Quality Evaluation of Dermatology Prescriptions: Completeness, Legibility and Rationality in a Tertiary Care Indian Hospital

Skin disorders are widespread, affecting nearly one-third of the world’s population. They constitute to be the 4^th most common cause of non-fatal disease burden worldwide, although their burden often remains underestimated. According to the Global Burden of Disease Study 2017, skin diseases result in 30 to 40 months of life lost due to disability for an adult. These conditions worsen the quality of life due to increased physical, social and psychological distress. They also impose a high financial burden owing to their chronic nature and the need for long-term therapy.

The rising prevalence of skin disorders significantly contributes to the global healthcare burden.^1–3

Dermatology offers a variety of drugs and combination products for treating skin disorders, employing both topical and oral therapies. Literature indicates that dermatologists prescribe nearly 5% of all antibiotics worldwide, often requiring extended treatment periods.^4–6 Patients getting medications relevant to their diagnosis in amount that fulfill their need for a sufficient amount of time at a reasonable price is referred to as the rational use of medicines.⁷

Evaluation of prescription pattern is the gold standard to promote the rational use of drugs. Prescription is a fundamental component of healthcare, providing specific instructions for patient treatment. Irrational prescribing or inappropriate usage of drugs might result in negative side effects, long-term infections, emergence of antimicrobial resistance and unnecessary medical exposures.^8,9 Illegible and incomplete prescriptions contribute to medication errors and adverse drug reactions, increasing treatment costs.

The World Health Organization (WHO) along with the International Network for the Rational Use of Drug (INRUD) have developed core drug use indicators for evaluating the rational use of drugs in healthcare settings, including prescribing, patient care and health facility indicators.¹⁰ Literature shows varied prescribing practices in dermatological disorders, such as high percentage of antibiotics prescribed per prescription, brand prescribing, polypharmacy and limited availability of drugs in developing countries. However, there are limited studies on the assessment of prescription patterns in Northern India, especially concerning aspects of legibility and completeness.^11–13 Therefore, this cross-sectional and observational study was undertaken to evaluate the quality of prescriptions by assessing completeness, legibility and rationality at a dermatology outpatient department of a tertiary care hospital in India, serving rural and semi-urban populations.

This was a cross-sectional and observational study conducted over a period of 12 months at the dermatology Outpatient Department (OPD) of a tertiary care teaching hospital in India catering to rural and semi urban populations.

Ethical clearance was obtained from the Institutional Ethics Committee (IEC), registered by CDSCO, MOHFW and DHR, ICMR according to ICMR/GCP guidelines. Written informed consent of the patients was taken before participating in the study. A patient information sheet was given to them and explained the purpose and details of the study in a simple manner. The confidentiality of the patient’s details was maintained. As the study was observational in nature, the patients were not subjected to any harm or risk.

The prescriptions of patients who visited the outpatient department of dermatology at the tertiary care hospital for the first time and/or newly diagnosed patients were included. The prescriptions from patients who refused to participate or contained no prescribed drugs were excluded. Overall, 3290 prescriptions were analyzed.

Patients were selected randomly. Data were collected from prescriptions and filled into the standard data collection form. Prescriptions were evaluated for completeness including date, patient information, diagnosis, treatment details and prescriber particulars. Prescriptions were assessed for legibility by three pharmacists as per 4-point legibility scoring Likert scale.¹⁴ The prescriptions were categorized as Grade one, when completely illegible; Grade two; when barely legible and required expertise of pharmacists; Grade three, when most of the things in prescriptions were moderately legible and Grade four, when prescriptions were completely legible. Further, the data were analyzed for medication patterns for various skin disorders and rationality using WHO’s drug prescribing indicators. Descriptive statistics were used to calculate frequency, averages and percentages.

3290 (100% of prescriptions) had complete typed information of the patients, including name, age, gender, address of the patient, registration number along with the date. Diagnosis was written in 2642 (80.33% of prescriptions). Past studies showed that the diagnosis was written in 64.2% and 75.35% of prescriptions respectively.^15,16 Chief complaints were mentioned in 1870 (56.83% of prescriptions). Recording of salient features related to physical examination were mentioned in 1831(55.66% of prescriptions). Patient’s history was mentioned in 1338 (40.66% of prescriptions). Results of laboratory tests investigations were mentioned in 1629 (49.5% of prescriptions). Allergy status of the patient was mentioned in 921 (28% of prescriptions). Table 1 shows the essential information about drugs was missing in several prescriptions. A rubber stamp was used for marking prescriber’s information including the name, designation and registration number in prescriptions, however it was found in 2303 (70% of prescriptions). The signature of the prescriber was mentioned in 3026 (92% of prescriptions).

All prescriptions 3290 (100%) were handwritten. 1228 (37.33%) of prescriptions were written in capital letters. Legibility score of Grade 1 was found in 49 (1.5% of prescriptions) indicating completely illegible prescriptions. 132 (4% of prescriptions) had Grade score 2; indicating barely legible prescriptions. 1881 (57.16% of prescriptions) had a Grade score of 3 indicating that most of the things in the prescriptions were moderately legible. 1228 (37.33%) of prescriptions were found to have a grade score of 4, reflecting completely legible prescriptions (Figure 1). Similar results were shown in the study carried out in 2021 with 68.5% of prescriptions were easily legible, 20% of prescriptions had difficult legibility and 11.5% of prescriptions were found to be illegible.¹⁷

Figure 2 shows the various types of skin diseases affecting people in regions surrounding the tertiary care hospital in Haryana. Acne was the most common disease in 430 (13.07% of prescriptions). 940 (28.57% of prescriptions) indicated miscellaneous disorders out of which 165 (17.54%) were infectious diseases such as pruritus, balanoposthitis, furunculosis, chicken pox, panniculitis and herpes zoster. 775 (82.46%) of miscellaneous were non-infectious diseases including alopecia, hirsutism, intertrigo, edema, lichen planus, pseudofolliculitis, allergic rashes etc. Comparing the results with a previous study, it was found that Tinea (15.25%), acne (12.36%) and drug-induced cutaneous responses (10.11%) were the three most prevalent ‘disorders.¹⁸

3290 prescriptions contained a total of 9607 drugs including drugs prescribed individually 7819 (81.39% of drugs) and as combination products 1790 (18.63% of drugs). Results indicating the pattern of drug use are shown in Figure 3. Antifungals were prescribed the maximum; 1990 (20.71%) of drugs. Miscellaneous drugs including antivirals, insect repellants, pigmentation correctors and antimetabolites constituted 500 (5.20% of drugs).

Our results were similar to a previous study,¹⁸ yet in contrast from others^4,10 where antihistamines were the most prescribed. In addition to these, skin care products such as oils, facewash, moisturizing creams and lotions, serum and hair oils, lip balms and sunscreen lotions were prescribed to form 1961 (16.96% of all drugs and cosmetics).

Our study showed that 4046 (42.12% of the drugs prescribed) were meant for topical use including creams, ointments, lotions, medicated soaps and powders, whereas 5561 (57.88% of the prescribed drugs) were oral formulations including tablets, capsules and syrups. The use of parenteral formulations was absent. Antibiotics, antifungal agents and antihistamines were prescribed for both topical as well as oral use. Antibacterial agents were prescribed as soaps or lotions. Steroids were mostly prescribed as topical, whereas NSAID’s were prescribed as oral formulations. Interestingly, our results were found to be opposite to the results obtained in a study conducted in 2015, where oral formulations were prescribed in lesser number than topical formulations.¹⁴ Another study showed that the most common dosage form was tablet (44.49%) followed by cream (24.05%).^18,19

Average number of drugs per prescription aims to determine the extent of polypharmacy practice at health care setting.²⁰ Figure 4 shows the number of drugs prescribed to patients. Average number of drugs per prescription as three was found to be comparable to the results of the past studies where it was found as 3.35, 3, 3.02 and 3.68 respectively.^18,21–23 1270 (38.61% of prescriptions) contained drugs below or equal to two. Current result also indicates that 290 (8.82% of prescriptions) contained five or more than five drugs.

Figure 1:
Legibility of prescriptions.

All the prescribed medications in 389 (11.83% of prescriptions) were written by their generic names, whereas 2901 (88.17%) prescriptions had medicines written by their trade names. Nearly similar results were obtained in earlier studies, where 3.6% and 6.95% of drugs were prescribed with generic names respectively.^21,24 On the contrary, several studies showed more than 50% of drugs prescribed by generic names, as reported with 77.3%, 85.8% and 50.33% generic names prescribing respectively.^22,25,26

From a total of 9607 drugs prescribed to 3290 patients, 1439 (14.98% of drugs) were antibiotics. 1020 (31% of prescriptions) contained a single antibiotic in them. In contrast, a previous study had 73.85% of prescriptions with antibiotics.²⁷ Similarly, several studies showed a higher percentage of antibiotics per prescription as 65.33%, 58% and 51.5%.^24,26,28

Figure 2:
Prescriptions indicating prevalence of skin diseases in patient.

Figure 3:
Percentage of prescriptions indicating pattern of drug use.

Figure 4:
Prescriptions indicating number of drugs precribed to patients.

This indicator determines number of times where an injectable drug is prescribed. It is noteworthy to mention here, that vaccinations are not considered as injections. Results showed that no injections were prescribed.

3850 (40.07% of drugs) were prescribed from India’s National List of Essential Medicines 2022 or the hospital formulary. Past studies indicate as low as 12% and 9% of drugs prescribed from EDL.^18,21 Few studies on the other hand showed 88.3% and 84% of drugs respectively prescribed from the EDL.^22,29

Dermatological diseases affect people of all ages. The diagnosis written in the prescriptions reflected the prevalence of skin disorders among semi-urban people in Northern India. The results of the pattern of drug use were in corroboration with the diagnosis mentioned in the prescriptions. Antifungals were prescribed the maximum, followed by fixed dose combinations of steroids with antifungals, steroids, antibiotics, antihistamines, NSAID’s and antibacterials. Selection of systemic or topical therapy depends on factors related to disease, patient and physician. It is simpler to prescribe an oral formulation than prescribe, educate and motivate a patient to use topical therapy, however, such kinds of practices should never be followed.¹⁹ Literature reports that patients tend to continue their treatment beyond the prescribed duration due to peer pressure, quick feel-good effect and lack of knowledge about harmful effects, in case of topical corticosteroids.¹⁹

It is of prime importance to mention the complete and correct details of the patient for medico-legal purposes. It further ensures that the patient receives drug therapy in the right amount as per the diagnosis. The patient’s details with date are printed at the time of registration, due to which our results are found to be highly favorable. Our study showed that diagnosis was not written in few prescriptions. Writing diagnosis in all the prescriptions is essential and could avoid medication errors. The determination of diagnosis is an important component of rational prescribing. The essential information of prescribed medications including dose, quantity, frequency, administration route and duration were not filled for all, making the prescriptions incomplete. The strength quantity, frequency and duration of drug therapy are critical parameters, which, if not clearly documented, can lead to ambiguity and errors.¹² Abbreviations for dosage forms such as T/tab for tablets, C/cap for capsules, Cr/C for creams, Oint for ointment, syp for syrup were observed frequently in our study. In general, physicians should avoid writing abbreviations in prescriptions. Illegible prescriptions can lead to mistakes. Poor communication in the form of illegible prescriptions can lead to confusion and errors; for example, drug names having similar spellings such as Clobetasol and Clobetasone may be dispensed or used interchangeably, if not written clearly. The study suggested the need of typed prescriptions for complete legibility.

One of the important indicators of rational drug use is determination of number of drugs per prescription.^7,22 The average number of drugs prescribed per prescription as per WHO should be less than 2, with an optimal range of 1.6 to 1.8. Polypharmacy is defined as use of multiple drugs (>5) in a patient.³⁰ When multiple drugs are used, the chances of adverse drug reactions, the risk of drug interactions and dispensing errors increases many folds. Higher number of drugs also led to decrease in medication adherence and elevate unnecessary expenses. As per the regulations, every physician should as far as possible prescribe using generic names, in capital letters, legibly and ensure the rationality, however, the confusion prevails due to availability of branded generics and lack of stringent regulations for bioequivalence testing in India, which could possibly be one of the reasons for low prescribing using generic names in our study.³¹

The frequency of antibiotic prescribing practice was found to be far less in contrast to previous studies that were suggestive of misuse of antibiotics and contributed to antimicrobial resistance.²⁷ The result for number of injections per prescription was in accordance with the guidelines of WHO, that recommends not to use injection when other forms of the drugs are available and thus reflects good prescribing practices. Our study indicates that improvement in prescribing the drugs listed from WHO’s EDL/ (NLEM in India) or a standard formulary is highly recommended the most recent list; NLEM of 2022 has included certain drugs used for the treatment of skin disorders such as Itraconazole and Terbinafine and deleted Cetrimide. These must be accounted for while prescribing, to make patients gain access to affordable rational treatment.

Studying the prescription pattern is a helpful tool to ensure rationality in prescriptions and establishing the criteria of optimum drug use and limiting medication errors. Skin diseases although widespread, are often underestimated and neglected. Analysis of prescription pattern describe the scope and patterns of drug use, current medication trends, quality of medications, adherence to standard guidelines, use of medicines from the essential drug list and usage of generic medications. Rational prescription in dermatological diseases can help to maximize clinical effectiveness and minimize the harm to the patient. The present study encourages the healthcare practitioners in dermatology to adhere to clinical guidelines, prescribe the medicines by generic names and from the essential drug list, keep drugs prescribed per prescription as low as possible, thereby enhance rational therapeutics. The prescriptions should be complete in all aspects and written in capital or computer-generated to avoid medication errors. This study could serve as the basis for policymakers and intervention studies in the future.

The authors are thankful to Department of Dermatology of Tertiary Care Hospital for permitting to perform the study.