1. Abstract Pattern of medicine use among in-patients in a tertiary health care setting using the WHO prescribing indicators Ehizokhale Peter Akhideno, Department Of Medicine,Irrua specialist Teaching Hospital, Irrua; Ambrose O Isah Clinical Pharmacology and Therapeutics Unit, Department Of Medicine, University of Benin Teaching Hospital; Keywords: Indicators, in-patients, rational drug use. Problem statement: Irrational use of medicines exemplified by polypharmacy, overuse of injections and antimicrobials have resulted in increased morbidity, mortality and cost burden for patients. This is especially more so in developing countries where in- patient medicines use are poorly characterized. This study evaluates the use of medicines among in-patients in a tertiary health care setting using the WHO drug use indicators. Objectives: To outline the pattern of use of medicines using the WHO prescribing indicators among in-patients in a tertiary health care setting with a view to attain a rational and safer pharmacotherapy. Design: A descriptive prospective study of patients admitted into the adult medical wards of a tertiary health care setting in Nigeria. Setting: This study was conducted at the University of Benin Teaching Hospital, a 620-bed tertiary health care setting. Study population: All patients admitted into the adult medical wards over a period of 9 months, numbering 507 were included in the study. Males were 269 and females 238. The mean age of participants was 48.9±17.8 years ranging from 17- 89 years. Policies: The WHO indicator was designed for out-patient encounters. Some studies including this, have modified the indicators for use in in-patient setting. Admitted patients were evaluated on days 0, (day of admission), 1, 3, 7, 10, 14 and weekly thereafter and at discharge. All medicines prescribed for patients were noted. Doses, frequency, and route of administration were recorded. Outcome measures: The WHO drug use indicator values. Results: The most frequent diagnoses were malaria, HIV/AIDS, diabetes and hypertension (18.9, 17.2, 17.0 and 16.8% of patients respectively). The mean duration of hospital stay was 11.9±11.3. The average number of medicines used per patient during admission was 9.1±3.8 (median 8); The number of drugs rose from 4.2 on admission to 8.3 on day 28, reducing to 6.3 on discharge. Prescription from essential medicines list and generic prescribing were 88.1% and 85.6% respectively. The percentage of admissions with injectables prescribed was 89.3%, decreasing from 75.1% on admission day to 48.7% on discharge, while those with antimicrobials prescribed was 61.9%, rising from 41.2% on admission to 68.4% on day 28, reducing at discharge to 49.3%. The percentage of admissions with antimalarials prescribed was 18.9%. STG was at developmental stage thus unavailable as at study. Conclusion: The WHO indicators would serve usefully perhaps with some modification in the study of drug use among in-patients. The rates of prescriptions of medicines on the EM list and use of generic names were fairly high, however the WHO recommendation is 100% leaving room for improvement. The rates of use of antimicrobials and injectables were high, suggesting overuse among in-patients. There is however a need to develop standard values for the basis of comparison as in-patients and out- patients differ in profile and severity of illness.

2. Introduction Use of medicines is considered to be an important step in patient care. However, irrational use of medicines exemplified by polypharmacy, overuse of injections and antimicrobials have resulted in increased morbidity, mortality and cost burden for patients. Tackling problems associated with rational medicine use and its monitoring has been a priority issue of the WHO. The development of standard indicators for such monitoring may be regarded as one of the most notable achievements in the efforts aimed at promoting rational use of medicines, especially since the WHO sponsored Nairobi conference of 1985 on rational medicine use. The indicators enable the characterisation of medicine use pattern, identification of inappropriate use and evaluation of interventional strategies.

3. Introduction These indicators were developed for out-patients and they have been used extensively for out-patients’ rational medicine use evaluation and monitoring. From available literature, rational use of medicines is poorly characterised among in-patients. This is even more so in developing countries. In-patient medicine use patterns are likely to differ from out-patients since they are usually more ill and likely to require more concomitant medicines. There are also some medicines which may only be administered among in-patients. In this study, an attempt is made to evaluate the use of medicines among in-patients using the WHO drug use prescribing indicators, with some modification to suit this purpose.

4. Objective To outline the pattern of medicine use, using the WHO prescribing indicators among in-patients in a tertiary health care setting with a view to attain a rational and safer pharmacotherapy.

5. Methods Study location: The University of Benin Teaching Hospital, Benin City, located in Southern Nigeria on longitude 5.6145 ⁰ E and latitude 6.3176 ⁰ N. It is a Federal government owned tertiary health care institution with 620 bed spaces including an 84-bed space medical wards. Inclusion criteria: All consecutive patients admitted to the medical wards. Exclusion criteria: 1. Patients that were wrongly diagnosed with medical illness and initially admitted into medical wards. 2. Patients referred from other wards after initial management for non-medical reasons. 3. Patients who could not or who declined to give consent.

6. Methods Conduct: The study is a descriptive prospective study. Information concerning all admitted patients were entered into a data collection form, modified from the WHO prescribing indicator form. Patients were evaluated on days 0 (admission day), 1, 3, 7, 10, 14, 21 and weekly thereafter till discharge and at discharge or death. Socio- demographic parameters including age, sex, religion, occupation amongst others were recorded at admission. Records were made of all medicines prescribed during admission, including dates, route, doses and frequency of administration. The hospital’s Essential Medicines List which was largely derived from the WHO Essential Medicines List was used to assess medicines prescribed. Patients’ morbidities were recorded at admission (initial diagnoses) and at discharge (final diagnoses). The final diagnoses were used in the evaluation of morbidity patterns and classified using the ICD-10 classification of diseases. Data was entered for statistical analyses using SPSS version 13.

7. Results Total number of patients evaluated = 507 Number of males = 269 (53.1%) Number of females = 238 (46.9%) Table 1: Age and duration of hospital stay (in days) of medical patients admitted into UBTH Benin City Mean ± SD median Age (years)All patients 48.9±17.8 46 Males 48.3±17.9 45 Females 49.5±17.7 46 Duration of hosp. stayAll patients 11.9±11.3 9 Males 10.9±10.2 7 Females12.9±12.3 10

8. Results S/NICD-10 classification TitleNumber of patients (%) 1A00 – B99Certain infectious and parasitic diseases290 (57.2) 2I00 – I99Diseases of the circulatory system125 (24.7) 3N00 – N99Diseases of the genitourinary system117 (23.1) 4G00 – G99Diseases of the nervous system105 (20.7) 5E00 – E90Endocrine, nutritional and metabolic diseases92 (18.1) 6K00 – K93Diseases of the digestive system58 (11.4) 7T36 – T50Drugs, medicaments and biological substances poisoning 52 (10.3) 8J00 – J99Diseases of the respiratory system38 (7.5) 9D50 – D89Disease of blood and blood forming organs12 (2.4) 10M00 – M99Musculoskeletal system and connective tissue disease6 (1.2) 11X20 – X29Contact with venomous animals and plants 4 (0.8) Table 2: Morbidity pattern of medical patients admitted in UBTH Benin City using the ICD-10 classification

9. Results S/NMorbidity(%) 1.Malaria18.9 2.HIV/AIDS17.2 3.Diabetes mellitus17.0 4.Hypertension16.8 5.Chronic renal failure13.8 6.Cerebrovascular accident12.4 7.Adverse drug reaction10.1 8.Tuberculosis9.7 9.Heart Failure7.9 10.Sepsis5.3 Table 3: Most frequent disease entities (top 10) diagnosed among patients admitted in UBTH Benin City

10. Results S/ N ATC main groupFrequency% of all prescriptions 1Alimentary tract and metabolism116725.6 2Blood and blood forming organs91420.1 3Cardiovascular system87819.3 4Antiinfectives for systemic use86819.1 5Nervous system3437.5 6Antiparasitic products1824.0 7Musculoskeletal system551.2 8Systemic hormonal preparation521.1 9Dermatologicals491.1 10Respiratory system370.8 11Antineoplastic and immunomodulating agents40.08 12General nutrients20.04 TOTAL4551100 Table 4: Major classes of medicines used for medical in-patients in UBTH using the anatomic therapeutic chemical classification

11. Results INDICATORVALUE Average no of medicines per admission 9.1 ±3.8 (median=8) Females:9.5±3.7(median=9) Males : 8.7±3.8 (median=8) % of medicines prescribed by generic name 85.6% % of drugs prescribed from essential medicines list 88.1% % of admissions with injections prescribed 89.3% % of admissions with antimicrobials prescribed 61.9% % of admissions with antimalarials prescribed 18.9% Table 5: Observed values for WHO indicators for medical in-patients in UBTH Benin City

12. Results Figure 1: WHO indicators for specific evaluated days of in-patient stay in the medical wards in UBTH Benin City

13. Conclusions/Implications The most frequent medicines used were mainly in the ATC classes ‘Alimentary tract and metabolism’ and ‘Blood and blood forming organs’, classes that include haematinics and antiemetics. Use of analgesics was also prevalent, all suggesting that symptomatic treatment is widely prevalent. When compared with the WHO recommended values, modest values were obtained for medicines prescribed in generic names (85.6%) and those prescribed from Essential Medicines List (88.1%). Admissions with injections and antimicrobials prescribed were 89.3% and 61.9% respectively. These high values may suggest an overuse of injections and perhaps antimicrobials. However, no reference values exist for in-patient care for comparisons. While there is need to develop such values, the impact of an interventional programme will be most revealing. In all, the WHO prescribing indicators with modifications, used in this study have highlighted areas for further research.