The World Health Organization )WHO) 2013 has estimated that high blood pressure (BP) is a major public health issue and causes one in every eight deaths, hypertension being the third leading silent killer in the world. Globally, cardiovascular diseases accounts for approximately 17 billion deaths a  year,  complications  of  hypertension account for 9.4 million deaths worldwide every year. Hypertension is responsible for at least 45% of deaths due to heart disease and 51% of deaths due to stroke (World Health Organization (WHO), 2013). In India, the situation is more alarming as hypertension attributes for nearly 10% of all deaths. Prevalence of hypertension in India is reported to vary from 10 to 30.9%. The average prevalence of hypertension in India is 25% in urban and 10% in rural inhabitants. Cardiovascular diseases are projected to cause 4.6 million deaths in India by 2020 (Mahmood et al., 2011). It is estimated that the worldwide prevalence of hypertension would increase from 26.4% in 2000 to 29.2% in 2025. Anti-hypertensive pharmacotherapy effectively reduces hypertension-related morbidity and mortality (Rachana et al., 2014).

 

Some important elements of drug use patterns are accuracy, appropriateness of dose, route of adminis-tration, dosage schedule, dosage form, subject medical history, if any allergic reaction previously with the prescribed drug, drug over utilization, drug under-utilization by the subject, adverse effect from current medications, drug disease interactions, and irrational therapeutics (Seiyadu and Parimalakrishnan, 2008). Irrational use of drugs is receiving medication inappropriately to their medical necessities for inadequate period of time, wrong dose intake and administering self medicament without physician advice. Drug utilization evaluation studies is one of the important measuring tool for measuring prescribing practices in health facility, distinguishing areas for betterment and developing drug prescribing practices, promote rational prescribing practices, reduce morbidity and mortality and decrease the economic burden in their cost of illness.

 

Drug utilization studies, which evaluate and analyze (Fowad et al., 2012) the medical, social and economic outcomes of the drug therapy are more meaningful, and observe the prescribing attitude of physicians with the aim to provide drug rationally. Drug utilization research is an essential part of pharmacoepidemiology as it describes the extent, nature and determinants of drug exposure (Ushadevi et al., 2013). Drug utilization data is required for analyzing annual drug acquisition cost, drug supply to the subjects, drugs over or under utilization, drug pricing cost, cost consumption analysis and use. The anatomical therapeutic chemical (ATC) and defined daily dose (DDD) methodologies are most important tool for measuring drug use, various drug therapy and comparing anti-hypertensive drug cost consumption and improve the  drug  use  practices  in  the  health  facilities/ region (WHO, 2012).

 

World Health Organization (WHO) ATC/DDD system is the compilation of the anatomical therapeutic chemical (ATC) classification system and the defined daily dose (DDD). The DDD metric along with the ATC classification form a powerful technical tool used for analyzing patterns of drug utilization and the quality of drug use and health outcomes and also for measuring number of defined daily doses per thousand patient days (DDD/1000 patient days) and 100 patient days (DDD/100 patient days). Advantages of DDD methodology are that they can measure drug exposure, inexpensive, easy to use and allows integration with other databases (WHO, 2010).

 

WHO core drug use indicators is a tool that measures (indicators), and can describe the drug use situation in a country/region/health facility. The indicators can serve as simple supervisory tools to detect problems in performance of individual providers or health facilities. The drug use indicators can be used as "first line measures". The indicators of prescribing practices measure the performance of health care providers in several key dimensions related to the appropriate use of the drugs (World Health Organization (WHO), 1993). The purpose of this study is to find out drug utilization pattern of anti-hypertensive medications therapy on outpatients and inpatients at general medicine department in a Tertiary Care Teaching Hospital.

 

 

Aims and objectives

 

The present study aims to evaluate on drug utilization pattern of anti-hypertensive medications therapy using WHO recommended core drug use indicators like: (a) Prescribing indicators; (b) Patient care indicators and (c) Facility indicators. Also to evaluate the total consumption or utilization of antihypertensive drug in hypertensive subjects using ATC/DDD metric system at general medicine ward in a tertiary care teaching hospital.

Study setting

 

A cross sectional drug utilization study was conducted in the subjects by the Department of General Medicine in outpatient department (OPD) and inpatient department (IPD) and total 1200 beds available with 29 wards established in a tertiary care teaching hospital located in rural Chidambaram, Tamil Nadu, South India.

 

 

Study design

 

The   cross   sectional,   quantitative  and  observational  study  was adopted.

 

 

Study duration and period

 

The study was conducted for a period of 13 months (August, 2013 to August, 2014) in a tertiary care teaching hospital.

 

 

Sampling unit

 

Sampling unit was systematic random sampling method and patient encounters taking place at the inpatient and outpatient health facility for the treatment of acute, chronic and severe illness on hypertension. A total number of study samples were 1407 new prescriptions prescribed for 201 hypertensive subjects. The size of the sample consists of hypertensive subjects with multiple concomitant diseases who are enrolled and accomplished in these present study requirements as stated in the inclusion and exclusion study criteria.

 

 

Ethical considerations

 

Prepared standard research protocol, subject’s proforma and informed consent form (Tamil/English) was approved by the Institutional Human Ethical Committee of Annamalai University (Approval letter No.: M18/RMMC/2013).

 

 

Study criteria

 

Inclusion criteria

 

1. Subjects who are newly diagnosed and established history of hypertension.

2. Subjects who are prescribed with one or more antihypertensive drug.

3. Subjects who are ≥ 35 years as well as both the genders.

4. The major co-morbidity disease of diabetes mellitus, hypertensive heart diseases, hypertensive retinopathy, diabetic foot ulcer, acute pulmonary edema, myocardial infarction and coronary artery disease associated with all stages on hypertension.

5. Subjects who are willing to participate and submitted informed consent form.

 

 

Exclusion criteria

 

1. Subjects with significant hepatic and renal diseases.

2. Pregnant women.

3. Subjects who had psychiatric illness, who were chronically ill-looking.

4. Subjects who were not treated with antihypertensive drug.

5. Subjects who were unable to give proper information for data collection form and not providing consent form.

 

 

Surveillance instruments

 

1. Standard socio demographic data collection form – age, substance abusers, number of days hospitalized, number of known/unknown case on hypertension, therapy duration, therapy duration with diabetic, major complications and other concomitant diseases.

2. Subjects informed consent form.

 

3. Prescribing Indicator form, patient care Indicator form and facility care indicator form.

4. Tamil Nadu Standard Treatment Guidelines (TNSTG) Year 2013 to 2014 effective from 04.03.2013.

5. Rajah Muthiah Medical College Hospital (RMMCH) Drug List.

6. WHO core drug use indicator guidelines.

7. WHO anatomical therapeutic classification (ATC)/defined daily dose (DDD) metric system.

8. WHO collaborating centre for drug statistics methodology by name or ATC Code.

 

 

Present study – Definitions

 

1. A drug utilization study is defined as research on “the marketing, distribution, prescription and use of drugs in a society, with special emphasis on the resulting medical, social and economic consequences (Ushadevi et al., 2013)”.

2. The World Health Organization defined daily dose (DDD) is a widely applied international metric that transforms the physical quantities of drugs (capsules, vials, inhalers, etc.) into a standard unit of measure (WHO, 2003).

3. The WHO ATC/DDD standard system is a useful tool for comparing data on drug use at the international, national and/or local levels (World Health Organization, 2001).

4. The defined daily dose is a technical, fixed unit of measure, defined as the assumed average maintenance dose per day for a drug used for its main indication in adults (WHO, 2012).

 

 

Data compendium

 

In this present study, subjects were interviewed with face to face interaction based on inclusion and exclusion criteria. Total 1407 new prescriptions were collected according to subjects’ case sheets IP/OP numbers by clinical pharmacist. In subject’s case sheets, anti-hypertensive medications were written and prescribed by qualified medical personnel and post graduate doctors.

 

A standard subject socio demographic and clinical features data collection form was prepared and the characteristic like age, gender, subject IP/OP number, diagnosis, subject present/past medical history, number of days hospitalized, knowledge on hypertension, therapy duration for hypertension, therapy duration for other major complications like coronary artery diseases (CAD), myocardial infarction (MI), dilated cardio myopathy (DCM) with hypertensive heart diseases, and diabetic complications like Type II diabetes mellitus, diabetic foot ulcer, diabetic retinopathy, and other concomitant diseases like hypertensive retinopathy, CVA hemiplegia, unstable angina, tuberculosis, and hypertensive nephropathy was included, and the individual data were collected from individual subject’s case sheets, then data was analyzed first manually and entered in Microsoft excel 2007.

 

To evaluate drug utilization pattern of anti-hypertensive medications in a tertiary care teaching hospital, WHO core drug use indicators and WHO ATC/DDD metric system were used. The assessment of prescribing pattern for rationality of drug therapy in hypertensive study population based on WHO core drug use indicators included the prescribing indicators, patient care indicators, and facility indicators. The individual subject’s case sheets data were analyzed, performed, gathered and enrolled manually in ordinary prescriber indicator form and then data was analyzed to find out the number of drugs prescribed, percentage of generic name, percentage of antibiotics, percentage of injections, percentage of prescribed drugs analyzed from Tamil Nadu Standard Treatment Guidelines (TNSTG) and Rajah Muthiah Medical College Hospital (RMMCH) drug list.

 

The assessment of patient care was observed by the indicators of average consultation time, average dispensing time, and percentage of drugs actually dispensed, percentage of drugs adequately labeled, patients knowledge of correct dosage and facility care observed by the indicators of availability of TNSTG drug list and RMMCH drug list and percentage availability of anti-hypertensive drugs surveyed in a tertiary care. Frequencies of utilization of antihypertensive drugs were measured and grouped in 5 major categories: angiotensin converting enzyme inhibitor (ACEI) (enalapril and ramipril), β-blocker (atenolol, metoprolol, propranolol and nebivolol), diuretics (hydrochlorothiazide and furosemide (loop diuretics), calcium channel blockers (CCBs) (amlodipine and verapamil), angiotensin receptor II receptor antagonists (telmisartan). The prescribed antihypertensive drugs complied with TNSTG and RMMCH drug list. In addition, the utilization of different drug classes like anti platelet drugs (aspirin, clopidogrel), lipid lowering agent (atorvastatin), anti-diabetics drugs (insulin, metformin + glipizide, glimipride), non-steroidal anti-inflammatory drugs (paracetamol, ibuprofen, diclofenac sodium), antianxiety/anti-depressants (alprazolam, midazolam, diazepam), anti-coagulant agent (low molecular weight of heparin), anti-hypercholesterolemia agent (fenofibrate), anti-angina (isosorbide nitrate), vitamin B complex and other drugs like antacid, calcium tablets, anti-cold, anti-allergic, haematinic, stool softener agent were also analyzed, evaluated and recorded.

 

Measurements of drug utilization of anti-hypertensive medication were based on WHO ATC/DDD metric system. The average bed occupancy rate (statistical data) was obtained from Medical Record Departments (MRD). Every day/month bed occupancy index was calculated by MRD. Total number of units (anti-hypertensive drugs) administered during study period data was collected from a 24 h drug store. Informed consent form was collected from subjects before the starting day of the study.

 

 

Descriptions about some important core drug use indicators

 

1. Average consultation time is defined as sum of all consulting time and divided by the number of encounters. It is expressed in minutes.

2. Average dispensing time is defined as sum of all dispensing times and divided by the number of encounters. It is expressed in seconds.

3. Percentage of encounters with an antibiotic prescribed: Percentage was calculated by dividing the number of patient encounters during which an antibiotic is prescribed, by the total number of encounters surveyed, multiplied by 100.

4. Percentage of encounters with an injection prescribed: Percentage was calculated to measure the overall level use of commonly overused and costly forms of drug therapy. It was calculated by dividing the number of patient encounters in which an injection was prescribed by the total number of encounters surveyed, multiplied by 100.

 

 

Statistical analysis

 

This present study data was collected, analyzed and entered in the ‘prescribing indicator form’ manually and statistical tools like frequencies, averages/means, standard deviations and percentages were applied in this study.

 

 

Measurement of drug utilization of anti-hypertensive medication using WHO ATC/DDD metric system

 

1. Consumption of anti-hypertensive drugs in DDD in a general medicine ward on monthly basis (from August, 2013 to August, 2014).

 

2. Total consumption of anti-hypertensive drugs in DDD in a General Medicine Ward: Utilization of drugs was measured by the formula of ATC/DDD metric system (Joel et al., 2014; WHO, 2010):

 

Total inpatient days for a given period = (no. of beds per day × study period)

 

 

 

 

 

 

 

A total of 1407 prescriptions which have anti-hypertensive medications with other therapeutic medications   prescribed  for   201  hypertensive  subjects who had multiple concomitant diseases were systematically randomly collected for this particular study. Data on subject’s socio demographical characteristics and clinical features of hypertensive with other concomitant diseases is demonstrated in  Table 1.  Socio demographical characteristics of 201 subjects’ data’s are demonstrated in Table 1. The median age of male subjects was 63 years (interquartile range 36 to 83 years). The median age of female subjects was 57 years (interquartile range 40 to 85 years). Substance abused was observed that both smokers and alcoholic addicts (94%) and 6% were non-smokers with non-alcoholics but caffeine addicts and 62% male subjects addicts with tobacco more than female subjects were used both tobacco and betel nuts (38%) as well as (60.5%) subjects had known case of hypertension and (39.5%) subjects no known case of hypertension. Regarding ‘therapy duration’ of hypertension it was observed that (n = 65) subjects had uncontrolled hypertension with irregular treatment. Emergency case admitted first in casualty then transferred to coronary cardiac unit (CCU) confirmed hypertension with major complications which was observed.

 

 

 

 

Data on classification of anti-hypertensive drugs and percentage analysis of overall drug utilization are demonstrated in Table 2. Data on some other drug classes were prescribed during the study period as shown in Table 3. Frequencies of utilization of antihypertensive drugs used as various drug therapy in hypertensive study population (n = 201) are shown in Table 4. Results of identification of the anti-hypertensive drugs for rationality of prescriptions in hypertensive with multiple concomitant diseases are shown in Table 5.

 

 

 

 

Data on the assessment of drug prescribing pattern for rational drug use in the hospital using WHO prescribing indicators is shown in Table 6.

 

 

The assessment of patient care indicators

 

Total (n = 201) encounters (subjects) were taken as appointments in various consulting unit in a tertiary care teaching hospital. During the study period, (n = 119) cardiac out patients took appointment on Tuesday at every 15 days twice in a month, subjects assembled one by one in a cardiac outpatient consulting room (one general clinicians accompanied with one post graduate) with a consultation starting time at morning (8.00 a.m) and finishing time at 12.30 p.m., and (n = 28) encounters in a male and female intensive medical care unit (MIMCU and FIMCU) and (n = 54) encounters in a Coronary Care Unit (CCU) were admitted as inpatients (cardiac), consulted with one well qualified physician accompanied with five post graduates. General medicine unit is divided into four units (Medicine I, II, III and IV) and these units can follow-up both out patients  and  inpatients  on  every day and night ward rounds in respect of concerned days. The clinical Pharmacist observed consultation time and dispensing time in the morning shift for five respective concerned days in a week and prescribed drugs administered to the internal subject by nursing personnel in the ward itself. The dispensary counter was located nearby the cardiac medicine ward where the inpatients were admitted and for outpatients dispensary counter it was located just opposite to the cardiac OP consulting room, specially established for outpatients. So the subject does not wait for longer time to get the drugs at the dispensary counter. Percentage of actually dispensed drugs and percentage of drugs adequately labeled was recorded and enrolled in the ‘patient care indicator form’ analyzed and then evaluated.

 

 

The assessment of facility care Indicators

 

Availability of essential drug list or formulary

 

Total 3717 (34.93%) free drug components were prescribed.   2132  (20.04%)   anti-hypertensive    drugs +

1585 (14.89%) common drugs were complying with Tamil Nadu Standard Treatment Guidelines (TNSTG) effective from 04.03.2013 and 6921 (65.1%) prescribed and percentage drugs actually dispensed to the subjects 5767(54.2%) drugs’ complied with Rajah Muthaih Medical College Hospital (RMMCH) drug list.

 

 

The assessment of drug prescribing pattern

 

Among 1407 prescriptions analyzed  for rational medication therapy: generic name (28.2%), Percentage of encounters with an antibiotic prescribed (14.9%), Percentage of encounters with an injection prescribed (46.76%), (34.9%) of free drug components prescribed as per Tamil Nadu Standard Treatment Guidelines (TNSTG) and (54.2%) prescribed as per Rajah Muthaih Medical College Hospital (RMMCH) Drug List of paid drug components, The most commonly prescribed antibiotics were as follows: Ciprofloxacin (3.6%) followed by Amikacin (1.1%), Amoxycillin (3.3%), Ofloxacin (4.9%) and piperacillin (2.0%) and more frequently prescribed injections were as follows: Ceftriaxone (28.2%), Insulin (8.2%), Piperacillin (2.0%), Amikacin (1.1%), and Low molecular weight of heparin (7.26%).

 

 

Availability of key (anti-hypertensive) drugs

 

We evaluated the availability of number of (52.63%) antihypertensive drugs surveyed in a tertiary care teaching hospital recommended for the treatment of hypertension based on WHO core drug use indicator. Patient care and facility care indicators based on WHO prescribing indicators are shown in Table 7. Results on patient care and facility care indicators for rationalities of drug use in a tertiary care teaching hospital based on WHO prescribing indicators are displayed in Table 7.

 

 

 

 

Measurement of drug utilization of anti-hypertensive medication using ATC/DDD metric system

 

Measurement of drug utilization of antihypertensive medications were observed as follows as: Angiotensin converting enzyme inhibitor (ACE I) Enalapril and Ramipril; beta blocking agents – metoprolol, atenolol, propranolol,   nebivolol;    calcium     channel    blockers –verapamil and amlodipine; angiotensin converting II enzyme inhibitor - telmisartan and diuretics. Furosemide and hydrochlorothiazide drugs were used during this period (August. 2013 to August, 2014) and monthly consumption of antihypertensive drugs was calculated in defined daily dose study data shown in Tables 8 to 10. During this study period (August, 2013 to August, 2014) the anti-hypertensive drug consumption data were collected and analyzed in general medicine ward. Total 82 subjects were randomly collected and enrolled in the study. Twenty eight (28) subjects were admitted in MIMCU and FIMCU, and 54 subjects were admitted in CCU. The number of beds available in the ward is 450 and the number of days spent was 397 days. The average bed occupancy rate during this study period was 0.6. Amlodipine medication was most frequently utilized with respect to the number of 32.55 DDD/100 bed days and then followed by Ramipril, with 24.70 DDD/100 bed days and enalapril, with19.55 DDD/100 bed days. The total consumption of anti-hypertensive drug was detected to be 122.07 DDD/100 bed-days. The impressed number of DDD assigned for each anti-hypertensive is given by the DDD/ATC WHO metric system as recorded in Table 11.

 

 

 

 

This present study is considered to be a good prescription based evaluation study and the study is used as one of the systematic way for rationality and assessment of drug utilization, aiming to measure the rationality which can reduce morbidity and mortality.

 

 

Age factor

 

The results of our study of age factor proposed that hypertension was more prevalent in male subjects (61.7%) than female subjects (38.3%).The mean age ± SD for male (elderly + non-elderly) was 62.6 ± 11.3 and female (elderly + non-elderly) was 60.45 ± 10.5. The course of study was confirmed with one previous Indian study (Jhaj et al., 2001) on hypertensive subjects who reported the number of male subjects as 51% and female subjects as 49% and another Indian study (Jainaf et al., 2014) revealed that the number of men was 52% and women was 48% on hypertensive subjects. Rachana et al. (2014) revealed that out of 300 prescriptions, hypertension was more prevalent in male subjects (55%) and female subjects (45%) which is confirmed with the present study on hypertensive subjects. In a confounding report (Lee et al., 1997) on hypertensive subjects, women (57%) and men (43%) suffered with hypertension in an overseas study conducted in Hong Kong.

 

 

Substance abused

 

The  substance  abused  in  this   study   population  were cigarettes smoking, alcohol, caffeine, tobacco, betel leaf, betel nuts and paan. Substance abused results has shown that total number of smokers, alcohol with caffeine addicts in male subjects’ was 94% and 6% female subjects were addicts with caffeine, and 62% male subjects were addicts with  tobacco,  paan  and  caffeine.

 

About 38% female subjects were addicts with tobacco and betel leaf and nuts. The present study has shown that age factor and smoking, tobacco, betel leaf and alcohol not only increased risk of hypertension, even though the course can be authored with sedentary life style, unhealthy eating habits, excess sodium intake, excess salt intake, restless work and stress. This statement agreed with a previous Indian study (Tiwari et al., 2004) which reported 26% hypertensive age groups.

 

 

Known case on hypertension

 

On accountability of known case on hypertension, we had 42 (20.89%) male subjects and 35 (17.41%) female subjects while with no known case on hypertension with newly diagnosed, it was 58 (28.85%) male subjects and 66 (32.83%) female subjects. This study data was collected from subject’s case sheet of subject present and past medical history.

 

 

Average length of hospital stay

 

A total of 82 subjects were admitted in the internal ward. 48 (58.54%) male and 34 (41.46 %) female subjects’, who stayed more than 10 days, had severe uncontrolled hypertension with increased blood sugar level and dilated cardiac myopathy, and were kept on constant observation for their blood pressure and blood sugar level. These subjects’ stay ranged from 10 to 17 days with reduced morbidity, and average length of hospital stays was 10.33 ± 6.66. Subjects who stayed less than 10 days observed that acute or chronic stage, newly diagnosed on hypertension with atherosclerotic disease and reduced morbidity during stayed in this study period and given appointment, counseled them to continuous proper pressure monitoring. This present study confirmed with one similar previous Indian study by Joel et al., 2014, who reported that the average length of hospital stay was 11.54 ± 7.57. The relationship between length of hospital stay and blood pressure monitoring needs to be inquired in further studies which would improve subject’s quality of life and reduce their morbidity and mortality.

 

 

Overall Drug prescribing pattern

 

Fowad et al. (2008) study revealed that out of 192 hypertensive subjects, overall drug prescribing pattern is as follows: diuretics 42.2%, β adrenergic blocker 41.2%, calcium channel blocker 39.1%, angiotensin converting enzyme inhibitor 26% and angiotensin receptor II antagonist 23.4%, α 1-blocker (9.4%). On accountability of overall drug prescribing pattern of this present study, 201 hypertensive subjects had very less usage than that reported by Fowad Khurshid et al in 2012. But in this present study, angiotensin converting enzyme inhibitor (ACE I) drug class (Enalapril and Ramipril) had 45.21%, which was more frequently used than study that reported by Fowad Khurshid et al in 2012.

 

 

Single therapy (54.17%) Vs Multiple combinations therapy (45.83%)

 

Mono therapy was more frequently used than combination therapy (54.17% vs. 45.83%) and very least prescribed drugs rate was as follows: Angiotensin II receptor antagonist 32 (1.5%), angiotensin converting enzyme inhibitor (ACE I) + angiotensin II receptor antagonist 22 (1.03%)  and  diuretics  +  calcium  channel blockers + β-Blocker 17 (0.79%) proposed in this present study. Combination therapy drug utilization had very less usage when compared with the study carried out by Fowad et al. (2008) Monotherapy of angiotensin converting enzyme inhibitor (ACE I) 31.7% and angiotensin converting enzyme inhibitor (ACE I) + β-Blocker 251 (17.8%) were more frequently utilized than reported by Fowad et al. (2008) who revealed that Monotherapy 45.4% vs. Combination therapy 54.6%.

 

 

Assessment of drug prescribing pattern

 

The prescription analysis for rational drug therapy was done using WHO core drug use indicators. The mean number of drugs per prescription is computed to the measure of degree of poly pharmacy, the mean found in the present study (7.56 ± 2.76 drugs per prescription) was administered due to multiple concomitant diseases in our hypertensive study population and prescriptions containing 4 to 10 drugs were prescribed in 98% cases, and use of poly pharmacy can also extend risk of an adverse reactions, drug interactions, cost of illness and medication errors (Shankar et al., 2010). On similar study found in Central India by Vandana and Sanjaykumar (2012), average number of drugs was 7.5 per subjects, Western Nepal study reported by Shankar et al. (2010), mean number of drugs was 7.73 ± 4.24, and overseas study conducted in Tanzania (Rimoy et al., 2008); while in the present study, anti-hypertensive drugs contained 1.0 to 3.0 drugs per prescription which is compatible with the Tanzania studies by Rimoy et al. (2008) (2 to 3 drugs). In percentage of prescribed generic name (measure the trends of prescribing by generic name), in the present study, a result of (28.2%) out of 1407 prescriptions was very much lower than that reported by (Bhavesh et al. (2012) (100.0%), similar study found in Lucknow district studied by Kumari et al. (2008) in 2008 showed 27.1% low generic name, another previous study found in Ethiopia reported by Akshaya srikanth et al. (2013) in 2013 showed 94.3%, and percentage of antibiotics prescribed was 14.9% (ciprofloxacin 3.6%, amikacin 1.1%, amoxycillin (3.3%, ofloxacin (4.9%) and piperacillin (2.0%) was lower than the study carried out by Bhavesh et al. (2012) (46.17%) out of 1200 prescriptions and another study reported by Nihar et al. (2000) studied in Dr. Rajendra Prasad Centre for Ophthalmic Sciences (RPC) hospital. In the present study, percentage of injections prescribed (46.3%) was higher than the study carried out by Bhavesh et al. (2012) (0.17%), the most common drug prescribed was Vitamin B Complex (7.65%) which had less usage than the results revealed by Bhavesh et al. (2012) (Vitamin B Complex 11.03%) and 34.9% of free drug components and  54.2%  paid   drug   components   in  a  tertiary  care teaching hospital, medical personnel prescribed and dispensed drugs according Tamil Nadu Standard Treatment Guidelines (TNSTG) effective from 04.03.2013 and Rajah Muthaih Medical College Hospital (RMMCH) drug list for the treatment on high blood pressure. These two guidelines were strongly accepted by health care professionals in a tertiary care teaching hospital.

 

 

The assessment of patient care Indicator

 

Percentage of drugs actually dispensed

 

About 89.15% of all drugs were actually dispensed (34.9% free drug components based on TNSTG + 54.2% paid drug components based on RMMCH drug list). This present study result showed a high frequency of drugs dispensed, when compared with overseas study in Ethiopia reported by Akshaya srikanth et al. (2013) (78% drugs actually dispensed), which is a possible alternative that the TNSTG and RMMCH drug list may manifest medical personnel prescribing medications to most of the hypertensive population thus reducing their morbidity and mortality. This phenomenon is defined by Pepe (1994) as a “consensus between the selection criterion and ‘culturally consolidated’ prescription practices”.

 

 

Average consultation time

 

With respect to the present study, results showed an average consultation time of 13.8 min, which is being classified as ‘excellent’ according to the limitations, with below 15 min as the WHO recommended standard. Though this consultation time is longer than the results revealed by Vania dos Santosa et al. (2004) (9.2 min) and overseas study which revealed that longest consultation time for Nigeria was 6.3 min, while another overseas study reported in Ethiopia by Akshaya Srikanth et al²⁰ was 4.13 min and shortest consultation time in Bangladesh was 54 s (Hogerzeil et al., 1993).

 

 

Average dispensing time

 

WHO recommended that the pharmacists spending time with subject should be at least 180 s dispensation with each subject. Hence, the duration of dispensation of 147.4 s (2.44 min) in the current study results is good, a proper dispensation and compatible with WHO recommendations, and this result compared with one overseas dispensation reported in the literature in Ethiopia studied by Akshaya srikanth et al. (2013) (4.13 min) and some shortest dispensation reported in the literature in Lopes et al. (1996) (17 s), Tanzania (77.8 s) (Rimoy et al., 2008), Campo Grande (Cunha et al.,  2002) (55 s), Nigeria (12.5 s), Vania dos Santosa et al. (2004) (18.4 s) and Bangladesh (23 s) (Hogerzeil et al., 1993).

 

 

Drugs adequately labeled

 

In this present study carried in a tertiary care teaching hospital at dispensary counter, all drugs were completely labeled, medicines packed with specified carton box with leaflets with 87.1% drugs adequately labeled and medicines prepackaged, with perfect and proper labeling.

This present study result is compatible with the Ethiopia study by Akshaya srikanth et al. (2013) (86.4% prepackaging and labeling).

 

 

Subjects’ adequately knowledge of correct dosage

 

Akshaya Srikanth et al (2013) study revealed that 77.4% of patient had adequate knowledge about all dosage schedules of the drugs. As a result of this current study subjects, 38.3% had knowledge than that reported by Akshaya et al. (2013). The current study population it was found that 61.7% subjects had inadequate knowledge about how to administer the drugs which has been prescribed. The reason for this was because most of the subjects were illiterate and older people, unable to travel from their home town, irregular treatment, long therapy duration, inability to read prescription due to age, elderly people were affected with mental problems and sedentary life style. So all these factors lead to very poor adequate knowledge on hypertension.

 

 

The assessment of facility Indicators

 

Availability of essential drug list or formulary

 

A total of 34.9% drugs is prescribed according Tamil Nadu Standard Treatment Guidelines (TNSTG) and mean ± SD number of drugs per prescription should be 2.64 ± 1.3, while 65.1% drugs is prescribed following Rajah Muthaih Medical College Hospital (RMMCH) drug list with mean ± SD per prescription as 4.92 ± 2.40 in a tertiary care teaching hospital.

 

 

Availability of key drugs

 

52.63% anti-hypertensive drugs were freely surveyed in this present study population in a tertiary care teaching hospital and the mean number of anti-hypertensive drugs contained 1.0 to 3.0 per prescription. This present study result is compatible with the Tanzania studies by Rimoy et al. (2008) (2 to 3 drugs).

 

 

Total consumption of anti-hypertensive drugs in DDD

 

The total antihypertensive drug consumption in General medicine wards was measured in impressed number of DDD/100 bed-days. In our study, class wise found that total antihypertensive consumption of (ACE I - Ramipril and Enalapril) (670.55 DDD) was highly utilized. But drug wise, high utilization was found in the general medicine wards having amlodipine with 32.55 DDD/100 bed days than other drugs which we analyzed in present study. A similar study report was found by Joel et al., (2014) (amlodipine 33 DDD/100 bed days) and another study by Jhaveri et al. (2014) postulated that amlodipine utilization in the wards was 29 DDD/100 bed-days. Current study found that total antihypertensive drug consumption in the General medicine wards were 122.07 DDD/100 bed-days.

ACE inhibitors were most frequently utilized and amlodipine was the highest consumed in the internal ward during this study. The clinical pharmacists can be effectively employed for rationality use of medication in hypertensive population on a routine basis. In the present study, cross sectional, observational study parameters was carried out and evaluated, and measured based on WHO core drug use indicator and ATC/WHO DDD metric system. Here, many of the prescriptions were rational, but further improvement is needed in drug prescribing practices and prescribers may contribute to the progress of rational prescribing drug practices in hypertensive study population. Patients too need to express their interest to know more about the drugs they have been prescribed, and this can promote a safe knowledge on their illness and special care, which would improve their quality of life. Further, the present study can lead to finding out the influence of prescribing practice on cost of burden in the subjects which will be carried out in a future research.

Authors declare that there are no conflicts of interest.