Prescribing quality in patients with chronic diseases at primary and secondary health care facilities using prescription quality index tool

Jalpa V. Suthar, Varsha J. Patel


Background: Prescribing quality is a matter of major concern worldwide. This study was carried out to determine the quality of prescribing in chronic diseases at primary health care (PHC) and secondary health care (SHC) settings using the new prescription quality index (PQI) tool.

Methods: A cross-sectional observational study was carried out at four PHC and two SHC facilities in Anand district of India. Patients attending these facilities for at least 3 months were included. Complete medical history and prescriptions received were noted. Total and criteria wise PQI scores were derived for each prescription. Prescriptions were categorized as poor (score of ≤31), medium (score 32-33), and high quality (score 34-43) based on PQI total score. The internal consistency of PQI was measured using item total correlation and Cronbach’s α so as to validate it in our settings. Data were analyzed using Statistical Package for Social Science 20.

Results: A total of 134 prescriptions were collected and evaluated for quality of prescribing. Mean age of patients was 60.6 ± 13.5 years. Mean PQI score was 23.60 ± 9.3 with 71.6% prescriptions being of poor quality. Quality of prescribing did not differ at PHC and SHC (P>0.05). Of 22 criteria, PQI score was strongly correlated with drug indication, drug effectiveness, evidence-based prescribing, unnecessary duplication, duration of therapy, and cost (P<0.01). PQI total score was negatively correlated to the number of drugs per prescription. Cronbach’s α for the entire 22 criteria were 0.90.

Conclusion: PQI was found to be a reliable tool for assessment of prescribing quality in chronic diseases.


Rational drug use, Prescription quality index, Quality of prescribing

Full Text:



Blatt A, Chambon R, Lemardeley P. Legal format and costs of prescriptions at the Central Hospital in Yaounde, Cameroon. Med Trop (Mars). 1997;57(1):37-40.

Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370(9582):173-84.

Barber N, Rawlins M, Dean Franklin B. Reducing prescribing error: competence, control, and culture. Qual Saf Health Care. 2003;12 Suppl 1:i29-32.

Lesar TS. Prescribing errors involving medication dosage forms. J Gen Intern Med. 2002;17(8):579-87.

Ni K, Siang C, Ramli M. Noncompliance with prescription writing requirements and prescribing errors in an outpatient department. Malays J Pharm. 2002;1(2):45-50.

Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med. 1991;151(9):1825-32.

Hennessy S, Bilker WB, Zhou L, Weber AL, Brensinger C, Wang Y, et al. Retrospective drug utilization review, prescribing errors, and clinical outcomes. JAMA. 2003;290(11):1494-9.

Lagerløv P, Hjortdahl P, Saxegaard L, Andrew M, Matheson I. Structuring prescribing data into traffic-light categories; a tool for evaluating treatment quality in primary care. Fam Pract. 2001;18(5):528-33.

Coste J, Venot A. An epidemiologic approach to drug prescribing quality assessment: a study in primary care practice in France. Med Care. 1999;37(12):1294-307.

Kerr EA, McGlynn EA, Adams J, Keesey J, Asch SM. Profiling the quality of care in twelve communities: results from the CQI study. Health Aff (Millwood). 2004;23(3):247-56.

Liu GG, Christensen DB. The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence. J Am Pharm Assoc (Wash). 2002;42(6):847-57.

Oborne CA, Batty GM, Maskrey V, Swift CG, Jackson SH. Development of prescribing indicators for elderly medical inpatients. Br J Clin Pharmacol. 1997;43(1):91-7.

WHO. How to Investigate Drug Use in Health Facilities: selected Drug Use Indicators. Action Programme on Essential Drugs, WHO/DAP/93.1. Geneva: WHO; 1993: 1-87.

Lechevallier-Michel N, Gautier-Bertrand M, Alpérovitch A, Berr C, Belmin J, Legrain S, et al. Frequency and risk factors of potentially inappropriate medication use in a community-dwelling elderly population: results from the 3C Study. Eur J Clin Pharmacol 2005;60(11):813-9.

Elliott RA, Woodward MC, Oborne CA. Antithrombotic prescribing in atrial fibrillation: application of a prescribing indicator and multidisciplinary feedback to improve prescribing. Age Ageing. 2002;31(5):391-6.

Ballesteros LC, Fernández San Martín MI, Sanz Cuesta T, Escortell Mayor E, López Bilbao C. The cost of inadequate prescriptions for hypolipidaemic drugs. VICAF Group. Pharmacoeconomics. 2001;19 5 Pt 1:513-22.

Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045-51.

Fitzgerald LS, Hanlon JT, Shelton PS, Landsman PB, Schmader KE, Pulliam CC, et al. Reliability of a modified medication appropriateness index in ambulatory older persons. Ann Pharmacother. 1997;31(5):543-8.

Hassan NB, Ismail HC, Naing L, Conroy RM, Abdul Rahman AR. Development and validation of a new prescription quality index. Br J Clin Pharmaco. 2010;70(4):500-13.

Tatro DS. A to Z Drug Facts. 5th Edition. St. Louis, MO: Wolters Kluwer Health Inc.; 2004.

Sweetman SC. Martindale. The Complete Drug Reference. 34th Edition. London, UK: Pharmaceutical Press; 2011.

WHO Model List of Essential Medicines. Available from: [Last cited on 2011 Jun 24].

National List of Essential Medicines of India. New Delhi: Government of India, Ministry of Health & Family Welfare; 2011.

National Formulary of India. 4th Edition. India: Government of India, Ministry of Health and family welfare, Indian Pharmacopoeia Commission; 2010.

British National Formulary (BNF). London: Pharmaceutical Press; 2011.

Skyggedal Rasmussen HM, Søndergaard J, Sokolowski I, Kampmann JP, Andersen M. Factor analysis improves the selection of prescribing indicators. Eur J Clin Pharmacol 2006;62(11):953-8.

Williams B. Brown T. Onsman A. Exploratory factor analysis: a five-step guide for novices. Australas J Paramed 2010;8(3). Available from:

Kumari R, Idris MZ, Bhushan V, Khanna A, Agrawal M, Singh SK. Assessment of prescription pattern at the public health facilities of Lucknow district. Indian J Pharmacol. 2008;40(6):243-7.

DeVon HA, Block ME, Moyle-Wright P, Ernst DM, Hayden SJ, Lazzara DJ, et al. A psychometric toolbox for testing validity and reliability. J Nurs Scholarsh. 2007;39(2):155-64.

Bjerrum L, Søgaard J, Hallas J, Kragstrup J. Polypharmacy: correlations with sex, age and drug regimen. A prescription database study. Eur J Clin Pharmacol. 1998;54(3):197-202.

Schuler J, Dückelmann C, Beindl W, Prinz E, Michalski T, Pichler M. Polypharmacy and inappropriate prescribing in elderly internal-medicine patients in Austria. Wien Klin Wochenschr. 2008;120(23-4):733-41.