National List of EMs of India . Conclusions: It is an encouraging finding that higher percentages of clinicians were aware about EM and also prescribed it. However, level of understanding related to P-drug concept and existence of essential medicines list are much below par. Also prescribing by trade name and heavy dependency on medical representatives for drug information is the matter of concern.
Keywords: Essential medicine, medical practitioners, personal drugs, rational use of medicine
|How to cite this article:|
Bajait CS, Pimpalkhute SA, Sontakke SD, Dakhale GN, Jaiswal KM, Urade CS. Evaluation of knowledge, attitude and practice of rational use of medicines among clinicians in a tertiary care teaching hospital. Int J Nutr Pharmacol Neurol Dis 2014;4:153-7
|How to cite this URL:|
Bajait CS, Pimpalkhute SA, Sontakke SD, Dakhale GN, Jaiswal KM, Urade CS. Evaluation of knowledge, attitude and practice of rational use of medicines among clinicians in a tertiary care teaching hospital. Int J Nutr Pharmacol Neurol Dis [serial online] 2014 [cited 2020 Jan 20];4:153-7. Available from: http://www.ijnpnd.com/text.asp?2014/4/3/153/132673
| Introduction|| |
According to World Health Organization (WHO) definition, rational use of medicine (RUM) requires that patients receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate period of time, and at the lowest cost to them and their community.  Prescribing is a complex and challenging task which must be based on scientific evidences, which requires knowledge of essential medicine (EM), RUM and personal drugs (P-drug). It should not be an automated action, without critical thinking or in response to commercial pressure. There are world-wide evidences of poor prescribing due to errors, polypharmacy, and inappropriate or irrational prescribing leading to serious health risks and financial burden to the patient.  To overcome these difficulties, the WHO has published the Guide to Good Prescribing, which takes the medical student through a structured problem-solved six-step process in choosing and prescribing a suitable drug for an individual patient, i.e., P-drug concept.  The idea was to make physicians familiar with few P-drug chosen from national essential drug list, based on efficacy, safety, suitability, and cost, with regard to the population they cater to. 
EMs, a cornerstone of RUM, are defined as those that satisfy the health care needs of majority of the population. This concept was defined in 1975 by WHO.  The first WHO essential medicines list (EML) was published in 1977 with revisions every 2 years. This model EML provides a template and serves as a guide for countries to prepare their own lists. The Ministry of Health, Government of India revised the National List of EMs of India (NLEMI 2011) in June 2011. The NLEMI 2011 contains 348 medicines.  EMLs have been shown to improve the quality and cost-effectiveness of health care delivery when combined with proper procurement policies and good prescribing practices. 
The concept of RUM was incorporated in practical curriculum of 2 nd year MBBS Pharmacology Teaching by Maharashtra University of Health Sciences, Nashik in 2000 to make students familiar with RUM. In the last two decades, we have moved from EM to P-drugs by practicing RUM and evidence based medicine. Though the majority of students recognize the importance of RUM, most of them have not been able to apply this knowledge in their routine medical practice.  A systematic review by Ross and Loke showed that there is no strong evidence whether educational interventions can improve prescribing by medical students and doctors.  As per the recommendations of WHO training in RUM is necessary for physicians in medical services. This is lacking in the developing countries; and if at all continuing medical education are conducted, they are mostly sponsored by drug houses having their own market interests. More importantly, physicians rely heavily on drug information provided by medical representatives (MRs). Dependence on independent, peer-reviewed sources is negligible leading to irrational prescription practices.
With this background, the present study was planned to evaluate knowledge, attitude and practice of RUM among clinicians in a tertiary care teaching hospital.
| Subjects and methods|| |
This was a cross-sectional, questionnaire based study carried out in 100 respondents including faculty members and junior residents (JRs) from clinical departments of a tertiary-care teaching hospital after approval from institutional ethics committee. Self-developed, prevalidated questionnaire consisting of both open-ended and close-ended items was used to obtain information about various issues concerned with RUM such as use of EM, concept of P-drugs, sources of drug information, etc., The questionnaire was first pre-tested in five respondents and appropriate modifications done. Final version of the questionnaire was distributed to the participants after explaining the nature and purpose of the study. Written informed consent was obtained from each participant. Doctors working in pre- and para-clinical disciplines were excluded from the study.
At the end of the study, all data were pooled and expressed as counts and percentages. Univariate analysis, which explores each variable in a data set separately, was carried out by using the fisher's exact test. Graph pad prism software manufactured by graph pad software [version 5.01] was used to analyze data. P < 0.05 was considered to be significant.
| Results|| |
Out of 160 clinicians contacted, 100 responded giving a response rate of 62.5%. Out of 100 respondents, 67% were men and 33% women with age ranging from 24 to 59 years. Nearly 56% respondents were JRs pursuing their post-graduation after MBBS, whereas 44% were faculty members with a post-graduate degree in any of the clinical disciplines [Table 1].
Although 87% respondents were aware about the term RUM and 83% practiced it, only 4% had NLEMI available at their work place and 5% clinicians were able to correctly name the parts of the prescription slip. Ironically, none of the participants were aware of the exact number of drugs/drug combinations included in NEML [Table 2]. About 22% respondents prescribed drugs by generic names while the majority of respondents (60%) prescribed by brand names [Table 3].
|Table 3: Attitude and practice of clinicians about different aspects of RUM (n=100) |
Click here to view
Nearly 93% respondents were aware about EM, but only 79% prescribed them. Percentage of clinicians prescribing EM was significantly higher in respondents having age more than 30. (P < 0.001), having clinical experience of more than 5 years (P < 0.001) and in faculty members as compared to JRs (P = 0.0027). Though 30% respondents practiced P-drug concept only 1% were aware about STEP criteria. Practicing P-drug concept was significantly more in JRs compared to faculty members (P < 0.0001) [Table 4].
Only 69% of respondents were always aware of the adverse effects, interactions, and contraindication of the drugs they prescribe.
Majority of respondents (84%) admitted of relying on information from MRs, 60% refer drug indices, 50% read standard text books, 45% use internet whereas only 40% respondents read review articles in journals for obtaining information about various drugs and regimens [Figure 1].
| Discussion|| |
RUM contributes to high-quality health care, while irrational use leads to health hazards and wastage of resources that are already insufficient in the majority of health care systems. This study is unique in a way that it is carried out exclusively in clinicians working in a tertiary care teaching hospital dedicated to specialty services for serious and complicated diseases. Hence, assessing knowledge of RUM among them in such set-up would be helpful in promoting RUM and improving health care services.
In the present study, though the majority of clinicians seem to be aware and prescribed EM, but surprisingly none of them was able to correctly quantify the drug/drug combinations in the NLEMI. The findings are similar to the previous study conducted by Mahajan et al.  This clearly indicates a lack of measures to update professional knowledge. Regarding EM, not only selection, but also its appropriate use is necessary for upgrading the quality of health care. 
The National List of EM (NLEM) is one of the key instruments in balanced health care delivery system of a country, which includes accessible, affordable, quality medicine at all the primary, secondary, tertiary levels of health care. The primary purpose of NLEM is to promote RUM considering the three important aspects, i.e., cost, safety, and efficacy. Furthermore, it promotes prescription by generic names. Some studies have reported improvement in the quality of health care following use of NLEM and standard treatment guidelines.  Hence, it is essential to adopt measures that will encourage their use.
In the present study, it is encouraging to know that the majority of clinicians practice RUM, but most of them prescribe drugs by brand name and very few were able to name parts of prescription. Various studies have revealed that prescribing medicines by brand name has become a routine practice. , This may be due to the fact that, prescribing practices of clinicians are mainly influenced by various incentives provided by pharmaceutical companies. This is a matter of concern and needs to be considered seriously.
The percentage of respondents practicing P-drug concept is less particularly in the group having experience more than 5 years. Another study also found that knowledge about P-drug concept was significantly more in younger clinicians.  The reason behind this may be that, concept of P-drug is a relatively new addition to the medical curriculum, hence, most of the senior clinicians may not be aware about it. However, even among JRs, percentage of practicing P-drug is less though they were exposed to this in their pharmacology curriculum during MBBS. This indicates that the P-drug concept has remained confined to pharmacology and has not become popular among clinicians. Involvement of clinicians is vital if the P-drug concept is to succeed. A problem-based learning session for teachers in medical colleges needs to be organized.
There was heavy reliability and dependence on MRs from different pharmaceutical companies for drug information, which is often biased and points to clear-cut favoritism toward the market-driven forces leading to irrational prescription behavior and irrational use of medicines. In one study, physicians admitted that their prescribing decision are influenced by MR and they are compelled to prescribe certain medicine at the cost of getting some incentives in the form of free samples, gifts or various kinds of supports.  Provision of independent, authentic and unbiased information through drug information centers, drug bulletins, participation in the development of treatment guidelines and drug formularies, formation of drug and therapeutic committees can very well decrease the irrational prescribing and can check this menace. ,
Almost, all of the respondents stated that they were always aware of the ingredients of the drug prescribed and they inform the patient regarding disease, drug therapy, regular follow-up and monitoring of drug therapy, which are welcoming changes in clinical practice. However, this response from clinicians should be viewed with caution since there are studies in which almost half of the patients reported that they were not informed about the name, cause, consequence, or complications of their disease and treatment and also about side-effects of drugs prescribed and drug-food interaction.  The findings may also vary in different settings, but still reliable and authentic response to such questions can be predicted only after knowing opinion of more patients.
Though, it is now a well-accepted fact that RUM is an important issue and that doctors are the major prescribers of medicines, teaching of RUM is not given much importance in most of the medical colleges.  This can be considered as a major cause of errors in prescribing with its adverse consequences subsequently. ,, Hence, sincere efforts are required to promote RUM among clinicians to avoid irrational prescribing.
WHO has suggested future strategy and directions regarding RUM like close coordination between process for the development of standard treatment guidelines and efforts to improve quality use of medicine, continued emphasis on the inclusion of EM concept in undergraduate and post-graduate medical curricula and emphasis on the effective utilization of drug and therapeutic committees at regional and district levels.  In conclusion, it is encouraging finding that higher percentages of clinicians were aware about EM and also prescribed it. However, level of understanding related to P-drug concept and existence of EML are much below par. Furthermore, prescribing by trade name and heavy dependency on MR for drug information is the matter of concern. Hence, there is a need to strengthen the mechanism for continuing professional development of clinicians to update their knowledge and skills to prescribe rationally.
| References|| |
|1.||World Health Organization. The Rational Use of Drugs. Report of the Conference of Experts. Geneva: WHO; 1985. |
|2.||Aronson JK. A prescription for better prescribing. Br J Clin Pharmacol 2006;61:487-91. |
|3.||World Health Organization. Guide to Good Prescribing. Geneva: WHO; 1994. |
|4.||Singh NR. P-drug concept and the undergraduate teaching. Indian J Pharmacol 2008;40:285. |
|5.||The Selection of Essential Medicines. WHO Policy Perspectives on Medicines. Geneva: World Health Organization; 2002. |
|6.||National list of essential medicines of India, 2011. Available from: http://www.cdsco.nic.in/. [Last cited on 2013 Dec 20]. |
|7.||Manikandan S, Gitanjali B. National list of essential medicines of India: The way forward. J Postgrad Med 2012;58:68-72. |
|8.||Patrício KP, Alves NA, Arenales NG, Queluz TT. Teaching the Rational Use of Medicines to medical students: A qualitative research. BMC Med Educ 2012;12:56. |
|9.||Ross S, Loke YK. Do educational interventions improve prescribing by medical students and junior doctors? A systematic review. Br J Clin Pharmacol 2009;67:662-70. |
|10.||Mahajan R, Singh NR, Singh J, Dixit A, Jain A, Gupta A. Current scenario of attitude and knowledge of physicians about rational prescription: A novel cross-sectional study. J Pharm Bioallied Sci 2010;2:132-6. |
|11.||Kar SS, Pradhan HS, Mohanta GP. Concept of essential medicines and rational use in public health. Indian J Community Med 2010;35:10-3. |
|12.||Hogerzeil HV. The concept of essential medicines: Lessons for rich countries. BMJ 2004;329:1169-72. |
|13.||Rathod R, Rathod A, Gupta VK, Ahmed T, Jha RK, Gaikwad N. Audit in dermatology for rational prescribing. Res J Pharm Biol Chem Sci 2012;3:518-24. |
|14.||Abidi A, Gupta S, Kansal S, Ramgopal. Prescription auditing and drug utilization pattern in a tertiary care teaching hospital of western UP. Int J Basic Clin Pharmacol 2012;1:184-90. |
|15.||Al-Areefi MA, Hassali MA, Ibrahim MI. Physicians' perceptions of medical representative visits in Yemen: A qualitative study. BMC Health Serv Res 2013;13:331. |
|16.||World Health Organization. Factsheet: WHO Policy Perspectives on Medicines-Promoting rational use of medicines: Core components Geneva: WHO; 2002. Available from: htpp://www.who.int/entity/medicines/publications/policyperspectives/ppm05en.pdf. [Last cited on 2013 Dec 20]. |
|17.||George B, Rao PG. Assesment and evaluation of drug information services provided in a south Indian teaching hospital. Indian J Pharmacol 2006;37:315-8. |
|18.||Basaran NF, Akici A. Patients' experience and perspectives on the rational use of drugs in Turkey: A survey study. Patient Prefer Adherence 2012;6:719-24. |
|19.||World Health Organization: Selection and rational use of medicines. Fact sheet: N338, 2010. Available from: http://www.who.int/mediacentre/factsheets/fs338/en/. [Last cited on 2013 Dec 20]. |
|20.||Maxwell S, Walley T, Ferner RE. Using drugs safely. BMJ 2002;324:930-1. |
|21.||World Health Organization. The Selection and Use of Essential Medicines-Report of the WHO Expert Committee. Geneva: WHO; 2011. p. 8-9. |
[Table 1], [Table 2], [Table 3], [Table 4]