E-drug: Indicators of optimum prescribing (cont'd)
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Dear E-druggers,
I will attempt here to summarize Chapter 9, "Irrational and Hazardous
Drug Use", from the book "Drug Supply and Use: Towards a Rational
Drug Policy in India" by Dr Anant Phadke (Sage Publications India). I
would however encourage readers to go through the full chapter of
the book, to get a proper flavour of the discussion therein.
1) Average No. of Drugs per Encounter:
Average Does not give an idea about the distribution of the variable.
Something like percentage of prescriptions containing more than 3
drugs is a better indicator (three drugs are generally sufficient for an
outpatient case). More than 3 drugs are required only once in a while.
Hence the percentage of prescriptions containing more than 3 drugs is
a good indicator of irrationality of prescription.
2) Percentage of Drugs with an Antibiotic Prescribed:
There is no data to decide what level of antibiotic use (in terms of
percentage of prescriptions containing an antibiotic) is to be regarded
as rational/irrational. Also, this permissible percentage will vary with
the proportion of infective diseases in the total quantum of diseases in
different areas. Which in turn would depend on the season as also
socio-economic class of patients. A better indicator would be the
percentage of patients receiving one or more irrational drug
combinations.
3) Percentage of Encounters with an Injection Prescribed:
Some injections used at out-patient clinics are quite rational: tetanus
toxoid, injectable vaccines, inj. penicillin or streptomycin (for TB) or
inj. adrenaline for acute attacks of bronchial asthma. A better indicator
would be percentage of encounters with an unnecessary injection
given.
4) Percentage of Prescriptions Containing a Hazardous Drug:
Apart from using a readily available list of banned and bannable drugs,
Phadke drew up guidelines (given in Appendix 1 of the book) to
identify hazardous use of a rational drug.
5) Percentage of Prescriptions Containing Unnecessary Drugs:
Phadke drew up standard prescriptions (SPs) for 92 common
conditions encountered. Any drug not included in these SPs were
considered unnecessary.
"...We have explained above as to how and why we added precision
to some of the WHO-INRUD indicators and have deleted some other
WHO-INRUD indicators (related to generic drugs, essential drugs, ORS
in paediatric diarrhoea). In this process we arrived at indicators which
focus only on undesirable drug use (the term 'undesirable'
encompasses both irrational and hazardous drug use.) In a way, these
indicators used in our study reflect the ground reality of drug use in
India."
The rest of the chapter goes on to discuss extent of undesirable drug
use in the Satara district of Maharashtra state of India, which was the
main focus of the research reported in the book.
The book is available from: Sage Publications in India, California or
London (but I suppose it may be easiest to get it from India).
Sales addresses:
* Sage Publications India Pvt Ltd, M-32 Market, GK-I, New Delhi
110 048
* Sage Publications Inc, 2455 Teller Road, Thousand Oaks,
California 91320
* Sage Publications Ltd, 6 Bonhill Street, London EC2A 4PU
The price of the paperback in India is Rs 165 (approx US$4/-).
S. Srinivasan
Low Cost Standard Therapeutics (LOCOST)
Baroda, India
[Thanks for this excellent summary, Srinivasan!
I do have a few questions, though: What is the basis for the author's
firm statement "three drugs are generally sufficient for an outpatient
case"? In most indicator studies in the world we find on average
between 1-2 drugs per prescription. Is that too little? And if so, why?
By the way, the "gold-scale" value for drug use indicators has been
requested as long as drug use indicators are around. To my know-
ledge there are studies being carried out now to know more about
these "gold-scale" values. The statement in comment Nr 3: "A better
indicator would be percentage of encounters with an unnecessary
injection given" begs for a definition of the term "unnecessary".
Because it is often difficult to make clear and verifiable definitions of
"necessary" and "unnecessary" drug use, the indicators presented in
the WHO manual try to stay away from that. Hilbrand Haak, E-drug
moderator].
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