Assessment of Rational Prescribing in General Outpatient Department of Kampala International University Teaching Hospital , Western Uganda

Introduction: Prevention of irrational use of medicines may reduce healthcare costs and potentially save lives. Aim: The aim of this study was to assess rational drug prescribing using World Health Organization (WHO) and International Network of Rational Use of Drugs (INRUD) indicators on prescribing in the General Outpatient Department of Kampala International University Teaching Hospital, Ishaka-Bushenyi, Western Uganda. Methodology: The study design was retrospective, descriptive and cross-sectional. A total of 884 prescriptions were selected by systematic sampling using an interval of 27 from 23,868 prescriptions available in the medical records of the General Out-Patient Department (GOPD) of Kampala International University Teaching Hospital (KIUTH) from April, 2016 to March, 2017. The selected samples were analyzed using Microsoft Excel 2013, to assess for conformity with the prescribing indicators. Results: The results showed that the percentage of recording of diagnosis was 90.72% (index of diagnosis—0.91). The average number of drugs per encounter was 2.6 (index of non-polypharmacy—0.77), and the percentage of drugs prescribed with the generic name was 90.21% (index of generics—0.9). Percentages of encounters with antibiotics and injectable drugs prescribed were 61.88% (index of antibiotics—0.48) and 5.43% (index of injectable drugs—1) respectively. Only 78.96% (index of EMSLU—0.79) of the medicines prescribed were from the Essential Medicines Supplies List of Uganda (EMSLU) or Uganda Clinical Guidelines 2016. The index of rational drug prescribing (IRDP) was found to How to cite this paper: Akunne, A.A., Lam, W.I., Ezeonwumelu, J.O.C., Ebosie, J.C. and Udechukwu, B.E. (2019) Assessment of Rational Prescribing in General Outpatient Department of Kampala International University Teaching Hospital, Western Uganda. Pharmacology & Pharmacy, 10, 48-60. https://doi.org/10.4236/pp.2019.101005 Received: November 25, 2018 Accepted: January 14, 2019 Published: January 17, 2019 Copyright © 2019 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access


Introduction
A drug prescription according to Sisay et al. [1] is a legible, accurate and complete medico-legal document of formal written instructions, from the prescriber to the dispenser and considered as the patient's visit endpoint with the health facility.Rational use of drugs (RUD) is an essential element in achieving quality of health and medical care of patients and the community as a whole [2].According to [3], the World Health Organization (WHO) defined rational use of drugs as patients receiving medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time and at the lowest cost to them and their community.Appropriate use of medicines can contribute immensely to the global reduction in morbidity and mortality with medical, social and economic benefits, and imparts credibility to the health facility system [4].However, the World Health Organization (WHO) has reported that around 50% of all medicines are inappropriately prescribed, dispensed or sold [5].
Irrational prescription of drugs is a common global occurrence in clinical practice with an enormous cost [4].It occurs in all countries and causes harm to people [6].Irrational use of medicines includes the use of too many medicines (polypharmacy), use of antibiotics for non-bacterial infections, inadequate dosages of antibiotics, use of injections when oral medication is more appropriate, prescribing medicines that contravene clinical guidelines, and patient self-medication [3].Basically, few studies have been carried out to assess the prescription patterns of health care facilities in Uganda using WHO prescribing indicators.That is average number of medicines prescribed per encounter, percentage of medicines prescribed by generic name, percentage of encounters with an antibiotic prescribed, percentage of encounters with an injection prescribed and percentage of medicines prescribed from Essential Medicines List.According to the report of baseline studies, all levels of health care facilities in Uganda recorded polypharmacy, low use of generic names, over-use of antibiotics and low adherence to standard treatment guidelines.The report thus concluded that there was poor medicines management in more than 1000 public health care facilities in Uganda [7].

Justification
Few medicines-use indicator studies have been carried out in Uganda and most of them were in public health facilities.Most of these studies have been carried out using a Supervision Performance Assessment and Recognition Strategy (SPARS) tool to assess the performance of public and not-for-profit health facilities and design interventions to improve medicines use in Uganda.The prescribing performance scores were found to be low for all levels of care).But, the SPARS tool is more of a management (performance assessment and intervention) tool rather than a research tool since it involves scoring based on standards set by ministry of Health rather than the exact WHO medicines use indicator reference standards [7].This gap necessitated the need to carry out this study to assess the current rational prescribing pattern in the General Outpatient Department (GOPD) of Kampala International University Teaching Hospital (KIUTH) using WHO and International Network of Rational Use of Drugs (INRUD) indicators.

Study Design
The study design was a retrospective, descriptive, cross-sectional study of patient medical records and prescription forms from the GOPD of Kampala International University Teaching Hospital, for some general information and WHO prescribing indicators [8].Besides the WHO core prescribing indicators, we also looked at the level of recording of diagnosis which helps the pharmacists to determine whether or not the prescribed medication is appropriate for the indication under treatment.

Area of Study and Period
Kampala International University Teaching Hospital (KIUTH) is a private/public partnership training hospital located in Ishaka-Bushenyi, Western Uganda, along Mbarara-Kasese Road.It is a well-established hospital with 700 beds and a range of specialist departments and clinics, including General Surgery, Orthopaedics, Obstetrics/Gynecology, Medical, Ophthalmology, Entomology, Dental Surgery, Paediatrics, Psychiatry and Mental Health and Physiotherapy.This study was carried out using patient records from General Outpatient Department (GOPD) of KIUTH between April, 2016 and March, 2017.

Sample Size Determination
According to the WHO guidelines, a minimum of 600 prescriptions should be used in a cross-sectional study describing the current prescribing pattern of a health facility [9].In this study, 884 prescriptions were used.• Combination medicines were counted as one and included [2].

Inclusion and Exclusion Criteria
• Prescriptions containing all the information needed i.e. names of the drugs, dosage form were included.
• Encounters that took place outside of the period from April, 2016 to March, 2017 were excluded.
• Prescriptions that did not contain all the information needed i.e. names of the drugs, dosage form were excluded.

Sampling Technique
The total number of prescriptions in the medical records from GOPD of KIUTH from April, 2016 to March, 2017 was 23,868.Out of this number, 884 prescriptions were selected using systematic sampling method with 27 as the sampling interval.

Data Collection
The data collection from the GOPD of KIUTH was carried out between April, 2017 and June, 2017.The sampling of prescriptions was made to spread throughout the period of study to reduce bias due to seasonal changes [3].The standard core drug use indicator forms were used to collect the data [10].The WHO guidelines and methods were observed to ensure data reliability [10].The total number of prescriptions during the study period was 23,868 which were kept in patient files in the Medical Records Centre of the hospital.
A pretest was carried out to confirm availability of the required information for the study and to allow for adjustments before the study.After the pretest, the data collection tool was adjusted to suit the study and to make data collection easy.

Data Analysis and Presentation
The data collected were checked for correctness and analyzed using Microsoft Excel 2013 based on the formula adopted from the WHO's manual for the five core WHO/INRUD prescribing indicators.The five core prescribing indicators include: average number of medicines per encounter, percentage of medicines prescribed by generic name, percentage of encounters with an antibiotic prescribed, percentage of encounters with an injection prescribed, and percentage of medicines from the Essential Medicines Supplies List of Uganda (EMSLU) or Uganda Clinical Guidelines 2016 (UCG).The average number of medicines per encounter was calculated as the total number of medicines prescribed divided by the total number of encounters sampled.The percentage of medicines prescribed by generic name was calculated as the numbers of medicines prescribed by generic name divided by the total number of medicines prescribed and multiplied by 100%.The percentage of encounters with an antibiotic prescribed and per-centage of encounters with an injection prescribed were calculated as the number of patient encounters with an antibacterial or an injection prescribed divided by the total number of medicines prescribed and multiplied by 100%.Finally, the percentage of medicines prescribed from the EMSLU was calculated as the number of medicines prescribed which are listed on the EMSLU divided by the total number of medicines prescribed and multiplied by 100% [11] [12].In addition to the five core indicators, the percentage of prescriptions with diagnosis was calculated as number of prescriptions with diagnosis divided by the total number of sampled prescriptions multiplied by 100%.
After the enumeration, the result of the continuous variable i.e. average number of drugs per encounter was recorded and presented as mean, while other variables were recorded and presented as percentages (%) [8].The observed values were then compared with the WHO reference values of the prescribing indicators to establish rational drug prescribing or otherwise.The WHO reference values are as presented in Table 1.
An index system developed by Zhang and Zhi [3] [14] to gauge the performance of a health facility in terms of drug utilization was used to determine the performance of KIUTH.For each prescribing indicator, an index was determined for it using a formula.For the calculation of non-polypharmacy, rational antibiotic and injection safety indices, the following formula was used: All other indices (index of generic name, index of Essential Drugs List and index of recording of diagnosis) were calculated by the following formula: Index Observed value Optimal value = The optimal index for each of the prescribing indicators was set as 1 and thus, the observed values closer to 1 is a measure of rational drug use and vice versa.
The Index of Rational Drug Prescribing (IRDP) which has a maximum value of 6 in this study was then calculated by adding up all the 6 indices [10].

Data Quality Control
The data collected using the data collection prescriptions forms was checked to ensure that all information required was recorded before entering it into Microsoft Excel 2013.After entering the data, it was rechecked (double entry) to ensure correctness of information in order to produce reliable results.

Ethical Considerations
Institutional consent was obtained from the Management of KIUTH via a letter from the School of Pharmacy, Kampala International University, Western Campus, Ishaka-Bushenyi, Uganda.
The principle of confidentiality was maintained in the course of this study.
Prescriptions were coded to maintain confidentiality of patients, and their data.

Results
The results obtained following the analysis of a total of 884 prescriptions sam-   which is below the optimum IRDP of 6, is a measure of poor drug prescribing practices outside WHO standards by the GOPD of KIUTH.
Figure 1 below shows a bar chart of both the observed and optimum indices of the index system.The observed index for injectable drugs was same as the optimum index, thus rational use of injections.In the order of decreasing indices, from 23,868 prescriptions available in the medical records of the General Out-patient Department (GOPD) of Kampala International University Teaching Hospital (KIUTH) from April, 2016 to March, 2017 are shown in the under-listed tables.

Figure 1 .
Figure 1.Bar chart showing the observed and optimum indices.

•
Encounters that took place during the period from April, 2016 to March, A. A. Akunne et al.

Table 2
below shows the observed values of the prescribing indicators after the analysis.The study showed the percentage of recording of diagnosis to be 90.72%,average number of medicines per encounter was 2.6, percentage of me-

Table 3
shows the values of the index of each of the prescribing indicators af-

Table 2 .
Observed values of the prescribing indicators.

Table 4 .
Observed and optimum index of rational drug prescribing.