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OJHAS Vol. 9, Issue 3:
(Jul - Sep, 2010) |
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| Comparison of the Knowledge in Core
Policies of Essential Drug List Among Medical Practitioners and Medical Students
in Galle, Sri Lanka |
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Hettihewa LM,
Department
of Pharmacology, Molecular Science and Biomedical Unit, Faculty of Medicine, University of Ruhuna, Sri Lanka,
Jayarathna
KAKT,
Department
of Pharmacology, Faculty of Medicine, University of Ruhuna, Sri Lanka. |
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Address For Correspondence |
Senior
Lecturer & Head, Department of Pharmacology,
Faculty
of Medicine,
University
of Ruhuna,
Sri
Lanka.
E-mail:
menik@med.ruh.ac.lk |
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Hettihewa LM, Jayarathna
KAKT. Comparison of the Knowledge in Core
Policies of Essential Drug List Among Medical Practitioners and Medical Students
in Galle, Sri Lanka. Online J Health Allied Scs.
2010;9(3):7 |
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Submitted: Aug 9, 2010;
Accepted:
Sep 28, 2010; Published: Oct 15, 2010 |
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| Abstract: |
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Selection of the best and safest medicine should be one of the national
economic policies in a country for good health care services. Introduction of
detailed module in rational use of medicine (RUM) to pharmacology syllabus
needed prior analysis of the existing knowledge among health care workers.
Therefore we assessed the knowledge and attitudes of essential drug list (EDL)
on medical practitioners (MPs) and medical students (MSs). Forty two MPs and 120
MSs from hospital and Faculty of Medicine were given a pretested structured
questionnaire related to core policies of EDL, contents, criteria for selection
and time frame for revision in RUM. Our study showed that only 29% of MPs were
confident about their knowledge in EDL and 17% of them had marked it as don’t
know. Study was expanded for quantitative analysis of the knowledge on the core
policies of EDL on them. Knowledge on contents, criteria for selection and the
time frame for revision of EDL were 63%, 83% and 17% in MPs. Of MSs, 87% had
sound knowledge in core contents, 32% in criteria for selection and only 50% of
MSs were aware about the correct time frame of revision of EDL. Knowledge in
contents of EDL was higher in MSs (87%) than MPs(63&). MPs were not aware
about EDL preparing criteria such as inclusion of generic names, common ailment,
majority ailments of the people (59%, 56% and 56% respectively). In contrast, MSs had > 93% of the knowledge in all three areas. However MSs had poorer
knowledge (32%) in criteria for selection of EDL than MPs (83%). Knowledge in
time frame for revision of EDL was 17% in MPs and 50% in MSs. We found that MPs
in the service were not convinced about their knowledge in EDL. Deficiency was
significant in the core contents of the EDL preparation. Therefore we suggest
that MPs need repetitive in-service training programme for practicing of RUM in
the national health facilities. We need to reiterative programme in the core curriculum regarding the criteria
for EDL selection. Though MSs had good knowledge in content of EDL, they are poor
in criteria for selection and time frame for revision.
Key Words: Rational
use of medicine; Essential drug list; Core policies; Medical practitioners;
Medical students
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It has been observed in many countries that the main thrust of
prescribing drugs has shifted from the list of cost effective and essential drugs
in the procurement systems to the big crisis of irrational prescribing.1
Prescribing drugs is an essential skill, which is required to be continuously
assessed and refined accordingly. It not only reflects the physician’s
knowledge of pharmacology and pathophysiology but also his/her skill in
diagnosis and attitude towards selecting the most appropriate treatment.2
The rational prescribing skills of clinicians can be assessed by conducting
periodic audits on knowledge by studying drug selection in prescriptions. In a
teaching hospital as the medical teachers are the role models for the students,
the prescribing behavior of the teachers can affect the students.3
There is an urgent need to ensure that patients are always given
evidence-based, cost-effective and rational treatments.2 This can be
achieved with the selection of the best and safest the
national economic policies in a country for good health care services.4
As the initial step, there is a need for former analysis of the existing
knowledge among health care workers is needed to the inclusion of detailed
module in rational use of medicine (RUM) to pharmacology syllabus.3,4
Therefore the present study was planned to assess
the knowledge of essential drug list (EDL)5,6 and the attitudes on
practicing EDL by medical practitioners (MPs) and medical students (MSs).
It was a prospective,
comparative cross sectional survey. The study was carried out at the
Teaching Hospital, Karapitiya and Faculty of Medicine, University of
Ruhuna. Knowledge on EDL was assessed in 42 MPs
and 120 MSs. The ethical clearance was granted by the ethics and review
committee of the institution.
The knowledge
on EDL was assessed in 42 MPs
and 120 MSs using a pretested structured questionnaire related to core
policies of EDL, contents, criteria for selection and frequency of revision
in RUM. Participants were selected from hospital and faculty staff and
students. The students that took part in this study were finished the
whole pharmacology syllabus in their undergraduate curriculum.
Questionnaire
is given in Table 1.
Table 1:
Questionnaire
on assessment of knowledge on rational
use of medicine of
health personnel
- My knowledge
on (Good / fair / don't know)
- Standard treatment guidelines/Essential drug list
- National
formulary/Hospital formulary
- Drug
and therapeutic committees
- Reliable drug information
sources
- Essential drugs
list is (Mark as True/ false)
- List of life saving
drugs
- List of drugs by
generic names
- List of drugs required
for common ailments
- List of drugs required
for majority of ailments and people
- List of drugs required
for priority needs of the population
- Core policies to promote more
rational use of drugs include (Mark as True/ false)
- Essential drug list
- Standard treatment
guidelines
- Restricting prescribing
- Cross sectional
supervision, audits and feedback
- Sufficient government
money
- Regarding standard
treatment guidelines (Mark as True/ false)
- It consists of clinical
features of the illness
- It is not necessary
to update the STG
- Include common treatment
practices but not the best practice
- Provide guidance
to orient new prescribers
- It is prepared according
to the personnel experience
- Criteria for
selection of essential drugs are (Mark as True/ false)
- Pattern of prevalent
diseases
- The training and
experience of available personnel
- Treatment facilities
- Relative efficacy
cost and suitability
- Latest drug in the
market
- Which of the
following is the most effective intervention to improve prescribing
practices (Mark as True/ false)
- Drug bulletin/newsletter
- Seminar
- Face to face education
- Pre service training of the doctors
- Drug information from pharmaceutical
industry
- Strongest evidence
comes from the following
- Randomized Controlled comparative
trials
- Review articles
- Meta analysis
- Clinical experience
- Text books
- Basic drug information
in formulary is / are
- Dose
- Dosing
interval
- Brand name
- Generic name
- Clinical indications
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How frequently should
Essential Medicines List be revised?
- Every quarter
- Every two years
- Every five years
- No revision required
- Every Year
Statistical analysis :Analysis was
done using microcal origin statistical package.
1.1 Percentage
of knowledge on key policies of RUM
We analyzed
the level of knowledge of MPs on RUM under the topics of standard treatment
guideline (STG)(A), EDL (B), national formulary/hospital formulary (NF/HF)(C),
drugs and therapeutic committees (DTC)(D) and reliable drug information
sources (RDIS)(E).
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The
level
of knowledge in key policies on RUM of 42 MPs were assessed. The percentages
of MPs who were confident on their knowledge were 26.83%, 29.27%, 24.39%,
9.76% and 29.27% on STG, EDL, NF/HF, DTC and RDIS respectively. Some
of MPs were convinced or not at all aware of STG in 7.32%, EDL in17%,
NF/HF in19.51%, DTC in 58.54% and RDIS in 12.2%. |
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Figure
1: Level of knowledge in key policies on RUM of 42 MPs |
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1.2
Percentage of knowledge of MPs and
MSs on ELD
One of our
main objectives was to find the shortage extent of the RUM module by
identifying the deficiency factors. So we further compared the extent
of knowledge of contents, criteria for selection and time frame for
revision in both MPs versus MSs using a questionnaire.
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Table 1:
Percentages of knowledge in contents, criteria for selection and time
frame for revision in EDL |
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Doctors |
Students |
| Contents |
63.38% |
86.63% |
| Criteria
for selection |
83.5% |
32% |
| Frequency
of revision |
17% |
50% |
| Mean |
54.63% |
56.21% |
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In both study
groups values are given as percentages. |
1.3 Comparison
of percentage of knowledge on key policies of EDL before and after the
questionnaire
Some of the MPs were confident on their knowledge on core policies of
EDL (29.27%).but the percentage of their true knowledge were 54.63%
according to the values of our study. So the gap analysis was conducted
between those two values. We decided to identify the group of MPs who
were not on a correct evaluation on their knowledge.
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Figure
2: Gap analysis in the knowledge of EDL of MPs
of their assessment and with our analysis |
We have identified a gap analysis in the knowledge of EDL of MPs
of their assessment and with our analysis.(Figure
2)
2. Analysis
of knowledge in different areas of EDL among MPs and MSs
We extended
our study to do a detailed analysis of the knowledge of EDL by dividing
it into contents, criteria for selection and time frame for revision
in both groups.
2.1
Percentage of knowledge on contents of EDL
Good knowledge
on contents of EDL is an important requirement for health care workers
in practicing RUM. One of the basic problems which contributes to the
irrational prescribing is the medical students are not adequately instructed1.So
we decided to find the level of knowledge of MSs and MPs on contents
of EDL. Figure 4 show that the level of knowledge in the contents of
EDL includes life saving drugs (A), generic names (B), Drugs required
for common ailment(C), drugs required for majority of ailment (D) and
drugs required for priority need (E).
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Figure
3a:
Knowledge on contents of EDL in MPs |
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Figure
3b: Knowledge on contents of EDL in MSs |
We
analyzed the knowledge on contents of EDL in MPs. Figure 3a shows the
values were 75% in life saving drugs, 41% in generic names, 44% in both
drugs required for common ailment and drugs required for majority of
ailment and 90% in drugs required for priority need.
Figure 3b shows that the knowledge on life saving drugs (54%),
generic names (96%), drugs required for common ailment(94%), drugs required
for majority of ailment(94%) and drugs required for priority need(95%)
among MSs.
2.2
Percentage of knowledge used on criteria for selection of EDL
There are WHO
recommended criteria for selection of EDL. So we analyzed the knowledge
of criteria for selection; Pattern of prevalent diseases (A), the training
and experience of available personnel (B), treatment facilities (C),
relative efficacy cost and suitability (D) and latest drug in the market
(E) in MPs and MSs. Taken all factors together we found that MPs had
83.5% and MSs had 32% in knowledge in all 5 criteria for selection of
EDL.
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Figure
4a:
Knowledge on criteria for selection of EDL in MPs |
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Figure
4b: Knowledge on criteria for selection of EDL in MSs |
The knowledge on criteria for selection of EDL
among MPs and was analyzed (Figure 4a). Extent of knowledge was 95% in pattern
of prevalent diseases, 59% in the training and experience of available
personnel, 76% in treatment facilities, 90% in relative efficacy cost and
suitability and 97% in latest drug in the market.
Figure
4b shows the level of knowledge of MSs on different
criteria for the selection of EDL. This figure shows that the knowledge
was 26%on pattern of prevalent diseases, 48% on the training and experience
of available, 38% on treatment facilities, 28% on relative efficacy
cost and suitability and 23% on latest drug in the market.
2.3 Level of knowledge on time frame for
revision
The frequency
of revision is an important fact in preparing the EDL. Our study showed
that the knowledge of MPs on time frame for revision of EDL was very
low (17%). The knowledge of MSs (50%) on time frame for revision was
higher than that of MPs.
3. Comparison
of knowledge between MPs and MSs
3.1 Comparison
of the knowledge of contents of EDL between MPs and MSs.
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Figure
5a:
Knowledge on contents of EDL in MPs |
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Figure
5b: Knowledge on criteria for selection of EDL in MPs and MSs |
We
compared the level of knowledge of MPs and MSs on contents of EDL. (Figure 5a) The
values were 63% and 87% on MPs and MSs respectively.
3.2 Comparison
of the knowledge on criteria for selection of EDL
Figure
5b shows that the knowledge of MPs (83%) on criteria for selection of EDL is
higher than the knowledge of MSs (32%).
3.3 Comparison
of the knowledge on time frame for revision of EDL
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Figure
5c: Knowledge of
MPs and MSs on time frame for revision |
The
knowledge of MSs (50%) on time frame for revision was higher than that
of MPs (17%). (Figure 5c)
Rational use
of medicine is an important area in modern medical practice. Essential
drug list is one of the key concepts in it. The knowledge of health
care workers needs evaluation at timely interval for the improvement
of teaching curriculum of pharmacology. We found that the proficiency
of knowledge in EDL in MPs was 29% and 54% of study group assumed that
they have a fair knowledge. In contrast 17% of MPs had revealed that
they are not aware about EDL. However we evaluated them and found that
the overall level of knowledge on EDL in MPs was 55% (63%, 83% and 17%
in contents, criteria for selection and time frame for revision respectively).
Results of
our study suggest that the knowledge on content areas such as generic
names, drugs required for common ailments and drugs required for majority
of ailment were less than 50% in MPs. In contrast, the knowledge in
MSs in same contents was more than 90%. We found that knowledge on life
saving drugs was 75% in MPs and 54% in MSs and knowledge in the drugs
required for priority need showed a significant amount in both groups
(>90%). We understand that they are not fairly convinced about the
some of the selection criteria of EDL. We further feel that
even though they have got the exposure of the knowledge during the undergraduate
phase the practicality and usage with the concept are not well understood.
We noted that
significant percentage of MPs and MSs were deficient in comprehension
in inclusion criteria of generic names, drugs required for common ailment
/ majority of ailment. As we all understand the importance of having
knowledge, and applicable skills in EDL are the guidelines considered
to advance their skills for better approach in clinical setting.
When we compare knowledge in all subcategories in EDL students had a
higher score and this can be enlightened by their recent exposure to
fresh knowledge of pharmacology. Therefore we suggest that repetitive
in service program could be greatly valuable as an enhancement strategy
in practical usage of EDL concept.
It was interesting
to see that though there are a stumpy knowledge in general contents
of EDL among MPs, knowledge in criteria for selection of EDL among MPs
was 83%. Students had very low knowledge on all criteria for selection
of EDL (32%).
Time frame
for revision of EDL is a very important factor in practicing RUM and
EDL should be revised at timely interval for better management of health
economy of the country. If not, it becomes incongruous not only for
the current requirement of the patients and increase the health cost
unnecessarily.
Taking overall
finding in our data base we suggest that pharmacology curriculum should
be ensured of the current needs and the scarcity of important areas.
We strongly believe that students should be skilled on EDL selection
and the implementation of skill development practical sessions on EDL
are greatly recommended.
For the enhancement
of good knowledge in EDL concepts and practical skills in doctors needs
frequent appraisal of the EDL concepts and amendment if any identified
at timely interval which can improve the recalling of the knowledge.
We believe that this process can make the EDL concept more familiar
to them.
Internship
is a period of medical apprenticeship under the supervision of a consultant.
They are expected to learn clinical skills, perform some clinical procedures
and demonstrate a good clinical judgment to arrive at patient management
decision. All the medical officers including intern medical officers
are in need of an intervention programme that might improve their knowledge
on EDL as well as the application skills in RUM. We recommend that
theoretical and practical teaching coupled with frequent assessment
of the knowledge and skills acquired by the students, would likely improve
their practicing EDL. Very little research on EDL is reported in the
world and we could not compare our results with other similar works.
Creation of altitudes on practicing EDL is an important issue in improving
practice of EDL. It should be started in medical student level. Authorities
should be sophisticated that practicing EDL will be cost effective to
the government. As we are studying the rational use of medicine we plan
to extend our study to analyze the level of knowledge on other areas
of RUM such as STG, NF/HF, DTC and RDIS.
- Aronson JK, Henderson
G, Webb DJ, Rawlins MD. A prescription for better prescribing. BMJ 2006;333:459-60.
- Introduction to
drug research by WHO 2003: Types of drug use information. pp 13-19
- Orme M, Forlich J,
Vrhovac B. Towards a core curriculum in clinical pharmacology for undergraduate
medical students in Europe. Eur J Clin Pharmacol 2002;58:635-640.
- The selection of
essential drugs – report of a WHO expert committee technical report
series 615
- The role of education
in the rational use of medicine by WHO regional office for south east
Asia 2006. pp 21-24
- WHO Model List of
Essential Medicines. 16th edition. 2009. World Health Organization.
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