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  1. 1. Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012 ISSN: 2141 - 4149 © Wilolud Journals, 2012 http://www.wiloludjournal.com ` Printed in Nigeria EVALUATION OF DRUG USE AND PATIENT CARE PRACTICES IN A REFERRAL HEALTH FACILITY IN YENAGOA, BAYELSA STATE, NIGERIA Ifeanyi E. Chima1, Olatunji S. Obidiya2 and Chibuike V. Mc Abraham3 1 Department of Clinical Pharmacy & Pharmacy Practice, Faculty of Pharmacy, Niger Delta University, Wilberforce Island, Bayelsa State, Nigeria. 2 Department of Clinical Pharmacy & Pharmacy Practice Niger Delta University, Wilberforce Island, Bayelsa State, Nigeria.ABSTRACTBackground: Evaluation of drug use and patient care practice is a very vital aspect of patient care. It alsomeasures the quality of care provided by health practitioners for patients. Data from this study is very essentialin healthcare management and planning.Objectives: To assess drug use and patient care practices at the outpatient section of a referral hospital inYenagoa, south-south, Nigeria, using WHO drug use indictors.Methods: The study was conducted at Federal Medical Centre, Yenagoa, Bayelsa State. A total of 2450prescriptions from the outpatient pharmacy were selected by systematic sampling and retrospectively studied. Aprospective study of the patient care practices and health facility indicators, which include consultation anddispensing times, revenue time, Patient’s knowledge of their medications and availability of key essential drugs,was also undertaken. Data collected was analyzed using WHO guideline for assessment of drug use in healthyfacilities.Results: The average number of drugs prescribed per encounter was 3.4; Percentage of encounters with at leastan antibiotic prescribed was 35.5%. Injections were prescribed in 22% of encounters. 62% of drugs wereprescribed by generic name while 87% of drugs prescribed were from the essential drug list. The meanconsultation and dispensing times were 11.5 and 3.5 minutes respectively. Two out of every three patientsinterviewed knew both the names and the duration of their medications while four out of every five knew thecorrect dosage of their medications.Conclusion:Many of the prescribing and patient care indicators assessed were found to be inappropriate and need to beimproved upon. . There was high tendency of poly- pharmacy and over prescription of antibiotics. The patients’knowledge of vital aspects of medication management was found to be inadequate. The overall picture of druguse suggests that the indicators at this facility are not yet at the optimal level.KEYWORDS: Drug use indicators, rational drug use, WHO guideline, patient care, essential drug list.INTRODUCTIONDrugs are very vital in health care delivery. Drug therapy is the most commonly used method for diseasetreatment in general practice. Hence, the availability and affordability of good quality drugs, coupled withrational use is fundamental to effective health care delivery in any country (Enato and Chima 2011). Rationaldrug use refers to the use of the right drug for the right indication in the right dosage and dosing frequency andfor the correct duration. However, inappropriate use of drugs abounds especially in developing countries due toirrational prescribing, dispensing and administration of medications (WHO, 1985, 1993; Bashrahil, 2010).In a bid to improve drug use practices globally, the World Health Organization developed a set of objectiveindicators for measuring health facility drug use practices in outpatient settings (WHO, 1993; Hogerzeil et al,1993). 10
  2. 2. Ifeanyi E. Chima et al.,: Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012The best way to investigate drug use in health facilities is by the usage of indicators created and validated by theWorld Health Organization (WHO, 1993).The following WHO Core drug use indicators are used to evaluate drug use and patient care practices globally: a. prescribing indicators-Average number of drugs per encounter, percentage of drugs prescribed by generic name, percentage ofencounters with an antibiotic prescribed, percentage of encounters with an injection prescribed, percentage ofdrugs prescribed from essential drug list or formulary.b. WHO patient care indicators: Average consultation time, average dispensing time, Percentage of drugsactually dispensed, percentage of drugs adequately labeled, patient’s knowledge of correct dosage. Othersindicators are: Availability of a copy essential drug list or formulary and availability of key essential drugs inthe facility.These indicators enable health care planners, managers and researchers to compare situations in differentfacilities or at different times (Enato and Chima, 2011).Several studies done on medication and patient care practices in various parts of Nigeria using the aboveindicators, often show irrational drug use in the form of over prescription of antibiotics and injections, polypharmacy and non adherence to the principles of essential drugs (Enato and Chima, 2011). The averagenumbers of drugs prescribed per patient had been found to vary from 3 to 7, the prescribing rate of injection hasa range of 40-70% and antibiotic use rate exceeds 50% (Odusanya, 2004).OBJECTIVES OF THE STUDY: To evaluate the pattern of drug use in the facility using WHO Core Drug Use indicators. To assess the quality of care given to patients using WHO Patient Care indicators.METHODOLOGYSTUDY SETTING: This study was carried out in Federal Medical Centre Yenagoa, the capital city of BayelsaState, South-South Nigeria. Yenagoa is a Local Government Area in Bayelsa State, Nigeria. Its headquarter is inthe town of Yenagoa (the State capital) in the south of the area at 4°55′29″N 6°15′51″E4.92472°N 6.26417°E.The LGA has an area of 706 km² and a population of 353,344 at the 2006 census.The postal code of the area is 561.Yenagoa is the traditional home of the Ijaw people, Nigerias fourth largest ethnic group after the Hausa, Yorubaand Igbo. The Ijaw form the majority of the town. English is the official language, but Epie/Atissa language, oneof the Ijaw languages, is the major local language spoken in Yenagoa.Since attaining the status of state capital in 1996, construction and other activities have accelerated appreciably.Yenagoas population is estimated at about 150,000 people.Yenagoa is the heart of the oil rich Niger Delta of Nigeria. It is bounded in the east and west by Port Harcourtand Delta States respectively linked by the east-west road; and at the south by the Atlantic Ocean. At the time ofthis study, the hospital had six wards and about two hundred bed spaces. It has an average general outpatientattendance 13,000 cases per annum. The general practice clinic has four consulting rooms with four doctors. ThePharmacy Department of the hospital had six registered pharmacists, six intern pharmacist, four pharmacytechnicians and four pharmacy trainee on their industrial training that dispense drugs as support staff. This typeof study to the best of our knowledge has not been done in this part of the country before now. The study wasdesigned essentially to assess the degree of rational use of drugs in this health facility using WHO core drug useindicators. 11
  3. 3. Ifeanyi E. Chima et al.,: Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012STUDY DESIGNThe data collection process was done both prospectively and retrospectively. The pharmaceutical prescribingpattern was retrospectively done while the patient care practices and health facility indicators were prospectivelystudied. In addition, the times spent by patients to assess their prescription and make payments were alsoevaluated.DATA COLLECTION PROCESSThe prescription sheets of the previous twelve months period were collected from the pharmacy department,sorted and systematically sampled. One in every three prescriptions was selected for the study. Three researchassistants were trained to extract the necessary information from the sampled prescriptions into data collectionforms. The information abstracted from the prescription forms are: The name of the medication, the route ofadministration, the dosage form, the dose and duration of therapy.The prescribing indicators evaluated in this study include: Total number of drugs prescribed per encounter,percentage of drugs prescribed by generic name, percentage of encounter with an antibiotic prescribed,percentage of encounter with an injection prescribed. The patient care indicators evaluated include: Consultationtime, dispensing time, patient’s knowledge of prescribed medications and adequacy of medication labeling.Also, the times spent by the patients to assess their prescriptions and make payments were also evaluated. Thesewere all done prospectively.The presence or absence of an essential drug list at the pharmacy unit was also noted. Classification ofantibiotics and the description of key essential drugs were based on WHO guideline.(WHO/DAP 1993)DATA ANALYSISThe information from the prescription forms were entered into a data collection form and sorted while data onpatient care practices were collected prospectively and entered into appropriate section of the data collectionforms.The prescribing, patient care and facility indicators were calculated using WHO guidelines (WHO/DAP 1993).The prescribing indicators were calculated as follows:Average number of drugs prescribed per encounter = Total no of drugs for all encounters Total no of encountersPercentage of drugs prescribed by generic name = Total no of drugs prescribed as generics Total no of drugs prescribedPercentage of encounters with an antibiotic prescribed = Total no patients who received one or more antibiotics Total no of encountersPercentage of encounters with an injection prescribed = Total no of encounters with one or more injections Total no of encountersPercentage of drugs prescribed from the EDL = Total no drugs from the EDL Total no of drugs prescribedAlso, the mean consultation time, the mean dispensing time, the mean assessment and revenue times were allcalculated by dividing the total time spent by the patient for each of the above activities by the number ofencounters assessed. Other patient care indicators that were evaluated include: percentage of drugs actuallydispensed, the percentage of drugs adequately labeled and the percentage of patients with adequate knowledgeof their medications. 12
  4. 4. Ifeanyi E. Chima et al.,: Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012RESULTSA total of two thousand four hundred and fifty (2450) prescriptions were used for the evaluation of theprescribing pattern. A total of forty (40) patients participated in the study regarding consultation and dispensingtimes. Thirty (30) persons participated in the study of revenue and waiting times while ninety (90) personsparticipated in the study of the knowledge of dispensed medications.Table 1 shows that the average number of drugs per encounter was 3.4. The percentage prescribed by genericname was 62% and the percentage of encounter with an antibiotic prescribed was 35.5%. The percentage ofencounter with an injection prescribed was 22.4% and 87% percent of drugs prescribed from the essential druglist.Table 2 shows that the mean consultation time was 11.5 minutes. The mean assessment and revenue times were48.2 seconds and 3.5 minutes respectively. The mean dispensing time was 5.0 minutes. The percentage of drugsactually dispensed and the percentage adequately labeled were 80.3% and 84.55 respectively.Table 3 shows that 66% of respondents knew the names and duration of their dispensed medications. Four out ofevery respondent knew the dosage of prescribed medications. Only 2% of respondents knew the side effects ofthe dispensed medications.TABLE 1. WHO PRESCRIBING INDICATORS S/N INDICATORS % REF. STD 1. Average number of drugs per encounter 3.4 1.6-1.8 2 Percentage of encounter with an antibiotic prescribed 35.5% 20-25.4% 3. Percentage of encounter with an injection prescribed 22.4% 10.0- 17.0% 4. Percentage of drugs prescribed by generic name 67% 100% 5 Percentage of drugs prescribed from EDL 87% 100% WHO- World Health Organization. REF. STD- Reference Standard. EDL- Essential Drugs.TABLE 2: WHO PATIENT CARE INDICATORS S/N PARAMETER 1. Mean Consultation time (mins) 11.5 2. Mean assessment time (secs) 48.2 3. Mean Revenue time(mins) 3.5 4. Mean dispensing time (mins) 5.0 5. Percentage of drugs actually dispensed 80.3% 6. Percentage of drugs adequately labeled 84.5%TABLE 3 RESPONDENTS’ KNOWLEDGE OF DISPENSED MEDICATIONS S/N PARAMETER PERCENTAGE 1. Knowledge of names of dispensed medications 66% 2. Knowledge of correct dosage of dispensed medications 80% 3. Knowledge of duration of dispensed medications 66% 4. Knowledge of side effects of dispensed medications 2%DISCUSSIONStudy of drug use patterns in health facilities is used to describe treatment practices and to assess performance ofhealth care providers. This allows healthcare planners, managers and researchers to make basic comparisonsbetween health facilities and also evaluate situations at different times in a particular health facility followinginterventions. 13
  5. 5. Ifeanyi E. Chima et al.,: Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012The average number of drugs prescribed per encounter obtained from this study was 3.4.The value is higher than some values obtained in Nigeria by Enato and Chima (2011) in Lokoja (2.94), Nwolisaet al., (2005) (3.13). A similar result was obtained in a secondary health facility in Lagos, Nigeria (Odusanya,2004) (3.5).This value indicates a relatively high level of poly pharmacy practice in prescription pattern. This may have avery negative effect on therapeutic outcome in patients. Among the likely negative effects this may pose areincreased incidences of side effects, drug-drug interactions, confusion where aged patients are involved, noncompliance by the patients as a result of the large number of drugs to be taken at a time (Babalola et al., 2011)Sixty two percent of the drugs from the study were prescribed by generic name. Higher values had been obtainedin some other studies. For instance, Babalola et al.,(2011) (69.81%), Nwolisa et al. (2006) (63.8%). The value ishigher than that reported by Enato and Chima (2011) (37%). This value is low and does not comply with theWHO recommendation that 100% of drugs should be prescribed using the International Non-proprietary Name,INN. Prescribing by non generic name is a form of irrational prescribing (prescribing a more costly brand whencheaper and equally effective alternatives are available). Factors that have been identified as contributingimmensely to this trend are the influence of drug promotional activities as well as pressure from pharmaceuticalmanufacturers’ representatives or detail men on prescribers.Antibiotics were prescribed in 35.5% of patient encounters. This value was lower than those obtained fromstudies done in some health facilities in Nigeria. For instance, 51% was obtained in a study done by Enato andChima (2011), 50.1% was obtained in a study by Babalola et al (2011) and 54.8% by Odusanya (2004). Thoughthis value is lower than that from other studies, it still indicates overprescribing of antibiotics because it is higherthan the range given by WHO (20%-25.4%). Over prescription of antibiotics often arise from prescribingantibiotics for presumed infections. High rate of antibiotic prescribing has a number of implications. Firstly, itcan result to non compliance when unaffordable antibiotics are prescribed. Secondly, it tends to promoteantibiotic resistance.The prescription rate for injections from this study(22.4%) was lower than that from some previous studies. Forinstance, in a study done by Babalola et al (2011) in some primary health institutions the rate of injectionprescribing was 71.74%. This relatively low rate of prescription of injection is encouraging as injection – relatedhazards and infections such as HIV/AIDS, hepatitis and tissue necrosis.Eighty seven percent of drugs in this study were prescribed from the Essential drug list (EDL). Higher valueshad been obtained from other studies in Nigeria (94%) (Babalola et al, 2011). Ninety two percent and 100%were obtained in two studies done in Edo state (Ozemoya, 1997). The value from this study, though lower thanthe WHO benchmark (100%) value, is an indication that the prescribers have a fair knowledge of the drugs inthe essential drug list. Though lower than the WHO benchmark (100%). However, improvement should be madeIt was observed that the pharmacy department had a copy of the EDL but none of the prescribers.It has been noted that patient care patient care practices impact on the quality of health care delivered andappropriate use of time influences the health seeking behavior of clientele (Isah et al, 1998) Contrary to findingsfrom various studies in different parts of the nation (Enato and Chima, 2011) (Isah et al, 1997), the meanconsultation time of 11.5 minutes obtained in this study was considered adequate for making appropriatediagnosis. An important factor that affects consultation time is the number of patients to attend to. Adequateconsultation time is an indication of adequate clinical care for the clientele; which directly impacts positively onpatients’ satisfaction.The time spent to assess their prescription for payment was so short and was consideredquite satisfactory considering the fact that sick patients are attended to almost immediately they arrive withoutnecessarily queuing before their prescriptions are assessed for payment. The time spent to make payment formedications could be further reduced for the benefit of the patient.The mean dispensing time (5 minutes) obtained was considered satisfactory and adequate for a meaningfulpharmacist- patient interaction to take place. The dispensing time is a measure of the quality of care given to 14
  6. 6. Ifeanyi E. Chima et al.,: Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012patients by the pharmacist in providing information about the dispensed drug. This interaction results inappropriate use of prescribed medications and ultimately a positive therapeutic outcome. The value obtainedshowed good quality of care. Inappropriate and unsuitable environment impacts negatively on dispensing time.Overall evaluation of drugs adequately labeled showed that 84.5% of drugs dispensed were adequately labeled.Four out of every five patients interviewed knew the correct dosage regimen of all their dispensed drugs. Thisresult is lower than some results obtained from earlier drug use studies (Ozemoya, 1997). However this resultwas similar to results obtained in some other studies (Massele et al, 2011). Knowledge of correct dosage ofmedication is a very central factor in the therapeutic process. Lack of it could jeopardize the whole process, thusresulting in several predictable undesirable outcomes. Two out of three respondents knew the names of all theirdispensed medications. This value is unsatisfactory, though higher than values obtained in a study in UBTH andcentral hospital with values as low as 33.8% and 10.8% (Ozemoya, 1997). A researcher had observed that whatis responsible for low values of respondents who knew the names of their dispensed drugs is the practice ofsome pharmacists and other health care givers not to disclose the names of the prescribed drugs. Another factoridentified in that same study was the short time spent by pharmacists in counseling patients on their medications.This results in some vital information such as name of drugs being left out. This trend has been changed by thefact that the new health care process encourages patients to actively participate in their care process.Two out of every three respondents in the study knew the duration of all their medications. This indicates that34% of the patients did not know the duration of their therapies. This entails that a patient may not complete histherapy especially in a case where a refill is necessary, the patient may not know for how long to continue therefills. The patient may even decide to share his drugs with another sick person who is having similar symptomsor may even decide to save the drug for another time when he feels better. A factor that has been identified asbeing responsible for the pharmacist occasionally not disclosing the duration of therapy is the fact that the totalquantity of drugs dispensed is usually equal to the quantity needed. Lower values of 30.0% and 3.5% have beenobtained in study in Edo State (Ozemoya, 1997).Only 2% of the respondents interviewed knew the side effects of their medications. A similar result wasobtained in the study done in UBTH and Central hospital in which 1% and 0% of the respondents respectivelyknew the side effects of their medications (Ozemoya, 1997). Lack of information on the side effects of a drugcould result premature discontinuation of therapy when the patient experiences the side effect, resulting in nonadherence and consequently therapeutic failure.CONCLUSIONThe findings from this study showed that pharmaceutical prescribing pattern and patient care practices wereinappropriate. There was high tendency of poly- pharmacy and over prescription of antibiotics. The patients’knowledge of vital aspects of medication management was found to be inadequate. The overall picture of druguse suggests that the indicators at this facility are not yet at the optimal level. Thus, the need for the training ofmedical and Pharmacy practitioners on rational drug use and the incorporation of same in the undergraduatecurriculum of both professions in various universities in the country.ACKNOWLEDGEMENTSWe wish to thank the management and staff of Federal Medical Centre, Yenagoa and the staff of the PharmacyDepartment for their support during the data collection process. We also thank Pharm (Dr) Daniel Orumwenseand Dr Suleiman, both of Clinical Pharmacy Department Niger Delta University, Wilberforce Island for theirmoral and technical support in the course of the research work.Conflict of interest:All views expressed in this paper are simply those of the authors and does not in any way represent that of themanagement of the hospital. The authors declare no conflicts of interest. 15
  7. 7. Ifeanyi E. Chima et al.,: Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012REFERENCESEnato E.F.O, Chima I.E(2011) Evaluation of drug utilization patterns and patient care practices. West AfricanJournal of Pharmacy 22 (1) 36-41Bashrahil.A (2010) Indicators for rational drug use and health services in Hadramout, Yemen. Eastern MediterrH J; 16 (2): 151-155.World Health Organization.(1993) How to investigate drug use in health facilities. Selected drug use indicators.WHO/DAP/93.1. WHO, Geneva.World Health Organization. (1985)The Rational Use of Drugs. Reports of the Conference of Experts. WHO,Geneva.Hogerzeil HV, Bimo, Ross-Degnan D et al. (1993). Field tests for rational drug use in twelve DevelopingCountries. Lancet, 342, 1408-1410.Isah AO, Laing J, Quick AFB et al.(2002). The development of reference values for the WHO health facilitycore Prescribing indicators. West Afr J Pharmacol Drug Res. 18:6-11.342, 1408-1410.Odusanya O.O (2004). Drug Use Indicators at a Secondary Health care facility in Lagos, Nigeria. Journal ofCommunity Medicine and Primary Health Care. 16 (1) 21-24Massele AY, Nsimbi SED, Rimoy G (2001). Prescribing habits in church-owned primary health care facilities inDar ES Salaam nd other Tanzanian Coast regions. East. Afr. Med. J., 78 (10): 510-514.Babalola C.P, Awoleye S.A, Akinyemi J.O, Kotila O.A (2011). Evaluation of prescription pattern in OsunState(Southwest) Nigeria. Journal of Public Health and Epidemiology Vol. 3(3), 94-98.Isah A.O, Ohaju-Obodo J, Isah E.C, Ozemoya O. (1997). Drug use profile in a Nigerian city hospital.Pharmacoepidemiology and Drug Safety; 6:319-324.Ozemoya O.E, (1997). Pharmaceutical and patient care practices in public health facilities in Benin city, EdoState. Master of Pharmacy Project Dissertation, Department of Clinical Pharmacy & Pharmacy Practice.Isah A.O, Ozemoya O.E, Onaiwu I.K (1998). Clinical consultation and pharmaceutical service times in twopublic health care facilities in Benin City. Afr J Med Pract; 5 (5): 234-237.National Population Commission. Available at : http://www.nigeriabusinessfile.com/nbfniginfo/index.php (Access: 18/02/2012).Received for Publication: 05/01/2012Accepted for Publication: 02/03/2012Corresponding AuthorIfeanyi E. ChimaDepartment of Clinical Pharmacy & Pharmacy Practice Faculty of Pharmacy, Niger Delta University,Wilberforce Island, Bayelsa State, Nigeria.E-mail: ifeanyimail@yahoo.com 16