PRESCRIPTION AUDIT USING THE WORLD HEALTH ORGANIZATION PRESCRIBING INDICATORS FOR INDOOR PATIENTS TREATED UNDER CMAAY/PMJAY INSURANCE SCHEMES IN A TERTIARY CARE TEACHING HOSPITAL

Objective: This study focused on the prescriptions audit of indoor patients treated under Pradhan Mantri Jan Arogya Yojana (PMJAY) and Chief Minister Arogya Arunachal Yojana (CMAAY) insurance schemes as per the World Health Organization (WHO) prescribing indicators.
Materials and Methods: Retrospective cross-sectional study was conducted and the prescriptions of around 960 patients were analyzed who were treated from June 2020 to December 2020 under CMAAY/PMJAY insurance schemes at Tomo Riba institute of Health and Medical Sciences in Arunachal Pradesh. Study was conducted in five departments and Information was collected through the review of case sheets. The post-operative day prescription was analyzed for the patients who have undergone surgery and the patients who were managed conservatively; admission day prescription was analyzed using the WHO core drug prescribing indicators. Following data were analyzed. (1) Average no of drugs prescribed per encounter; (2) percentage of encounter having antibiotic; (3) percentage of drugs prescribed by generic name; (4) percentage of encounters with an injection; and (5) percentage of drugs prescribed from the essential drug list.
Results: A total of 960 indoor patients treated under five departments, out of which 359 (37.4%) treated under general surgery, 383 (39.9%) under Obstetrics and Gynecology department, 65 (6.8%) under ENT department, 68 (7.1%) under orthopedics department, and 85 (8.9%) under General medicine department. All departments taken together, the average number of drugs used per patient was 4.91. Antibiotics were prescribed in 92.18% of the total patients when all departments were included, single antibiotic was used in 72.18%, two antibiotics in 17.29%, and three in 2.7% of the total patients. Overall, the generic names were written in 67.3% of the total drugs and the most commonly used route was parenteral route, in about 98.19% of the total prescribed drugs. From the essential drugs list, 89.33% of the total drugs were prescribed. Fixed drug combination was used in 13.59% of the total drugs prescribed.
Conclusion: In our study, the percentage of prescriptions with average no of drugs per prescription, antibiotic used, injections used were much higher when compared to the WHO core prescribing indicators. The reason might be because we have analyzed the prescription of indoor patients and most of them were post-operative patients, so it is justified. While prescribing, the physicians and surgeons followed WHO essential drug list but use of generic names was in few prescriptions. The generic name use to be more emphasized, encouraged, and promoted.


INTRODUCTION
Prescription audit helps to improve the quality of prescribing drugs in the institute. By prescription audit the quality of the prescribing drugs can be evaluated. It is a quality improvement process where a positive change can be made in the patients care. The standard of prescription reflects rational prescribing and the competence of the clinician [1,2]. The outcome and patient care can be improved by doing regular prescription audits and comparing it with set standards of prescription writing [3].
By doing regular prescription audits, the rational use of medicines can be motivated. As a result, the quality of prescription can be increased in a cost-effective way, decreasing the incidence of adverse drug reactions, and also increasing proper utilization of resources [4,5].
The World Health Organization (WHO) has given the Internationally accepted criteria for standard prescription writing as a guide for good prescription [6][7][8]. The way of writing of prescriptions can be compared with the WHO given internationally accepted criteria [4,9].
Various studies concerned with prescription audit have been done in the past [10][11][12].
Pradhan Mantri Jan Arogya Yojana (PMJAY) and Chief Minister Arogya Arunachal Yojana (CMAAY) are the initiatives of central and state Government, respectively, which are employed by the Chief Minister Arogya Arunachal Society for free cashless health-care services to the people of the State [13].
The present study was planned to analyze prescription audit using the WHO prescribing indicators for indoor patients treated under CMAAY/PMJAY insurance schemes at Tomo Riba institute of Health and Medical Sciences (TRIHMS) in Arunachal Pradesh, North East India with following objectives. 1. To investigate the rational use of drugs for completeness legibility and to characterize the drug use in the medical college as per the WHO recommended core drug use indicators and to analyze the prescription errors 2. To carry out a complete therapeutic audit and to know what was

METHODS
This retrospective cross-sectional study (Prescription audit) was carried out in TRIHMS, Naharlagun, Arunachal Pradesh. The case records of all the indoor patients treated under department of General Surgery, Obstetrics and Gynecology. ENT, orthopedics and General Medicine from June 2020 to December 2020 under CMAAY/PMJAY insurance schemes were collected from the medical record Department of TRIHMS. A total of 960 patients treated under five departments, out of which 359 got treatment under surgery, 383 under Obstetrics and Gynae, 65 under ENT, 85 under medicine and 68 under orthopedics. The prescriptions written on the day of the admission for all cases who were managed conservatively and for all those patients who underwent surgery procedure, the prescriptions written post operatively (only the prescription followed immediately after surgery, not the subsequent prescriptions) were analyzed. The i.v fluids given were not taken in consideration.
The broad classification of the various cases according to the diagnosis was done and thereafter the prescriptions were analyzed using the WHO core drug prescribing indicators. For the diagnosis, which could not be grouped together and as it was long list to mention each, they were clubbed together in others category. The following things were analyzed. 1. Average no of drugs prescribed per encounter. The prescription with combination of drug was considered as one 2. The percentage of encounter in which the antibiotic was prescribed.
Furthermore, the total no of antibiotic in every prescription was calculated 3. Percentage of drugs prescribed by generic name 4. Percentage of encounters with an injection 5. Percentage of drugs prescribed from the essential drug list.

Statistical analysis
Data were expressed as mean±SD, numbers and percentages. Collected data were entered into Microsoft_Excel_2019 and subsequently statistical analysis was done using the same.

Ethics committee permission
Ethical permission to conduct the hospital-based study was obtained from Institution Ethical Committee before commencement of the study (IHECTRIHMS/ETHICS/01/2019-20). Data confidentiality was maintained during and after data collection.
Average number of days stayed was maximum under department of Medicine (9.4 days), followed by orthopedics (8.7 days), General surgery (6.5 days), ENT (3.78 days), and least was under obstetrics and gynecology (3.73 days) ( Table 2).
Maximum no of average drugs used per case was by the department of obstetrics and gynecology (6.44), followed by the department of Medicine (4.31), ENT (3.96), Surgery (3.91), and Orthopedics (3.28). For all departments taken together (960 patients), the average no of drugs used per patient was 4.91 (Table 8).
Maximum prescriptions having antibiotics were prescribed by the Department of Obstetrics and Gynecology (100%), followed by the Department of Orthopedics (97%), Department of General Surgery (96.9%), Department of ENT (89.2%), and General Medicine (35.2%). In most of the patients', single antibiotic was used. Including all the benefitted indoor patients' antibiotics was prescribed in 92.18%, single antibiotic in 72.1%, two antibiotics in 17.2%, and three in 2.7% (Table 9).
Overall, nearly 98% of the total drugs were given by parenteral route. Maximum drugs given by parenteral route were prescribed by Obstetrics and Gynecology Department (99.8%), followed by Orthopedics (98.2%), ENT (94.9%), General Surgery (94.3%), and General Medicine (85.24%) Department. Inhalational route was used maximum times by the general medicine department whereas syrups were used only few times (Table 11).
Most of the combinations used were combination of antibiotics with beta lactamase inhibitors, either clavulanic acid, sulbactam or tazobactam except cefixime with dicloxacillin which was used in 14 patients and imipenem and cilastatin combination in two patients (Table 13).

DISCUSSION
PMJAY and CMAAY are the initiatives of central and state Govt., respectively, which is being implemented by the Chief Minister Arogya Arunachal Society with a vision to accord quality and cashless healthcare services to the people of the State envisaging Universal health care to all by 2030 [13].
Prescription audit helps to improve the quality of the prescription. Standards of prescriptions can be improved by doing it on regular basis. This study was planned to analyze the prescriptions for the indoor patients who were benefitted under CMAAY/PMJAY insurance scheme for better understanding of prescription pattern which can help in better implementation of scheme.
As per our study conducted in 960 patients 70% were female and 30% were male, this was because from the Department of Obstetrics and Gynecology around 383 patients were included. Average days of patient stay in hospital were in between 3.73 days and 9.4 days. In most of the admitted cases, surgery was done except in a few cases which were managed conservatively. The maximum number of cases dealt by    [14][15][16][17]. The reason for this variation might be because the studies were conducted in different type of patients and situations.
As per our study, antibiotics were prescribed in 92.18% of total cases, which is much higher than recommendation of the WHO core prescribing indicator where optimal value is < 30%. In some other studies, the percentage of encounter with antibiotics was 54% and 21.78% [18,19]. The reason could be similar, that is, our study was conducted in mainly postoperative and critically ill patients where antibiotics are prescribed commonly.
The generic names were used in 67.3% of the total drugs prescribed by all departments is less than the WHO core prescribing indicator which suggests that 100% of the drugs prescribed should be with generic names. In some of the other studies conducted by Rai et al., Sunny et al., and Chakraborthy et al., the percentage of generic names were 11.3%, 3.6%, and 47%, respectively, which is less than our study results [20][21][22].
In our study, the most common route for giving medicine was parenteral route (98.19%) which is much higher than the WHO core prescribing indicator which indicates the optimum value of percentage of encounter with injections should be less than 20%. As per the study conducted by Rai et al.,42.3% of drugs were injectable and another study by Sharonjeet et al., 75.17% of drugs were injectable which is less than the result of our study (98.19%) [20,23]. This may be due to the post-operative and critically ill patients' prescriptions were analyzed where parenteral therapy is commonly used.
In this study, 89.33% of the total drugs prescribed by all departments were from the essential drugs list which is comparable to the WHO recommendation that all medicines (100%) should be from the essential drug list. In some other studies, conducted by Singh et al., Sema et al., Chandra et al. and Singh et al., percentage of drugs from the essential drug list was 81%, 100%, 72.91%, and 88.3%, respectively, which is less than the result of our study except that conducted by Chandra et al. [24][25][26][27]. In our institute, we have framed our own essential drug list based on the WHO essential list and the physicians and surgeons are sensitized at regular interval to follow it. This may be the reason behind as most of the drugs are prescribed from it.
The percentage of total drugs prescribed as fixed dose combination was 13.59%. All the fixed dose combinations were combinations of antibiotics with beta lactamase inhibitors like clavulanic acid, sulbactam, and tazobactam. Apart from this, in 14 patients, combination of cefixime with dicloxacillin (both antibiotics) and in two patients, imipenem and cilastatin was used. These combinations are commonly used in therapy to increase the spectrum of activity, decrease resistance and inhibit the degradation of antibiotics. There was no irrational fixed dose combination used.
The study was done for limited period of time and the admitted patients in various departments were unequal. Furthermore, study was done specially in admitted patients under specified insurance schemes, so we found it difficult to correlate the data in our study with the few available studies. More studies are needed to extrapolate our results for a larger population.

CONCLUSION
There were no irrational combinations used. Most of the drugs used were from the essential drug list. The percentage of prescriptions with average no of drugs per prescription used was higher when compared to the WHO core prescribing indicators. Considering the aspect that our data is mainly of the post-operative and critically ill indoor patients, there was need for antibiotic and analgesic to be used, hence it is justified. While prescribing the physicians and surgeons followed the WHO essential drug list as they are sensitized at regular interval to follow it. Generic names were in few prescriptions. It needs to be more emphasized, encouraged and promoted. Overall, our study shows that in the insurance scheme of CMAAY/PMJAY running in our institute,     there was rational use of drugs. However, there is need for more studies in this region to extrapolate our results in larger population.

Data availability
The primary data gathered by the authors, which supports the finding of this study are available from the corresponding author and can be shared if a request is being received after due permission from the Chief Medical Superintendent, TRIHMS, Govt. of Arunachal Pradesh and the Chief Executive officer, CMAAY.