The practice of dispensing prescribers a threat to

The practice of dispensing prescribers – a threat to appropriate medicines use? Trap B and Hansen EH Euro Health Group, Denmark & Danish University of Pharmaceutical Sciences, Copenhagen, Denmark c o n s u l t a n t s

Abstract Problem Statement: In many countries, the functions of prescribing and dispensing are kept separate, principally to avoid a conflict of interest on the part of the prescriber, who might profit from both prescribing and selling medicine. This separation also optimises rationality of therapy by having pharmacy staff to review the prescription and ensure good practices in dispensing. However, little is known of how the quality of prescribing is influenced by the for-profit motive related to prescribing by dispensing prescribers. Objectives: To evaluate prescribing quality among dispensing doctors (DD) in comparison to doctors leaving the dispensing to pharmacies. Design: An analytical, cross-sectional, comparative survey. Setting: Individual medical practices situated in Harare, Zimbabwe. Study Population: Patient records collected from 29 randomly selected private sector dispensing doctors (DDs) and 28 non-dispensing doctors (NDDs). Outcome Measures: The quality of prescribing was assessed using three assessment criteria: (a) standard treatment guidelines; (b) the World Health Organization/INRUD rational drug use indicators; (c) a panel of experts assessing the appropriateness of prescribing. Results: The study identified major differences between the prescribing of DDs and NDDs. DDs prescribed significantly higher amounts of medicines, injections, antibiotics, mixtures, cough preparations and analgesics per patient than did NDDs. The higher prevalence of prescriptions was strongly associated with “symptomatic treatment”, general over-prescribing of antibiotics and prescription of medicines with lower clinical value. DDs’ choice of antibiotics in the treatment of upper respiratory tract infections was in general appropriate, but sub-curative dosages were prescribed to almost one fifth of DDs’ patients. Sub-curative doses of cotrimoxazole were prescribed in 23% of DDs’ encounters versus 9% by NDDs. DDs prescribed analgesics and psychotropic medicines more frequently in treatment of upper respiratory tract infection than did NDDs. Consultation time was shorter for DDs compared to NDDs, 8. 7 minutes versus 13. 0 minutes. Conclusions: DDs were significantly more likely than NDDs to have poor prescribing practices: symptomatic treatment and polypharmacy, over-use of antibiotics and injections, and prescription of sub-optimal dosages. The study findings might be an important pointer for DDs in relation to “for-profit prescribing” throughout the world. .

Background § The number of DDs has increased in several developing and developed countries. § Little is known about: • the implications of dispensing by doctors on the rationality of drug use and quality of care • how the quality of prescribing is influenced by the for-profit motive related to prescribing by dispensing prescribers. § In many countries, the functions of prescribing and dispensing are kept separate, principally to avoid a conflict of interest on the part of the prescriber, who might profit from both prescribing and selling medicine. A Dispensing Doctor (DD) is defined as a medical practitioner permitted to sell and dispense a drug to some or all of his patients, either as an exemption to the general legislation governing the provision of pharmaceutical services or as part of the overall provision of medical services

Study Aims Very few studies have evaluated the prescription habits of DDs and these studies are found inappropriate for making reliable comparisons between the practices of DDs and NDD. The aims of our study have been to: § Describe and assess the appropriateness of medicines use by DDs compared to NDDs.

Method Design Analytical, Cross-sectional, comparative survey Setting Zimbabwe, Harare Population 170 DDs, 1635 NDDs Sample size 29 DDs (17%) and 28 NDDs (1. 7%) Inclusion rate 76% DD/74% NDD of selected and reachable Patient records 30 pt. Encounters per practice Data on prescribing practices were collected from: § Patient records from individual medical practices § From April to July 1997 § By 3 data collection teams § Each team surveyed 17 -21 practices equally distributed between DDs and NDDs

Assessment Criteria • • WHO/INRUD RDU indicators Golden standard (STG) Medicines prescribed Diagnosis or symptoms Dosage- duration Correctness score list- Panel assessment Consultation time URTI and use of cotrimoxazole

Results Significant prescribing differences between DDs and NDDs: DDs N=29 NDDs N=28 Ave. No. drugs/encounter 2. 3 1. 7 Ave. No. injections/encounter 0. 30 0. 10 Ave. No. antibiotics/encounter 0. 72 0. 54 Ave. No. mixtures/encounter 0. 43 0. 25 Ave. Consultation time (min) 8. 7 13. 0 RDU Indicator DDs compared to NDDs: • Prescribe 37% more drugs per patient • Gave injections 3 times more frequently • Prescribed 33% more antibiotics • 72% more mixtures per encounter or close to every 2 pt compared to every 4 pt. • Different consultation time • See more patients per day

DDs compared to NDDs in treatment of URTI: • Prescribed more drugs, injections, analgesics, c & c preparations and psycholeptics per encounter. • Choice of antibiotics was rational, but differed. Both groups over-prescribed antibiotics. • Symptomatic treatment and medicines with lower clinical value.

DDs compared to NDDs in treatment of URTI: • Frequently prescribe sub-curative dosage and fewer curative dosages • Almost 1/5 of all DDs pt. are prescribed sub-curative dosages In use of cotrimoxazole use of sub-curative dosages were: • 23% for DD versus 9% by NDDs

P-values from regression analysis: Drug use Inj. use Mixture DD 0. 01 0. 05 Race Caucasian 0. 01 Low Density Loc. 0. 00 0. 01 Number of pt. 0. 03 Predictor variables use Consul. time • Practice type was found to be a variable explaining differences in prescribing, with DDs prescribing a higher average no. of drugs, injections and mixtures.

Conclusion § DDs provide less appropriate prescribing than NDDs characterised by: " Symptomatic prescribing – a drug for each symptom " Polypharmacy " Over-use of antibiotics and injections " Sub-optimal dosages § DDs inappropriate medicine prescribing Jeopardises patient safety, makes treatment unnecessarily costly There is a need for: Ø Ø Ø WHO to make recommendations to guide countries regarding regulation of DD Making clear separation and regulation between the functions of prescribing and for profit dispensing. Regulating “profit dispensing prescribers” and “prescribing pharmacists” at country level

References 1. Trap B, Hansen EH, Hogerzeil HV. Prescription habits of dispensing and nondispensing doctors in Zimbabwe. Health Policy and Planning; 2002: 17(3): 288 -295. 2. Trap B and Hansen EH. Cotrimoxazole prescribing by dispensing and nondispensing doctors: Do they differ in rationality? Tropical Medicine and International Health; 2002: 7(8): 1 -8. 3. Trap B and Hansen EH. Treatment of upper respiratory tract infections – a comparative study of dispensing and nondispensing doctors. Journal of Clinical Pharmacy and Therapeutics. 2002: 27: 1 -11. 4. Trap B and Hansen EH. Dispensing prescribers – a threat to appropriate medicines use? Essential Drugs Monitor, Issue No. 32, 2003: 9