Pattern of medication use in geriatric patients at primary healthcare facilities in Karawang, Indonesia
Received 17 September 2018
Accepted for publication 15 January 2019
Published 8 February 2019 Volume 2019:11 Pages 1—5
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Amy Norman
Peer reviewer comments 3
Editor who approved publication: Professor Rajender Aparasu
Rizky Abdulah,1 Widya N Insani,1 Novia E Putri,1 Helda P Purba,1 Dika P Destiani,1 Melisa I Barliana2
1Department of Pharmacology and Clinical Pharmacy, Universitas Padjadjaran, Bandung, Indonesia; 2Department of Biological Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
Background: Rational drug use is a critical component in patient care, particularly among the elderly who often have multiple medical problems. The aim of this study was to assess the pattern of medication use among the elderly visiting primary health care facilities.
Methods: A retrospective cross-sectional study was conducted at 25 primary health care facilities in Karawang District, Indonesia, and patients aged ≥60 years visiting the facilities from January to December 2014 were included. A systematic random sampling technique was used to select the study samples. Each prescription was assessed using the WHO prescribing indicators.
Results: A total of 10,118 prescriptions with 31,927 drugs were assessed. The average number of drugs prescribed was 3.15 (range: 1–7). Drugs prescribed by generic name comprised 98.09% (n=31,318) of the total number of drugs. Medical appointments wherein an antibiotic was prescribed constituted 23.45% (n=2373) of the total number of prescriptions. No injections were prescribed in this study setting. Drugs prescribed from the essential drug list comprised 83.07% (n=26,522). Paracetamol (13.44%), vitamin B complex (8.05%), and aluminum–magnesium hydroxide (7%) were the most frequently prescribed drugs, whereas amoxicillin (44.03%), chloramphenicol (13.10%), and ciprofloxacin (12.00%) were the most frequently prescribed antibiotics.
Conclusion: Our findings highlight that polypharmacy and prescription of essential drugs remain subjects of concern in geriatric health care. Regular medication review and promoting the use of the essential drug list among health care professionals are encouraged in primary care settings.
Keywords: WHO prescribing indicators, inappropriate prescribing, rationale prescribing
Inappropriate prescribing is one of the major challenges in the public health sector. It is associated with adverse consequences, including prolongation of illness, emergence of antimicrobial drug resistance, undesirable side effects, and increased cost of treatment.1,2 As defined by the WHO, rational drug use implies that patients receive medicines appropriate to their clinical needs, with adequate dose and sufficient duration, and at the lowest cost that can be afforded by patients and the community.3 The ultimate goal of rational prescribing is to optimize therapeutic outcomes and ensure patient safety.4
The most common influential factors of inappropriate prescribing include lack of adequate information regarding the correct treatment, poor patient–physician relationship, unavailability of appropriate alternative medicines, and improper prescribing supervision.5,6 It is estimated that 60% of medicines in public health care facilities are prescribed inappropriately in developing countries.7
Rational prescribing has significant importance for the elderly. However, the prescribing practice for this population is challenging for several reasons. Multiple comorbidities and complex treatment regimens render the elderly particularly vulnerable to drug-related adverse effects. In addition, prescribing in the elderly is often more problematic due to alterations in physiological functions, which can lead to compromised pharmacokinetics.8,9
The vital step to address the issue of inappropriate prescribing is to quantify the extent to which this phenomenon occurs.10 This finding can be used as the foundation for designing an intervention to promote rational drug use. Several instruments have been developed to assess the quality of prescribing.11–13 WHO developed a set of prescribing indicators to evaluate the appropriateness of medication, including the number of drugs prescribed per medical appointment; the percentage of drugs prescribed by generic name; and the percentage of medical appointment with antibiotics, injections, and drugs prescribed from the essential drug list.14 This is a widely accepted quantitative instrument and has been applied in various settings in >30 developing countries.15
Indonesia is one of the countries that adopt universal health care coverage for the entire population. In the current system, primary health care is the prominent frontline of health care service; thus, the quality of health care delivery must be adequate to effectively screen and manage diseases, particularly for the elderly who comprise the largest consumers of medication. Nevertheless, there is limited information on the quality of prescribing for Indonesian elderly patients in the primary health care setting. Therefore, the aim of this study was to assess the pattern of medication use among elderly patients receiving primary health care using the WHO prescribing indicators.
An observational retrospective cross-sectional study was conducted at 25 primary health care facilities in Karawang District, Indonesia. The data source was the prescriptions of geriatric patients aged ≥60 years visiting the facilities from January to December 2014. A systematic random sampling technique was used to select the study samples. The target sample size was calculated based on the estimated proportion of geriatric patients receiving inappropriate prescribing as 58.1% according to a previous study.16 A minimum sample size of 2,926 prescriptions was required to obtain a 95% confidence level. The term prescriptions refer to all treatments per medical appointment. Ethical approval was obtained from the Health Research Ethics Committee of Faculty of Medicine, Universitas Padjadjaran, Indonesia. Informed consent was not required since no intervention or changes from common practice was performed. To ensure all data remained confidential, data collection did not include any personal information that could identify the participants. The study was in accordance with declaration of Helsinki.
From each prescription, data on demographic characteristics (age and sex) and patient’s medication (name and number of drugs prescribed) were collected. The data were assessed using the WHO prescribing indicators according to the following formulas:
- The average number of drugs prescribed per medical appointment = Total number of different drug products/total number of medical appointments. This was calculated to examine the degree of polypharmacy.
- Percentage of drugs prescribed by generic name = (Total number of drugs prescribed by generic name/total number of drugs prescribed) × 100.
- Percentage of medical appointment in which an antibiotic was prescribed = (Number of medical appointment in which an antibiotic was prescribed/total number of appointments) × 100.
- Percentage of medical appointment with an injection prescribed was not calculated because no injection was prescribed in this study setting.
- Percentage of drugs prescribed from the Indonesian national essential drug list = (Number of drugs that are in the essential drug list/total number of drugs prescribed) × 100.14
Statistical analysis was performed using descriptive statistics, expressed as proportion and mean values, depending on each indicator. Normality of the data was examined using the Kolmogorov–Smirnov test. Spearman’s correlation test was used to assess the association between the age of the patients and the number of drugs prescribed. P<0.05 was considered statistically significant. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) version 17.0 (IBM Corporation, Armonk, NY, USA).
A total of 10,118 prescriptions from 25 primary health care facilities were included in this study. More than half of the patients were female (54.3%, n=5,493). The majority of patients were in the age group of 60–74 years (90.2%, n=9,125). The demographic characteristics of the study patients are presented in Table 1.
Table 1 Demographic characteristics of the patients
Among the 10,118 prescriptions, the total number of drugs prescribed was 31,927, with an average of 3.15 drugs (range: 1–7). Almost half (48.1%, n=4,871) of the patients received three drugs, whereas approximately one-third of them received four or more drugs (Table 2). Statistical analysis revealed a moderate but statistically significant correlation between increasing age and higher number of prescribed drugs per prescription (r=0.55, P=0.001).
Table 2 Number of drugs prescribed per medical appointment
The percentage of drugs prescribed by generic name was close to optimal, ie, 98.09% (n=31,318). Medical appointment wherein an antibiotic prescribed was 23.45% (n=2,373). No injection was prescribed in this study setting. Drugs prescribed from the essential drug list constituted 83.07% (n=26,522) of the total number of drugs. Table 3 summarizes the results of the assessment of the prescribing quality.
Table 3 Results of the assessment of the prescribing quality (n=10,118 prescriptions)
The most frequently prescribed drugs were paracetamol (13.44%), vitamin B complex (8.05%), and aluminum–magnesium hydroxide (7%). Amoxicillin (44.03%), chloramphenicol (13.10%), and ciprofloxacin (12.00%) were among the most frequently prescribed antibiotics (Tables 4 and 5).
Table 4 Most frequently prescribed drugs
Table 5 Most frequently prescribed antibiotics
Inappropriate prescribing is a major concern in the health care service, particularly in developing countries where the health system and health monitoring are often not well established.15 This study evaluated the prescribing quality using the WHO prescribing indicators among Indonesian elderly patients. Owing to the scarcity of studies from Indonesia, the results of this study can serve as baseline information for health care professionals and policymakers to further improve drug therapy.
We found that the number of drugs prescribed was the most notable indicator that deviated from the standard recommended by WHO. The average number of drugs prescribed was 3.15, which exceeded the WHO standard (1.6–1.8). Unnecessary combination of drugs could increase the risk of nonadherence and adverse drug effects, particularly in the elderly.14 Our finding was higher than those reported in Pakistan (2.3),10 Ethiopia (1.9),16 Zimbabwe (1.3),17 and Sudan (1.4)18 but relatively lower than those reported in China (3.5),19 Iran (3.68),20 and India (3.7).21,22
In this study, we found that the majority of drugs were prescribed by generic name (98.09%, n=31,318), which was already in accordance with the WHO standard.14 The use of the generic name is important as a safety measure for patients because it depicts a clear identification that can enable better communication between health care professionals.23 Prescribing generic drugs can also help sustain affordable access to medication, particularly in lower middle-income countries such as Indonesia.24 Nevertheless, the study setting might influence this finding. Prescribing generic drugs is a common practice in public medical centers, whereas the trend in private facilities is relatively different.25,26 A much lower rate of prescribing generic drugs has been reported in private medical centers (1.6%–24.5%).25,27–29 Prescribers in private health care facilities may perceive that prescribing generic products is not financially rewarding.17,30 In addition, a negative perception on the quality and efficacy of generic products has been demonstrated to be another major barrier of generic prescribing.29 One of the key strategies for enhancing public confidence in generic medicine is providing information and education, particularly regarding the strict regulation of the bioequivalence standard in drug authorization approval and evidence on comparable clinical outcomes between the originator and its generic products across a wide range of diseases.31–33
Medical appointment wherein an antibiotic prescribed was 23.45% (n=2,373) of the total appointments, which was in accordance with the WHO recommendation (20%–26.8%). Primary care accounted for 74%–80% of all antibiotic prescriptions,34,35 which indicates that the antibiotic-prescribing quality in these facilities can play a major role in preventing the misuse and overuse of antibiotics. Appropriate prescribing of antibiotics can prevent the risk of antimicrobial resistance and increase the chances of successful treatment completion.36 Selecting an appropriate antibiotic based on the results of microbiological testing of the pathogen is associated with substantial advantages in improving patient outcomes.37,38 However, it cannot always be performed in limited-resource facilities like primary care setting, which can lead to the tendency of regularly prescribing broad-spectrum antibiotics to address suspected infections.10
Drugs prescribed from the essential drug list were 83.07% (n=26,522) of the total number of drugs prescribed, which were lower than the WHO standard (100%). This value was slightly higher than that reported by a survey conducted in a region from Southeast Asia (81%) during 2006. The essential drug list is a vital instrument to improve access to medicines that satisfy the priority of the population’s health care needs.39 Adherence to the essential drug list can lead to better medication management and more rational prescribing because these drugs have been judiciously selected based on scientific evidence regarding their quality, safety, efficacy, and cost-effectiveness.40 Improvement in adherence can be achieved by adequate sensitization of the essential drug list among health care professionals and the availability of an enforcement mechanism.17
Our finding suggests that regular medication monitoring by pharmacist is needed in primary care setting to improve current prescribing practice.23 Previous studies emphasized the importance of the following three aspects of drug monitoring, ie, regular medication review, identification of adverse reactions, and monitoring the effect of newly prescribed medication.41–43
This study has some limitations. First, the justification of the selection of medicine could not be evaluated using the WHO prescribing indicators, and this may affect our judgment on the rationality of medication. Second, in contrast to a longitudinal study, since our study was cross-sectional, it did not allow the assessment of possible trends associated with changes in the national policy on health care provision.
Our findings highlight that polypharmacy and prescription of essential drugs remain subjects of concern in geriatric health care. Regular medication review and promoting the use of the essential drug list among health care professionals are encouraged in primary care settings.
The authors report no conflicts of interest in this work.
Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care. 2002;11(4):340–344.
Garg M, Vishwakarma P, Sharma M, Nehra R, Saxena KK. The impact of irrational practices: a wake up call. J Pharmacol Pharmacother. 2014;5(4):245–247.
Organization WH. The Pursuit of Responsible Use of Medicines: Sharing and Learning from Country Experiences. Geneva: World Health Organization; 2012.
Choonara I. Rational prescribing is important in all settings. Arch Dis Child. 2013;98(9):720.
Ojo MA, Igwilo CI, Emedoh T. Prescribing patterns and perceptions of health care professionals about rational drug use in a specialist hospital clinic. J Public Health Afr. 2014;5(2):242.
Yousefi N, Majdzadeh R, Valadkhani M, Nedjat S, Mohammadi H. Reasons for physicians’ tendency to irrational prescription of corticosteroids. Iran Red Crescent Med J. 2012;14(11):713–718.
Hogerzeil HV. Promoting rational prescribing: an international perspective. Br J Clin Pharmacol. 1995;39(1):1–6.
Mallet L, Spinewine A, Huang A. The challenge of managing drug interactions in elderly people. Lancet. 2007;370(9582):185–191.
Milton JC, Hill-Smith I, Jackson SH. Prescribing for older people. BMJ. 2008;336(7644):606–609.
Atif M, Azeem M, Sarwar MR, et al. WHO/INRUD prescribing indicators and prescribing trends of antibiotics in the accident and emergency department of Bahawal Victoria Hospital, Pakistan. Springerplus. 2016;5(1):1928.
American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–631.
O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213–218.
Renom-Guiteras A, Meyer G, Thürmann PA. The EU(7)-PIM list: a list of potentially inappropriate medications for older people consented by experts from seven European countries. Eur J Clin Pharmacol. 2015;71(7):861–875.
WHO. Promoting Rational Use of Medicines: Core Components-WHO Policy Perspectives on Medicines. Geneva: World Health Organization; 2002.
Laing R, Hogerzeil H, Ross-Degnan D. Ten Recommendations to improve use of medicines in developing countries. Health Policy Plan. 2001;16(1):13–20.
Desalegn AA. Assessment of drug use pattern using who prescribing indicators at Hawassa university teaching and referral hospital, South Ethiopia: a cross-sectional study. BMC Health Serv Res. 2013;13(1):170.
Ofori-Asenso R, Brhlikova P, Pollock AM. Prescribing indicators at primary health care centers within the WHO African region: a systematic analysis (1995–2015). BMC Public Health. 2016;16(1):724.
Hogerzeil HV, Bimo B, Ross-Degnan D, et al. Field tests for rational drug use in twelve developing countries. Lancet. 1993;342(8884):1408–1410.
Wang H, Li N, Zhu H, Xu S, Lu H, Feng Z. Prescription pattern and its influencing factors in Chinese county hospitals: a retrospective cross-sectional study. PLoS One. 2013;8(5):e63225.
Karimi A, Haerizadeh M, Soleymani F, Haerizadeh M, Taheri F. Evaluation of medicine prescription pattern using World Health organization prescribing indicators in Iran: a cross-sectional study. J Res Pharm Pract. 2014;3(2):39–45.
Aravamuthan A, Arputhavanan M, Subramaniam K, Udaya Chander SJ. Assessment of current prescribing practices using World Health organization core drug use and complementary indicators in selected rural community pharmacies in southern India. J Pharm Policy Pract. 2017;10(1):1.
Zelko E, Klemenc-Ketis Z, Tusek-Bunc K. Medication adherence in elderly with polypharmacy living at home: a systematic review of existing studies. Mater Sociomed. 2016;28(2):129–132.
Akl OA, El Mahalli AA, Elkahky AA, Salem AM. WHO/INRUD drug use indicators at primary healthcare centers in Alexandria, Egypt. J Taibah Univ Med Sci. 2014;9(1):54–64.
Cameron A, Ewen M, Ross-Degnan D, Ball D, Laing R. Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis. Lancet. 2009;373(9659):240–249.
Roy V, Gupta U, Gupta M, Agarwal AK. Prescribing practices in private health facilities in Delhi (India). Indian J Pharmacol. 2013;45(5):534–535.
Dinge F, Abdulah R, Sumiwi SA. Evaluation of prescription pattern for internal medicines outpatients using World Health organization indicators. Pharmacol Clin Pharm Res. 2018;2(3):59–62.
Erah PO, Olumide GO, Okhamafe AO. Prescribing practices in two health care facilities in Warri, southern Nigeria: a comparative study. Trop J Pharm Res. 2003;2(1):175–182.
Mohlala G, Peltzer K, Phaswana-Mafuya N, Ramlagan S. Drug prescription habits in public and private health facilities in 2 provinces in South Africa. East Mediterr Health J. 2010;16(3):324–328.
Kumar R, Hassali MA, Saleem F, et al. Knowledge and perceptions of physicians from private medical centres towards generic medicines: a nationwide survey from Malaysia. J Pharm Policy Pract. 2015;8(1):11.
Trap B, Hansen EH, Hogerzeil HV. Prescription habits of dispensing and non-dispensing doctors in Zimbabwe. Health Policy Plan. 2002;17(3):288–295.
Kesselheim AS, Misono AS, Lee JL, et al. Clinical equivalence of generic and brand-name drugs used in cardiovascular disease: a systematic review and meta-analysis. JAMA. 2008;300(21):2514–2526.
Paton C. Generic clozapine: outcomes after switching formulations. Br J Psychiatry. 2006;189:184–185.
Dunne SS, Dunne CP. What do people really think of generic medicines? A systematic review and critical appraisal of literature on stakeholder perceptions of generic drugs. BMC Med. 2015;13:173.
Wise R, Hart T, Cars O, et al. Antimicrobial resistance. Is a major threat to public health. BMJ. 1998;317(7159):609–610.
O’Connor R, O’Doherty J, O’Regan A, Dunne C. Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review. Ir J Med Sci. 2018;187(4):969–986.
Organization WH. The World Medicines Situation. Geneva: World Health Organization; 2004.
Pradipta IS, Sodik DC, Lestari K, et al. Antibiotic resistance in sepsis patients: evaluation and recommendation of antibiotic use. N Am J Med Sci. 2013;5(6):344–352.
Leibovici L, Shraga I, Andreassen S. How do you choose antibiotic treatment? BMJ. 1999;318(7198):1614–1616.
WHO. WHO Model List of Essential Medicines. Geneva: World Health Organization; 2015.
Eom G, Grootendorst P, Duffin J. The case for an essential medicines list for Canada. CMAJ. 2016;188(17–18):E499–E503.
Gnjidic D, Tinetti M, Allore HG. Assessing medication burden and polypharmacy: finding the perfect measure. Expert Rev Clin Pharmacol. 2017;10(4):345–347.
Farrell B, Monahan A, Thompson W. Revisiting medication use in a frail 93-year-old man experiencing possible adverse effects. CMAJ. 2014;186(6):445–449.
Farrell B, Merkley VF, Thompson W. Managing polypharmacy in a 77-year-old woman with multiple prescribers. CMAJ. 2013;185(14):1240–1245.
This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.Download Article [PDF]