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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 33-41

Assessment of morbidities and pattern of medication use among medical in-patients in a university teaching hospital South-South Nigeria


1 Department of Internal Medicine, Irrua Specialist Teaching Hospital, Irruar, Nigeria
2 Department of Internal Medicine, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
3 Department of Pharmacology and Therapeutics, University of Medical Sciences, Ondo City, Ondo State, Nigeria

Date of Submission16-Nov-2017
Date of Acceptance30-Jan-2018
Date of Web Publication30-Apr-2018

Correspondence Address:
Dr. Olumuyiwa John Fasipe
Medical Lecturer and Senior Physician, Department of Pharmacology and Therapeutics, Faculty of Basic Clinical Sciences, University of Medical Sciences, Along Laje Road Ondo City, Ondo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhrr.jhrr_96_17

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  Abstract 

Aim: The pattern of morbidities in a setting often influences the pattern of medications prescribed. Intensified global efforts to improve the rational use of medications necessitated the development of medication use indicators. Materials and Methods: This was a descriptive, prospective study in which inpatients admitted into the internal medicine wards of a teaching hospital over a 9-month period between December 2015 and August 2016 were evaluated on specific days following admission using the World Health Organization-International Network for the Rational Use of Drugs (WHO-INRUD) prescribing indicators. Results: A total of 507 patients were evaluated; 269 patients (53.1%) were male, 238 patients (46.9%) were females, and their age range was 17–89 years. The most common morbidities among these inpatients were infectious diseases such as Malaria (18.9%) and HIV/AIDS (17.2%). The noninfectious disease conditions, diabetes mellitus (17%), and hypertension (16.8%) were next in prevalence. Most patients (412 patients; 81.3%) had more than one morbidity. The most commonly prescribed medications were 5% glucose in saline (300 patients; 59.2%), Vitamin B complex (257 patients; 50.7%), and furosemide (183 patients; 36.1%). The average number of medications prescribed per patient during admission was 9.1 ± 3.8 drugs, while the median number of medications used during admission was eight drugs. The percentage of medications prescribed by generic names was 85.6%, while 88.1% of medications were prescribed from the essential medicines list. Conclusion: The pattern of medication use was largely in-keeping and consistent with the pattern of morbidities despite confirmatory diagnosis and symptomatic treatment observed in most instances. This translates to rational and safer pharmacotherapy practices as the modified WHO-INRUD prescribing indicator will be a useful monitoring tool for rational medication prescriptions among inpatients.

Keywords: Medical inpatients, medication use, morbidity pattern, Nigeria, rational pharmacotherapy, tertiary hospital, World Health Organization-International Network for the Rational Use of Drugs indicators


How to cite this article:
Akhideno PE, Isah AO, Fasipe OJ. Assessment of morbidities and pattern of medication use among medical in-patients in a university teaching hospital South-South Nigeria. J Health Res Rev 2018;5:33-41

How to cite this URL:
Akhideno PE, Isah AO, Fasipe OJ. Assessment of morbidities and pattern of medication use among medical in-patients in a university teaching hospital South-South Nigeria. J Health Res Rev [serial online] 2018 [cited 2018 Jul 20];5:33-41. Available from: http://www.jhrr.org/text.asp?2018/5/1/33/231537


  Introduction Top


The therapeutic use of medicines is considered to be a major component of patient management in health-care setting where medications may be used for prevention, diagnoses, and treatment of disease.[1],[2],[3] Pharmacological interventions, though invaluable in patient care, carry inherent risks of medication-related problems such as adverse drug reactions and drug–drug Interactions.[2],[22],[23],[24] In addition, the consequences of inappropriate use of medications cannot be overlooked.[2],[3],[4],[25],[26],[27]

There have been increased efforts globally aimed at improving medication use practices, especially since the World Health Organization (WHO) sponsored meeting of experts in 1985 held at Nairobi, Kenya, on rational medication use.[4],[28] Essential to monitoring such efforts that were agreed at the Nairobi conference was the development of standardized and objective methods capable of measuring medication use in health facilities. This will describe medication use patterns and prescribing behavior.[5],[29],[30],[31] The WHO in collaboration with the International Network for the Rational Use of Drugs (INRUD) thus developed indicators for objective measurement of rational use of medications.

The WHO-INRUD indicators can be quickly and efficiently used in many settings to assess potential problems in drug use and to prioritize and focus subsequent efforts to correct these problems.[2],[5],[32],[33],[34] They enable the characterization of medication use pattern, identification of inappropriate use, and evaluation of interventional strategies.[6],[35] Most of these studies have been focused on outpatient settings,[7],[8],[9],[10] for which the indicators were originally designed.[5],[12],[14] Data for medication use among inpatients, especially in developing countries like Nigeria remain scarce. It is of utmost importance to characterize medication use pattern among inpatients, especially in developing countries where practices relating to inappropriate medication use are likely to be worse off. In-patients', medication use pattern is likely to differ considerably from out-patients' for several reasons including severity of illness thus requiring more medications concomitantly, some peculiarities arising from the differences regarding in-patient morbidities and the consequent treatment as for chemotherapeutic agents in the treatment of cancers.[11],[13],[25],[36] The usual trend is for the pattern of medication use in a particular setting to closely match the pattern of diseases in that setting, otherwise a mismatch will suggest inappropriate use of drugs.[12],[13],[14],[33],[34],[35],[36] This study was designed to assess the morbidities and characterise the pattern of medication use among medical in-patients in the University of Benin Teaching Hospital, Benin City, using the WHO-INRUD prescribing indicators, with a view to determine the usefulness of the indicators at higher levels of health care; further contributing to attaining a rational and safer pharmacotherapy practices.


  Material and Methods Top


This was a descriptive, prospective study with serial entry points for the patients admitted into the internal medicine wards of the University of Benin Teaching Hospital (UBTH), Benin City, Edo State, South-South Nigeria over a 9-month period from December 2015 to August 2016 and were fulfilling the inclusion criteria for evaluation. Patients are generally admitted through the accident and emergency unit where they are reviewed by various cadres of medical doctors until they are transferred to the wards under unit consultants. Some patients are admitted directly from the outpatient clinics into the wards, while a few may be transferred in from other nonmedical wards. The patients are then reviewed daily in the various units and managed till discharge.

The inclusion criteria for evaluation were all the patients admitted to the medical wards after commencing the study provided they granted their informed consents to participate in the study.

The exclusion criteria were as follows:

  1. Patients already on admission before commencing the study
  2. Patients admitted from other wards after initial management for nonmedical condition (s)
  3. Patients diagnosed and subsequently managed for nonmedical condition (s) after initial medical diagnosis and management
  4. Patients who did not grant their informed consents to participate in the study.


Data information about these patients were entered into a data collection form modified from the WHO-INRUD prescribing indicator form.[5] Each patient was evaluated on days 0 (day of admission), 1, 3, 7, 10, 14, 21, and weekly thereafter till day of discharge. An encounter was regarded as a patient studied on admission on such specified days. Records of all medications prescribed were entered including the dates, route, doses, and frequency. Changes made in patients' therapies were also noted.

The morbidity information was recorded at admission (initial diagnoses) and at discharge (final diagnoses). Any additional diagnoses while on admission were also noted and considered as part of the final diagnoses. The final diagnoses were used in the evaluation of morbidities pattern and were classified using the tenth edition for International Classifications of Diseases (ICD-10) criteria,[14] while medication used were classified using the Anatomical Therapeutic Chemical (ATC) classification.[15] Repeated admission of the same patient was regarded as two separate admissions when separated by an interval of at least one month, otherwise such admission was considered as a single admission and the interval excluded from the duration of hospital stay.[16] Data collected were encoded and analyzed using the Statistical Package for Social Sciences (SPSS) version 17 (released 2008; SPSS Inc., Chicago, IL, USA). Results were expressed as mean ± standard deviation or percentage values where necessary. The t-test and Chi-square were used to compare means and proportions, respectively. The level of statistical significance was set at P < 0.05.

Ethical clearance was obtained from the UBTH Ethical Research Committee before commencing this study. The Ethical Clearance/Protocol Research Number issued for the study was ADM/E.22 A/VOL. VII/104. In addition, a verbal informed consent was obtained from each of the patients whose medical records were used while the medical records for those who did not grant their informed consent were excluded from the study. Participants' confidentiality were respected and maintained by ensuring that no unauthorised person had access to the information on the data information sheets, that no information can be traced to the subjects (as coding system was used for the data information sheets instead of writing the patients' names on them) and no unauthorised use of information was made.


  Results Top


A total of 507 patients were studied during the 9-month prospective period under review from December 2015 to August 2016.

[Table 1] shows the sociodemographic characteristics of the respondents, comprising of 269 males (53.1%) and 238 females (46.9%). The mean age of patients admitted was 48.9 ± 17.8 years, ranging from 17 to 89 years. The age difference between males and females was not statistically significant (t = 0.771, df = 505, P = 0.44).
Table 1: Age and sex distribution of medical in-patients evaluated for medication use in the University of Benin Teaching Hospital Benin city from December 2015 to August 2016

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The morbidity pattern of patients is represented in [Table 2], which shows that more than half of the patients –290 patients (57.2%) were admitted for infectious and parasitic diseases. Disease of the circulatory system, notably, hypertension and heart failure was the second most prevalent in 125 patients (24.7%). Next in order of prevalence was disease of the genitourinary system (renal disease) in 117 patients (23.1%). Others are shown in [Table 2].
Table 2: Morbidity pattern of patients admitted in internal medicine wards in University of Benin Teaching Hospital Benin city from December 2015 to August 2016

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The most frequent morbidities when disease entities are taken individually are shown in [Table 3]. A diagnosis of malaria was made in 96 patients (18.9%) of admitted patients, making malaria the most frequent disease condition diagnosed. This was followed by HIV/AIDS, which was diagnosed among 87 (17.2%) patients admitted. Diabetes mellitus, hypertension, and chronic renal failure closely followed at 86 patients (17%), 85 patients (16.8%), and 70 patients (13.8%), respectively.
Table 3: Ten most prevalent disease entities diagnosed among patients admitted into the medical wards in University of Benin Teaching Hospital Benin city from December 2015 to August 2016

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The number of comorbidities are depicted in [Figure 1] as most patients (412 patients; 81.3%) had more than one morbidity. A total of 95 patients (18.7%) were admitted for only one morbidity, 175 patients (34.5%) had two comorbidities, 161 patients (31.8%) had three comorbidities, while 19 patients (3.7%) had five or more comorbidities.
Figure 1: Frequency distribution for number of comorbidities for patients admitted into internal medicine ward in the University of Benin Teaching Hospital Benin City from December 2015 to August 2016

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[Table 4] shows the major classes of medications used for the patients and their respective frequency of prescription. The ATC classification was used to classify these medications.
Table 4: Classes and frequency of medication use for medical inpatients in the University of Benin Teaching Hospital Benin city from December 2015 to August 2016 using the anatomic therapeutic chemical classification

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Some patients had no medication (admitted for observation) while some had several medications, sometimes up to 18 medications per admission (such as cases of HIV/AIDS patient with tuberculosis). The sum of all the medications prescribed for the 507 patients was 4551 prescriptions. Most often, medications were prescribed from the class alimentary tract and metabolism 1167 prescriptions (25.6%), followed by the class blood and blood-forming organs 914 prescriptions (20.1%). The classes cardiovascular system and anti-infective for systemic use' were ranked third and fourth with 878 prescriptions (19.3%) and 868 prescriptions (19.1%), respectively. Others are shown in [Table 4].

The most frequently prescribed individual medications were 5%. Glucose saline infusion in 300 patients (59.2%), followed by Vitamin B complex in 257 patients (50.7%), and furosemide in 183 patients (36.1%). [Table 5] shows the most frequently prescribed medications and their frequency of prescription with respect to the number of patients. Notably, the antibacterial drugs-metronidazole in 150 patients (29.6%), ciprofloxacin in 132 patients (26.0%), and Co-amoxiclav (Amoxicillin-clavulanate) in 100 patients (19.7%) were among the most frequently prescribed medications, so were the antihypertensives - lisinopril in 170 patients (33.5%), amlodipine in 96 patients (18.9%), and nifedipine in 86 patients (17.0%).
Table 5: Most frequently prescribed medications for patients in internal medicine wards in the University of Benin Teaching Hospital Benin city from December 2015 to August 2016

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Taking a patients admission grossly as an encounter, the derived values for the WHO-INRUD prescribing indicators are as shown in [Table 6]. The average number of medications prescribed (or used) per patient during admission was 9.1 ± 3.8 drugs, while the median number of medications used during admission was eight drugs (IR = 3.96–11.88 drugs). The percentage of medications prescribed by generic names was 85.6%, while 88.1% of medications were prescribed from the essential medicine list. A total of 453 patients (89.3%) had injections prescribed, 314 patients (61.9%) had antibacterials prescribed, while 379 patients (74.8%) used infusions. Antimalarials were prescribed for 96 patients (18.9%).
Table 6: Prescribing indicators for medical inpatients evaluated for medication use in the University of Benin Teaching Hospital Benin city from December 2015 to August 2016

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[Table 7] shows when specific days were taken as encounters and the indicators evaluated as such. The following can be deduced from [Table 7]:
Table 7: Prescribing indicators for specific evaluated days of inpatient stay in the medical wards in the University of Benin Teaching Hospital Benin city from December 2015 to August 2016

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  • The number of inpatients on admission was reducing as the length of hospital stay was increasing.
  • The average number of medications per patient was increasing throughout the admission duration but had reduced during discharge as most of the patients were clinically stable and were being discharged home on few oral drugs except for some set of patients that still need to be on parenteral medications such as insulin in the case of diabetes mellitus.
  • The percentage number of patients on injections and infusion medications was reducing throughout the duration of admission and even at discharge as most of the patients were clinically stable and were being discharged home on few oral drugs except for some set of patients that still need to be on parenteral medications like insulin in the case of diabetes mellitus.
  • The percentage number of patients on antibacterial agents reached the first peak value of 60.9% on the 14th day of admission, and then experienced a sharp decline to a troughed value of 53.8% by the 21st day of admission before undergoing another sharp and resurgence increase to the highest peak value of 68.4% by the 28th day of admission. Finally, at discharge, the percentage number of patients using antibacterial drugs decreased to 49.3% which was comparable to the value of 48.7% on the first day after admission. This sharp increase in the percentage number of patients on antibacterial agents between the 21st and 28th day of admission could be attributed to the fact that there was increased propensity to develop febrile nosocomial infections during admission, delayed availability of results for microbial sensitivity tests, and concomitant use of more antimicrobial agents when those inpatients were deemed not to be responding well to initial medical therapy after spend at least 3 weeks on admission.



  Discussion Top


The morbidity pattern of admitted patients shows that certain infectious and parasitic diseases included in the ICD-10 class A00 B99 was the most prevalent. This class consists of diseases such as malaria, HIV infection, and tuberculosis. This finding is in keeping with the general trend in tropical medicine as evidenced by in-patient morbidity surveys at the Ahmadu Bello Teaching Hospital in 2003[17] and a previous study at the UBTH.[18] These studies suggest that infectious diseases still rank among the most prevalent causes of morbidity and mortality in Nigeria in particular and Sub-Saharan West-Africa at large. The next most prevalent class was I00 I99 or 'diseases of the circulatory system, including hypertension and heart failure. This, again is in keeping with the morbidity pattern in studies from this part of the globe.[17],[18] The second edition of 'disease and mortality in Sub-Saharan Africa, a world bank sponsored study, describes cardiovascular disorders as the second most common cause of adult deaths and a major cause of chronic illness and disability in Sub-Saharan Africa.[19]

The ten most frequently diagnosed diseases showed that malaria was the most frequently treated morbidity. A total of 96 patients (18.9%) were treated for malaria while on admission. Most of these patients were admitted for other comorbidities and were treated presumptively for malaria. A WHO collaboration study in the same locality (Southern Nigeria) showed that among outpatients, malaria was also the most prevalent disease.[9] There may therefore be some justification for the empirical treatment of malaria when patients develop a febrile illness while on admission or when a patient admitted initially for a febrile illness fails to respond to antibiotics, as this practice was often the case in this study. However, this empirical trend of treatment for malaria without first conducting laboratory test is expected to change drastically over the next few years as current WHO and National guideline recommend and advocate for Rapid Diagnostic Test before commencing Artemisinin-based Combination Therapy for malaria infection.

In this study, diabetes mellitus and hypertension were ranked third and fourth among the most prevalent morbidities. In several studies, these noncommunicable diseases tend to compete favorably with infectious diseases in terms of prevalence in Sub-Saharan West Africa as risk factors such as sedentary lifestyle, chronic smoking habits, chronic alcohol consumption, psychoactive drug abuser, and obesity are becoming more prevalent and rampant.[17],[18],[19]

Most of the patients (412 patients; 81.3%) were having more than one morbidity as this concurred with previous studies done. Most often, they were diagnosed with two comorbidities (175 patients; 34.5%) or three comorbidities (161 patients; 31.8%) as this can be attributed to the fact that malaria, HIV-infection, hypertension, and diabetes mellitus are prevalent and rampant in Nigeria and Sub-Saharan West.

Regarding medication use pattern, the ATC group of medicines classified as 'Alimentary tract and metabolism' was the most frequently prescribed class. This is not consistent with the pattern of morbidity where infectious diseases ranked highest. This was due to the fact that this class consists of an otherwise diverse group of medicines such as antiemetics, laxatives, vitamins, minerals, among others which individually contributed less than anti-infective agents. However, the ATC classes 'blood and blood-forming organs' and 'cardiovascular system' ranking 2nd and 3rd, respectively were consistent with the morbidity pattern where diseases of the circulatory system was second most prevalent.

The most frequently prescribed medications were 5% glucose in saline, Vitamin B complex, and furosemide. These drugs - 5% glucose in saline and Vitamin B complex were the first and second top most prescribed medications, respectively, in this study because they were routinely being prescribed for admitted medical in-patients due to the fact that most of them presented with moderate-to-severe dehydration, inability to tolerate orally, fever, and poor appetite caused by those febrile infectious diseases such as severe malaria, HIV/AIDS, tuberculosis, septicemia, and meningoencephalitis that top the morbidity pattern list using the ICD-10 classifications. In addition, these medications are also being prescribed as part of medical therapy for very ill patients, and for medical emergency conditions such as stroke, diabetic ketoacidosis, and adverse drug reactions. While furosemide was the third most commonly prescribed medication in this study because; diseases of the circulatory system (notably hypertension and heart failure) and diseases of the renal system (notably chronic renal failure, acute renal failure, nephrotic syndrome, and HIVAN) are being treated with furosemide as they occupied the second and third most frequently diagnosed/treated disease entities, respectively, in the morbidity pattern list using the ICD-10 classifications. Medications used for symptomatic therapy, such as paracetamol and metoclopramide, were also commonly prescribed, a finding consistent with that observed among inpatients in internal medicine department in Switzerland.[11] Artemether/lumefantrine combination was the most commonly used antimalarial and appeared among the first fifteen topmost frequently prescribed medications. This is in keeping with the Nigerian guidelines for treatment of malaria which recommended Artemether/lumefantrine as first choice for malaria therapy.[21] Expectedly, from the morbidity pattern, antibiotics and antihypertensives were among the most frequently prescribed medicines.

Considering the pattern of medication use according to the WHO-INRUD indicator, injections were prescribed in 453 participants (89.3%) of admissions, while antibacterials were used in 314 patients (61.9%) of admissions. These values were much higher than outpatient values. However when the values on specific days were evaluated, and such days were considered as encounters, some comparison can be drawn with out-patients' data as well as the WHO standard values for outpatients. The mean number of medications used per patient per day increased from 4.2 drugs to 8.3 drugs from hospital day 0 to day 28, and at discharge, the mean number of medications was 6.3 drugs. If these values are compared to the mean values in out-patient encounters found in same southern parts of Nigeria, 3.7 in Benin City,[7] 3.9 in Warri [8] and 3.5 in Lagos,[20] it means that from admission day more drugs were used among in-patients. The number of in-patient medications per patient per day on admission was as expected far in excess of those recommended for out-patients using the WHO derived standard values by Isah et al.[36] (1.6-1.8 medicines per encounter). This comparison may not be appropriate as inpatients are generally more ill and likely to require more medications concomitantly than outpatients. Furthermore, some medications such as parenteral injections and infusions can only be administered in an inpatient setting.[11] This latter view is supported by the values derived in a study among Swiss inpatients [11] where a median number of 5–6.3 drugs from day 5 to day 18 was observed. This study observes a median of 6–7 drugs from day 3 to day 21 and thus similar. Antibacterials and injections in particular also appeared to have been over used when compared to outpatient observations [8],[20] and the WHO standard values.[8] However, as mentioned above, in-patients are peculiar and thus will require derivation of their own standard reference values, in addition similar in-patient studies should be carried out in Nigeria and Sub-Saharan West-Africa for meaningful comparisons. The increase in average number of medications used per day per patient over time spent on admission (4.2–8.3 from day 0 to day 28) may be explained by the fact that the patients staying longer are usually more ill and have more comorbidities and therefore receive more medications. As they improve and are able to take orally, more drugs may also be prescribed, especially for symptomatic treatment. For example, hematinics for anemia and analgesics for headaches and pains. Like the general trend in the use of all medications, the proportion of patients on antimicrobials per day increased throughout admission, only dipping, understandably on the day of discharge since patients' therapies are usually reviewed at discharge and number of medications reduced to minimum required. The increasing tendency for antimicrobial use may be due to nosocomial infections, delayed results of microbial sensitivity tests, and concomitant use of more antimicrobials when patients are deemed not to be responding well to initial medical therapy. Injections and infusions, on the other hand, showed a decreasing tendency with duration of admission. This is the expected scenario as patients improve and start tolerating orally. However, about 247 patients (48.7%) still received injections on discharge day suggests some overuse and delayed review of injections during admission (patients continued using them when it was not necessary). The percentage number of patients on injections at discharge was contributed largely to by diabetic patients, many of whom are discharged home on insulin injection. The prolonged use of injections may also be rational in a few patients with illnesses such as diabetes mellitus, meningitis, and encephalitis.

The percentage of medications prescribed from Essential Medicines List EML (88.1%) and by generic name (85.6%), were high compared to what obtains in Primary Health Care settings in India,[1],[14] and in primary and secondary health care settings in Nigeria among out-patients.[8],[12],[20] At another tertiary health care facility in Nigeria, in a prospective review of out-patient prescriptions, these values were 96% and 49.5% respectively.[10],[12] Prescriptions for in-patients in a tertiary health care setting are expected to be more scrutinized and supervised more by specialists. The presence of an active Clinical pharmacology and therapeutics unit, availability of essential medicine list, stocking of drugs on the essential medicine list, and strict enforcement/monitoring of the medication use in the institution of study are influencing factors. However, the values for these indicators by WHO standards should be 100%, still leaving room for improvement.

About one out of every five patients (18.9%) was treated for malaria during admission. Of interest is the presumptive treatment which hopefully will decline following the recent recommendation of the WHO and National guidelines insisting on laboratory tests prior to initiation of malaria treatment.[21]

The pattern of prescribed medications was to a large extent in-keeping and consistent with the pattern of morbidities despite confirmatory diagnosis and symptomatic treatment observed in most instances. The modified WHO-INURD indicator can reasonably be used among in-patients to monitor rational and appropriate use of medications; as in-patient medication use values for the indicator was higher than that of out-patients reference values in previous studies and appear to be rational and consistent to some extent due to the severity of the diseases and duration of hospitalisation. There is need for more future researches directed and focused at in-patient studies using the modified WHO-INRUD indicators in order to enable a profiling of in-patient use of medications thus enabling the development of reference values to characterise medications use in such settings. This study was solely restricted and limited to only medical in-patients admissions, as out-patients and other non-medical ward patients were excluded from the study.


  Conclusion Top


The infectious diseases malaria and HIV/AIDS were the most frequently treated diseases among these medical in-patients, while the non-communicable diseases diabetes mellitus and hypertension were also commonly diagnosed, being only slightly less in frequency than malaria and HIV/AIDS. The pattern of prescribed medications to a large extent reflects the pattern of morbidities with anti-infective and antihypertensive agents being the most commonly used medications. This study also shows that the modified WHO-INURD indicator can reasonably be used among in-patients to monitor rational and appropriate use of medications; as in-patient medication use values for the indicator was higher than that of out-patients reference values in previous studies and appear to be rational and consistent to some extent due to the severity of the diseases and duration of hospitalisation. There is need for more proactive in-patient studies using the WHO-INRUD indicator to enable profiling of in-patient use of medications, and thus enabling the development of reference values to characterise the use of medications in such settings.

Acknowledgments

The authors of this research work want to specially acknowledge and thank the Almighty God for granting us wisdom and understanding to prepare this research work for publication.

.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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