|Year : 2019 | Volume
| Issue : 5 | Page : 626-632
Rational drug use and prescribing behavior of family physicians in Erzurum, Turkey
EO Calikoglu, E Koycegiz, Z Kosan, A Aras
Department of Public Health, Ataturk University, Medical Faculty, Erzurum, Turkey
|Date of Acceptance||04-Feb-2019|
|Date of Web Publication||15-May-2019|
Dr. E O Calikoglu
Ataturk Universitesi Halk Sagligi Anabilim Dali, Yakutiye, Erzurum
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Widespread irrational medical prescription adversely affects the outcomes of patient health and medical services. Aim: This study aims to investigate the determinants of medical prescription behavior of family physicians in Erzurum Province. Materials and Methods: This cross-sectional descriptive study was conducted during August–December 2016 on a voluntary sample of 191 out of 234 physicians (81.6%) working at family health centers in the districts of Erzurum. Physicians were visited at their workplaces, and data were collected using a self-administered and structured, 45-item questionnaire. Results: The mean age of the physicians was 34.7 ± 7.9 years, and 70.7% (n = 135) of the participants were males. About 83.8% (n = 160) of physicians responded “yes” or “sometimes” to the question “Do you prescribe medicine on demand of the patients?” The two most important factors that affected the prescribing behavior of the participants were the pharmacology lectures attended during medical education (50.8%) and the prescribing experience acquired during clinical internship (46.0%). Presentations given by the representatives of drug companies, in-service training programs after graduation, and Internet/mobile phone applications had the lowest rate of contribution as behavioral determinants. The participants perceived having sufficient information in the areas of indication for use (77.5%) and daily dose (72.8%). Only 4.2% of participants deemed their knowledge of medication costs sufficient. Pharmacology lessons were found to be more effective in the prescribing behaviors of the physicians who had less than 10 years of professional experience (Chi-square = 12.131; P = 0.002). Conclusion: Rational medical prescription continues to be a trouble among family physicians. The study findings suggest a substantial knowledge gap in participating physicians occurring after graduation and clinical internship training, in the areas of costs of medicine and rational medical prescribing.
Keywords: Family, physicians, prescriptions, primary health care
|How to cite this article:|
Calikoglu E O, Koycegiz E, Kosan Z, Aras A. Rational drug use and prescribing behavior of family physicians in Erzurum, Turkey. Niger J Clin Pract 2019;22:626-32
|How to cite this URL:|
Calikoglu E O, Koycegiz E, Kosan Z, Aras A. Rational drug use and prescribing behavior of family physicians in Erzurum, Turkey. Niger J Clin Pract [serial online] 2019 [cited 2019 May 23];22:626-32. Available from: http://www.njcponline.com/text.asp?2019/22/5/626/258266
| Introduction|| |
The opening remarks on the World Health Organization (WHO)'s webpage underscore a crisis: “The irrational use of medicines is a major problem worldwide. The WHO estimates that more than half of all medications are prescribed, dispensed or sold inappropriately, and that half of all patients fail to take them correctly. The overuse, underuse, or misuse of medicines results in wastage of scarce resources and widespread health hazards.”
The concept of rational medicine usage was first defined by the WHO in 1994 as “providing the proper medicine at proper dose for appropriate duration according to the clinical findings and characteristics of the individual.” In the guideline titled “Guide to Good Prescribing,” the WHO defines a six-stage systematic approach for the use of rational medicine.
In 2010, the WHO has upgraded its definition of rational use of medicines as to include medication cost: rational medicine use requires that “patients receive 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.”
The use of irrational medicine has many consequences such as the development of antimicrobial resistance, reduction in patients' adherence to treatment, medication interactions, wasting of limited resources, disease relapse, prolongation of treatment duration, increased frequency of side effects, and increased treatment costs.,,,,,
According to WHO data, the worldwide cost of medical expenses in 2012 was approximately 6.5 trillion dollars. Besides, the WHO has reported that medical expenses have increased and this increase is more than the increase in total health expenses. While the proportion of medical expenses among total health expenses was approximately 15.2% in 2000, it was estimated in average at 30.4% in 2006. In Turkey, medicine expenditure jumped from 5.2 billion Turkish liras (TL) in 2002 to 16 billion TL in 2011. According to a report published by the Ankara Chamber of Commerce in 2006, about 7% of the medicines in pharmacies in Turkey go to waste as expired, while the expiration dates of 60% of the medications at homes are off even without opening the box. The cost of these medicines was expected at about 500 million dollars.,
Different factors have been accused in the etiology of irrational prescriptions. Due to ignorance or self-medication, patients may come to the doctors with irrational prescription requests. In addition, lack of medical knowledge of rational medication uses and lack of medical devices for diagnosis were proposed as some reasons behind irrational prescription.
In the context of the health reforms in Turkey, we decided to repeat a study done in 2006,, presuming positive changes in the medical prescription behaviors of primary care physicians over the past 10 years. We aimed to evaluate the prescription behaviors of the family physicians in Erzurum province from the perspective of rational medical prescription use and discuss the measures which can be taken to prevent irrational prescribing.
| Materials and Methods|| |
A cross-sectional study was conducted. According to the data provided by the Provincial Public Health Directorate, 234 family physicians were working at the family health centers during the study period. Without sampling, all physicians in the study population were targeted, and all these physicians were invited to participate in this study; no incentives were offered to participate. A total of 191 family physicians (response rate 81.6%) agreed to participate.
Data were collected between 15 August and 31 December 2016 through a 30-item, self-administered, and structured questionnaire, designed on the basis of hypotheses developed from a literature search and an earlier survey. The primary hypotheses of the study were “the studied general practitioner's lack of appropriate knowledge on rational prescription” and “the most common irrational prescription items are pain medications.”
The study was approved by the Clinical Research Ethics Committee at Atatürk University Medical Faculty (Meeting No. 5, Decision No. 09; Date: 31 May 2016), and the permission for the study was granted by the provincial Governorship Public Health Directorate (No. 38940367/663.08; Date: 08.08.2016). Information was provided on the subject and purpose of the research before the application. Verbal consent was obtained from each participant, and names were not recorded on the questionnaire. The study was conducted in accordance with the principles of the Declaration of Helsinki.
Each questionnaire took about 5 min to complete. The questionnaire was used to determine the sociodemographic characteristics of the participants including age, sex, and years on the job, their perceived knowledge of rational prescription (10 items), perceived importance of the prescription criteria of rational medicine use (7 items), and factors affecting their prescribing behaviors (7 items). All the opinion questions were of 3-point Likert type (3: Most important, 2: Important, 1: Least important). Cronbach's Alpha of the 10 essential items on personal prescription (indication, dose, contraindication, side effects, interaction, bioavailability, bioequivalence, mechanism of action, application route, and cost) was calculated as 0.832. The study used four surveyors, who received specific orientation and training.
Descriptive statistics were expressed in mean and standard deviation or percentage, and frequency. Chi-square test was used to evaluate differences between the groups. A P value of <0.05 was considered statistically significant.
| Results|| |
The mean age of the physicians was 34.7 ± 7.9 years (range, 25–64 years), and 70.7% (n = 135) of the participants were males. The mean time of professional experience was 9.1 ± 7.2 years (range, 2 months–39 years). A total of 11.0% (n = 22) of the physicians had not yet completed 1 year in their occupation, while 40.8% (n = 78) of them had ≥10 years of professional experience. The mean number of daily patients seen was 35.9 ± 18.1 (range, 5–130). A total of 42.9% (n = 94) of physicians examined 21–40 patients daily, while 6.3% (n = 12) of them examined more than 61 patients daily.
We have also asked the physicians “Do you prescribe medications on demand of the patients, except for the medicines they use consistently with the diagnosis of the physicians?” to which 83.8% (n = 160) of physicians responded “yes” or “sometimes” and 16.2% (n = 31) responded “never.” There were no significant differences in the responses concerning the sex (χ2 = 2.425; P = 0.298) or experience (χ2 = 3.404; P = 0.493) of the physicians.
Painkillers were the most frequent on-demand prescribed medications followed by gastrointestinal system medications [Table 1].
The physicians perceived their knowledge sufficient mostly regarding indication (77.5%; n = 148) and daily dose (72.8%; n = 139), and least satisfactory in prices. Self-assessment of the knowledge level of the family physicians related to medicines is presented in [Table 2].
|Table 2: Self-assessment of the knowledge level of family physicians regarding medicines|
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The major factors determining the prescribing behaviors of the physicians were found to be pharmacology lessons in the medical faculty (50.8%; n = 97), prescribing skills acquired during clinical training (49.2%; n = 94), and self-learning after graduation (43.5%; n = 83). The advertisements by the representatives of medicine companies, postgraduation in-service training programs, and Internet/mobile phone applications were found to be the least influential factors [Table 3].
The most critical criteria selected by the physicians during prescription were the efficacy (67%; n = 128), safety (46.1%; n = 88), and suitability of a medication (34%; n = 65). The least important criteria, on the other hand, were the price of a prescription and its bioavailability [Table 4]. However, there was no significant difference in the self-assessment levels between the physicians who had less than 10 years of professional experience and those who had ≥10 years of professional experience (P > 0.05).
|Table 4: Self-assessment of the family physicians concerning the criteria used during prescription|
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No significant differences were found between the experience of the doctor and the criteria used during prescription (P > 0.05). On the other hand, there were some differences in the factors affecting prescription behaviors of doctors above and below 10 years of experience. Pharmacology lessons, examination of the prescriptions in clinical training, discussion with colleagues, and Internet/mobile phone applications were found to be more effective in prescribing behaviors of the physicians who had less than 10 years of professional experience (χ2 = 12.131, 0.002; 6.729, 0.035; 14.754, 0.001; and 16.514, P < 0.001, respectively), while in-service education programs were more effective for experienced doctors (χ2 = 8.602; P = 0.014). Advertisements by representatives of medical companies (χ2 = 12.186; P = 0.431) and autodidacticism after graduation (χ2 = 14.743; P = 0.256) were not significantly effective [Figure 1].
|Figure 1: Effects of different factors on prescription behaviors concerning the duration of the professional experience|
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| Discussion|| |
In this study, the pharmacology courses during the medical school and the prescribing behaviors acquired in clinical training were found to be the important factors affecting prescribing practices of the physicians. In a similar study by Akici et al., the main factors were found to be Vademecum, pharmacology books, and medication leaflets. In a previous study conducted in Erzurum, the significant factors were found to be self-learning after graduation and presentations of pharmaceutical representatives.
In a survey conducted in 12 cities in Turkey in 2016, pharmacology lessons and the prescribing skills gained from clinical instructors were found to be among the most important three determinants of medical prescription behavior, similar to the findings of this study. This might be due to the positive effects of the education programs on “problem-oriented rational therapy” introduced in 1996 to medical schools in Turkey. In this study, most of the physicians with less than 10 years of professional experience reported that pharmacology lessons were the primary factor affecting their prescribing behaviors. In pre- and poststudies evaluating the educations in rational pharmacotherapy, the success rates of the participants increased, which indicates that education related to rational medical prescription is beneficial.,,,,, The presence of advertisements of drug companies among the least influential factors in affecting the prescribing behavior may be related to the Regulation on Promotional Activities of Human Medicinal Products, which limits medical promotion activities.
In this study, the most influential factors for prescription were efficacy, safety, and suitability of a medication, similar to a previous study conducted in Erzurum in 2006 and the study by Demirkıran and Şahin conducted in Ankara. The most influential criteria in prescription, according to the study by Akici et al. and the study by Theodorou et al., were efficacy and cost. In a study by Reichert et al., 88% of the physicians reported that price was the most influential factor. In the investigation by Ozata et al., 77.76% of the physicians had “always” or “sometimes” considered the price of a medication during prescription. However, in this study, we found the cost as the least influential criterion.
As in this study, several other studies investigated the knowledge of cost and considered price as a prominent factor separately. In this study, price was not found to be influential and also the ratio of the physicians who had sufficient knowledge of the cost of medications was found to be significantly lower. However, in the studies by M. Ryan et al., Lisa M. Korn et al., and McGuire et al., most of the physicians reported that cost was important during prescribing, although a high percentage of physicians did not have any sufficient knowledge about the prices of medications.
An important focus of this investigation was the on-demand medical prescription behavior. We found that 83.7% of the physicians reported that they “always” or “sometimes” prescribed according to the demand of the patients. The ratio of the physicians answering as “always” or “sometimes” to the same question was 74.2% in the study by Akici et al. and 67.1% in the study by Ozata et al.,
In this study, the most frequent on-demand medicines were the painkillers, gastrointestinal system medicines, vitamins and minerals, and antibiotics. In a research conducted by Mollahaliloglu et al. investigating 3,201 prescriptions in 10 provinces in Turkey, the most frequent prescribed medicines were antibiotics (35.0%–43.0%), followed by analgesics (39.0%–48.0%), and gastroprotective medicines (9.0%–20.0%). The WHO indicates that optimally, less than 30% of prescriptions should contain an antibiotic. As to an Iranian study, antibiotics were prescribed in 52.1% of prescriptions.
Antibiotic overprescription is an essential problem in Turkey. With most antibiotic prescriptions being issued by family physicians, the overprescribing of antibiotics puts patients at risk of side effects, produces unnecessary costs, and increases the probability of bacterial resistance, creating a national health problem. The real or perceived pressure the patients put on family doctors to overprescribe antibiotics seems to have even expanded from Turkey to Germany where general practitioners are concerned by the similar irrational antibiotic demands of the Turkish immigrants.
Prescription monitoring programs have been introduced to decrease wasting of medications. Forty-nine states in the United States have developed prescription medicine monitoring programs, which digitally store controlled substance dispensing information and make those data accessible to prescribers, pharmacies, and law enforcement officials. The electronic prescription (e-prescription) of medicines was introduced in 2012 in Turkey, and it is mandatory since 2013. Of the total prescriptions, the ratio of e-prescriptions written in January 2013 was estimated at 70.9%. In Turkey, according to the “Prescription Information System (PIS),” a system similar to the one in the United States, which enables monitoring and auditing prescriptions, 34.9% of the prescriptions written by the family physicians in 2011 contained antibiotics. Since then, according to the PIS data, the proportion of antibiotics prescribed by family physicians in Erzurum has been decreasing (29.3% in 2013, 27.0% in 2014, 26.1% in 2015, and 24.8% in 2016).
In Turkey, the “Rational medicine use national action plan 2014–2017” included a plan to harmonize the prescription information system with e-prescription and to make the system functional. Moreover, in 2017, a project has been introduced in Turkey to prevent unnecessary prescriptions of antibiotics with rapid antigen tests, which can be easily applied during physical examination.
| Limitations|| |
Although most of the population was sampled, there may be some limitations due to study design. The general limitations of questionnaire studies apply for the demographic questions and the scales. On the other hand, direct observation of the prescription behaviors or file reviews could yield more trustable data.
| Conclusion|| |
Rational medical prescription continues to be a trouble among family physicians. The study findings suggest a substantial knowledge gap in participating physicians occurring after graduation and clinical internship training, in the areas of costs of medicine and in rational medical prescription.
| Recommendations|| |
Better integration of the pharmacology education with problem-oriented rational treatment programs, more rigorous supervision in prescribing during clinical training, higher quality in-service training, and continuous medical education could improve the prescribing attitudes and skills of physicians and reduce irrational medicine use. The inclusion of current medicine prices in the Turkish electronic prescription system and physician education on medicine cost-effectiveness would be beneficial, as most physicians have limited knowledge about the medication prices, a fact confirmed by this study. Inappropriate use of medications is likely to cause harm to both patients and health systems, and therefore, policymakers and physicians should try to reduce this infirmity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]