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Eur . J . Cl in . P ha rm aco l . 17 , 183 -18 7 (1980)E u r o p ean Jo u r n a l o fC l i n i ca l P h ar m aco l o g y© by S pr inge r -Ver lag 1980

Aud iting H ospital Dru g Utilisationby M eans of Defined Daily Do ses per Bed-DayA M ethodological Study

U . B e r g m a n 1, I. C h r i s t e n s o n 3 , B . J a n s s o n 3, a n d B . - E . W i h o l m t, 2

i D e p a r t m e n t o f C l i n ic a l P h ar m a c o l o gy ,2 D e p a r t m e n t o f I n t e r n a l M e d i c i n e , K a r o l i n s k a I n s t i tu t e t , H u d d i n g e U n i v e r s i t y H o s p it a l , a n d

3 D e p a r t m e n t o f P h a r m a c y , H u d d i n g e U n i v e r s i t y H o s p i t a l , H u d d i n g e , S w e d e n

S u m m a r y . T h e u t i l is a t i o n o f h y p n o t i c s , s e d a t i v e s, a n dm i n o r t r a n qu i ll is e r s ( H S m T ) w a s s t u d i e d b y m e a n s o fd r u g - d e l i v e r y a n d h o s p i t a l o c c u p a n c y st a t is t ic s f o r

1 9 7 5 - 1 9 7 7 i n a S w e d i s h u n i v e r s i t y h o s p i t a l . A t o t a lo f 0 . 5 3 s o - c a l le d d e f i n e d d a il y d o s e s ( D D D ) / b e d - d a y

w e r e d e l i v e r e d i n 1 9 7 5 , i m p l y i n g t h a t e v e r y s e c o n d

p a t i e n t m i g h t h a v e r e g u la r l y b e e n p r e s c r i b e d H S m T .T h e b e n z o d ia z e p i ne s w e r e p r e d o m i n a n t w i t h 7 1 % o f

t h e d e l i v e r i e s . F i v e m a j o r d r u g s a c c o u n t e d f o r 8 8 % .T h e d r u g p a tt e r n a n d t h e r a n g e o f D D D / b e d - d a y( 0 . 0 9 - 1 .1 8 ) d i f fe r e d c o n s i d e ra b l y b e t w e e n t h e

d e p a r t m e n t s . D r u g s n o t r e c o m m e n d e d b y th e h o s p i-

t a l ' s P h a r m a c y a n d T h e r a p e u t i c s C o m m i t t e e a c -c o u n t e d o n l y f o r 3 % o f d e l i v e ri e s . I n a d r u g s u r v e i l-l a n c e s tu d y p e r f o r m e d i n t w o m e d i c a l w a r d s, H S m T

w e r e p r e s c r i b e d f o r 4 3 % o f 2 7 4 p a ti e n ts . D r u g d e l i v -e r y a n d p r e s c r i p ti o n d a t a w e r e i n b r o a d a g r e e m e n t .D r u g i n f o r m a t i o n a c t i v i t i e s i n t h e h o s p i t a l h a d a

c l e ar ly d i s c e r n a b l e i n f l u e nc e o n t h e d e l i v e r e d D D D /b e d - d a y . T h i s m e a s u r e i s a n i n e x p e n s i v e i n d i c a t o r o f

d r u g u t i l i s a t i o n i n a h o s p i t a l a n d a s u i t a b l e b a s i s f o r

t h e r a p e u t i c a u d i t.

K e y w o r d s: d r u g u t i l is a t i o n , p r e s c r i b i n g h a b i ts ; h y p -

n o t i c s , s e d a t i v e s , m i n o r t r a n q u i l l i s e r s , d e f i n e d d a i l y

d o s e s , t h e r a p e u t i c a u d i t

T h e p a t t e r n o f d r u g u t i l is a t i o n in h o s p i t a l s v a r i e s c o n -s i d e r a b l y w i t h i n a n d b e t w e e n c o u n t r i e s [ 1 2 , 1 4] . T h i si s t r u e b o t h f o r s p e c if i c a n d s y m p t o m a t i c d r u gt h e r a p y . C o n t i n u o u s f o l l o w - u p o f d r u g u t i l i s a t i o n i sn e c e s s a r y i n t h e e d u c a t i o n a l p r o c e s s o f t h e r a p e u t i ca u d i t [ 7 , 9 ]. D r u g s u r v e i l l a n c e p r o g r a m s c a n b e u s e df o r t h i s p u r p o s e , b u t t h e y a r e v e r y e x p e n s i v e . In t h isp a p e r w e p r e s e n t a n e w l y d e v i s e d a n d l e s s c o s t l y

a l t e rn a t i v e m e t h o d .

I n m o s t h o s p i t a l s , d r u g - d e l i v e r y a n d h o s p i t a l -o c c u p a n c y s t a t i s t i c s a r e r e g u l a r l y p r o d u c e d f o r

e c o n o m i c p u r p o s e s . B y c o n v e r t i n g t h e a m o u n t s o fd r u g s d e l i v e re d f r o m t h e p h a r m a c y t o t h e w a r d s i n t os o - c a l l e d d e f i n e d d a i l y d o s e s ( D D D ) I ; [ 2, 3 ] i t i s

p o s s i b l e t o c r e a t e a u n i t f o r c o m p a r i s o n o f d r u g c o n -

s u m p t i o n [ 5 ] .T h e p u r p o s e o f t h is i n v e s t i g a t io n w a s t o s h o w t h a t

t h e n u m b e r o f D D D d e l i v e r e d p e r b e d - d a y t o d i ff e r-e n t w a r d s i s a c l in i c a ll y r e l e v a n t m e a s u r e o f d r u g u t i -l i s a ti o n i n a h o s p i ta l . D a t a o b t a i n e d u s i n g t h ism e t h o d w e r e v a l i d a t e d ( c o m p a r e d ) w i t h d r u g s u r-

v e i l l a n c e d a t a . H y p n o t i c s , s e d a t i v e s a n d m i n o r t r a n -q u i l li s e rs ( H S m T ) w e r e c h o s e n f o r t h e s t u d y , b e c a u s e

o f t h e ir w i d e - s p r e a d u s e a n d b e c a u s e m a r k e d d i f f e r-

e n c e s i n t h e i r u t i l i s a t i o n e x i s t b e t w e e n s i m i l a r h o s p i . -t a I w a r d s i n S w e d e n [ 1 5] .

M e t h o d s

Drug D elivery Data

T h e a m o u n t o f e a c h d r u g d e l i v e re d f ro m o u r h o s p i ta l

p h a r m a c y t o e a c h w a r d i s c o m p u t e r i s e d q u a r t e r ly f o r

i n t e r n a l c h a r g i n g . T h e n u m b e r o f p a c k a g e s o f d i f f e r-e n t s t r e ng t h s a n d a d m i n i s tr a t i o n f o r m s o f H S m T , a sd e f i n e d i n t h e r e g i s t e r o f S w e d i s h P h a r m a c e u t i c a lS p e c i a l i t i e s [ 1 ] , w e r e m a n u a l l y c o n v e r t e d t o D D D[2 ]. T h e n u m b e r o f D D D d e l i v e r e d t o e a c h w a r d w a st h e n d i v i d e d b y t h e n u m b e r o f b e d -d a y s , i . e . t h e

a v e r a g e n u m b e r o f p a ti e n t s i n e a c h w a r d p e r d a y ; th ed a y s o f a d m i s s i o n a n d d i s c h a r g e w e r e c o u n t e d a s o n eb e d - d a y . T h e s u r g i c a l o p e r a t i n g u n i t s , i n t e n s i v - c a r e

i T h e D D D i s th e e s t i m a t e d a v e r a g e m a i n t e n a n c e d o s e fo r th e

ma in ind ica t ion o f a d rug , a s e s tab l i shed by the Nord ic C ounc i lon M ed ic ines [2] .

0 0 3 1 - 6 9 7 0 / 8 0 / 0 0 1 7 / 0 1 8 3 / $ 0 1 . 0 0



I 8 4 U . B e r g m a n e t a l .: A u d i t i n g H o s p i t a l D r u g U t i l i sa t i o n

T ab le 1 . T he u t i l i s a t ion o f hypno t i cs , s eda t ives and m inor t r anqu i l l is e r s i n var ious depar tm en t s o f Hudd in ge U niver s i ty Hos p i t a l i n 1975

D r u g p a t te r n N u m b e r o f

D D D / b e d - d a y

D e p a r t m e n t s o f A n t i h i s ta m i n e s B a r N - B e n z o d i - C h l o r a l O t h e r s T o t a l

w i t h s e d a t iv e t u r a t e s a z e p i n e s h y d r a t e ( % ) ( % )

e f f e c t ( % ) ( % ) ( % ) ( % )

Pedia tr ics 18 30 51 1 0 100 0.09

M ed ic ine 9 3 78 5 5 100 0 . 55

P n e u m o l o g y 7 5 7 9 3 5 1 0 0 0 . 6 4

Al l e r g o logy 11 3 67 I 3 6 100 0 . 70

Neu r o logy 9 13 58 16 5 101 0 .51

Gen er a l s u r ger y 6 14 73 2 5 100 0 . 66

T r ans p lan t s u r ger y 0 10 82 0 8 100 0 . 79

Ur o logy 1 8 86 2 3 100 0 . 49

Or top ed ics 3 6 83 5 3 100 0 . 30

Gyn eco logy and Obs te t r i cs 4 37 58 0 0 99 0 . 40

Oph tha lm ology 7 1 88 3 1 100 0 . 45

Oto- r h in o- l a r yng o logy 16 8 72 2 2 100 0 . 49

Psyc hiatry 33 5 55 4 3 100 1.18

T ota l 11 12 71 3 3 100 0 . 53

M E D I C I N E

G E N . S U R G E R Y

0 0 .1 0 , 2 0 . 3 0 . 4 0 . 5 0 . 6 0 . 7i I I l I I I [ I I J I t I

1 9 7 5 ~ .\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ "~ \ " 1

1 9 76 k \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ ~ l1 9 7 7 ~ , , \ \ \ \ \ \ \ ~ \ \ \ \ \ \ \ \ ~ \ \ \ ~ 1

!

1975 L \ \ " ~ ' , , ~ X \ ~ \ \ \ \ \ \ \ \ \ \ \ ~1 9 7 6 ~ \ \ \ \ ~ \ \ ~ \ \ \ \ \ \ \ \ \ \ \ ' - . ~1 9 7 7 b , \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ ~ l

G Y N E C O L O G Y & 1 9 7 5 \"~"N~\'~"N\~"N\~\"Nxl1976 X \ \ \ \ \ \ \ " " \ \ \ \ \ \ ' q

O B S T E T R IC S 1 9 77 I ~ \ ~ \ \ \ \ \ \ \ \ ' x ]

O T H E R S e x ¢ t= 1 9 7 5 ~ \ \ \ \ \ \ \ \ \ \ \ \ \ \ ' ~ . ~ . \ \ ~P e d i a t r i c s & 1 9 7 6 ~ ~ \ \ ~ . ~ ' ~ , \ \ \ \ ~ " ~ , \ \ \ \ \ \ " ~P s y c h i a t r y 1 9 7 7 L ~ \ \ \ \ \ \ \ \ \ ~x" \ \ \ \ \ \ x x "~

0.8 DDDI bed-

' I day

Fig . 1 . Ut i l i sa t ion o f hypno t i cs , s eda t ives, and min or t r anqu i l -

l i se r s i n D D D / b e d - d a y d u r i n g 1 9 7 5 - 7 7 i n t h e g e n e r a l w a r d s

f o r a d u l t p a ti e n ts . I n t h e D e p a r t m e n t o f M e d i c i n e t h e d e c r e a s ef r o m 1 9 7 5 t o 1 9 7 6 w a s 1 1 % . I n t h e D e p a r t m e n t o f G e n e r a l

S u r g e ry t h e r e w a s a n i n c r e a s e o f 1 7 % d u r i n g t h e s a m e p e r i o d

and a decr eas e o f 36% in the f o l lowing year . Al l t he changes

ar e s ign i f i can t ( p < 0 . 001) . I n t he Dep ar tm en t o f Ge ner a l

S u r g e r y b a r b i t u r a te u s a g e d e c r e a s e d f r o m 1 4 % t o 2 % a n d t h a t

o f s e d a ti v e a n t ih i s ta m i n e s i n c r e a se d f r o m 6 % t o 2 0 % b e t w e e n

1 9 7 5 - 1 9 7 7 . I n t h e D e p a r t m e n t o f G y n e c o l o g y & O b s t e tr i c s

b a r b i t u ra t e u s e d e c r e a s e d fr o m 3 7 % t o 2 1 % a n d b e n -

z o d i a z e p i n e s i n c r e a s e d f ro m 5 8 % t o 7 0 %

and em ergency w ards and the ou tpat i en t c l in i cs were

exc luded from a l l ca lcu lat ions .

Drug Surveillance Data

In the surve i l lance s tudy , wh ich was conducted in two

of the s ix med ica l wards , the reasons for prescr ib ing

and wi thdrawal o f drugs were recorded dur ing

March-June 1975 [4] . A l l drug doses taken by the

pat i en ts were ver i f i ed by s ignature of a nurse . In

Sweden nurses are a l lowed to "prescr ibe" and

admin i ster s ing le doses o f a few drugs wh ich are

se l ec ted by the head physic ian . A l l doses o f the same

drug "pre sc~bed" by nurses for a pat i en t for the

same ind icat ion were counted as one "nurse prescr ip -

t ion". The prescr ip t ion and admin i strat ion of HSmT

to 274 pat i en ts , wh o were adm it ted and d i schargeddur ing the s tudy , were analysed [4] . The ch i - square

me thod was u sed for s tat is t ica l ca lcu lat ions .

Resu l t s

Drug Delivery Data

O v er a l l d e l i v e r ie s o f H S m T co r r e s p o n d ed t o a f ul l

D D D f o r e v e r y se c o n d p a ti e n t i n 1 9 7 5 ( T a b l e 1 ) b u t

t h e r e w as a w i d e v a r i a t i o n ( 1 3 - f o l d ) b e t w een d ep a r t -



U. Be rgm an e t a l . : Aud i t ing Hosp i t a l Drug Ut i l i s a tion 185

Table 2 . C omp ar i son be tween de l ive r ie s of hypnot ic s , s eda t ive s and mino r t r anqui l li s e r s and surve i ll ance da ta for two medica l wa rds

De l ive ry da ta Surve i l l ance da ta

1975 M arch- Jun e 1975

( D D D ) D D D P r e - D o s e s D D D

mg del ive red scr ipt ions given given(%) (%) (%) (%)

Antihis tamines with sedat ive effect :prome thaz ine (25)

propiomaz ine (25)

Barbi tura t e s :amoba rbi t a l (100)

pe n t oba r b i t a l ( i 00 )phenoba rbi t a l (100)

Benzodiazepines :chlorazepa te , d ipota s s ium (20)

diazepam (10)

ni t r azepam (5)

oxazepam (50)

Chlora l hydra te (1000)Othe r s :

c lome thiazole (1500)p r om e t ha z i ne /e m e pr on i um b r om i de ( 1 t a b l et )

10 7 10 16

1 8 5 8

77 70 69 66

6 9 7 66 6 9 4

100 100 100 100

(6990) (196) (936) (687)

ments , wi th Pedia t r ic s and Psychia t r iy as the

e x t re me s . The be nz od i a z e p i ne s domi na t e d i n a l l

de pa r t m e n t s , bu t t he re w a s c ons i de ra b l e var i a ti on i nt he c ho i c e o f ind i v i dua l d rugs . Thus , m ore b a rb i t u -

ra t es w e re u se d i n t he D e pa r t m e n t s o f P e d i a t ri c s a ndGyn e c o l ogy a nd O bs t e tr i c s t ha n i n t he o t he r de pa r t -

me n t s , w he re a s a n t i h is t a mi ne s wi t h a s e da t i ve e f fe c t

w e r e o v e r r e p r e s e n t e d i n t h e D e p a r t m e n t o f

Psychia t ry (al l d i f fe rences p < 0 .001) .

A l t h o u g h 3 1 d i f f e re n t H S m T ( 2 7 w i th s y n o n y m s

e xc l ude d ) we re de l i ve re d , f i ve ma j o r d rugs

a c c oun t e d fo r 88% o f de l i ve r i e s (n i t r a z e pa m 47% ,

d i a z e p a m 2 0 % , p r o m e t h a z i n e 9 % , a m o b a r b i ta l 8 %

a nd c h l o ra l hyd ra t e 4% ) . D rugs t ha t we re no t r e c om-

m e n d e d b y t h e h o s p i ta l 's P h a r m a c y a n d T h e r a p e u ti c s

C o mm i t t e e a c c oun t e d fo r on l y 3% o f de li ve ri e s,

In t he ge ne ra l wa rds fo r a du l t pa t i e n t s , t he

D e p a r t m e n t s o f M e d i c i n e , G e n e r a l S u r g e r y , a n dGyne c o l ogy a nd Obs t e t r i c s we re t he ma j o r ove ra l l

c o n s u m e r s o f H S m T i n 1 9 7 5 . T h e y a c c o u n t e d ,

re spe ct i vel y , fo r 25% , 19% a nd 12% o f the

de l ive r i es o f t he se d rugs . Dur i ng a t h re e -y e a r pe r i od

t he u t i l i sa t ion o f H S m T de ve l ope d d i ff e re n t ly in t he

three depar tments (F ig . 1) .

Drug Surv e il l ance D a ta

H S m T we re p re sc r i be d 196 ti me s fo r 117 o f t he 274

pa t i e n t s (43% ) . Twe l ve d i f f e re n t d rugs we re p re -

s c r ibe d a mong s t wh i c h n i tr a z e pa m (40 % ) a nd

d i a z e pa m (27% ) we re p re domi na n t . In t e re s t i ng l y ,

7% (14 / 196) o f t he p re sc r i be d hypno t i c s we re ne ve r

a dmi n i s t e re d t o t he pa t i e n t s be c a use t he y d i d no t

ne e d t he m. In a ll , 936 dose s f rom 178 p re scr i p t ionswe re g i ve n t o 111 pa t ie n t s . F o r 30% o f t he p re scr i p -

t i ons on l y one dose wa s g i ve n , bu t on l y 7% we re

s ingle dose presc r ip t ions (F ig . 2) . F or n i t razep ' am and

d i a z e pa m, t he m e a n da i l y dose g ive n wa s 5 .0 mg a nd

6 .2 mg , r e spe c ti ve l y ( c f t he D D Ds i n Ta b l e 2 ) .

T h e m a j o r i n d ic a t io n s t a te d f o r u s i n g H S m T w a s

i nsomni a (Ta b l e 3 ) . N o i nd i c a ti on wa s s t a te d fo r

21% o f t he p re sc r i p t i ons , bu t 87% o f t hose dose s

w e r e a d m i n i s t e r ed b e t w e e n 8 a n d 1 2 p . m . , w h i c h

sugges ts insom nia as the indica t ion .

Delivery versus Surve i l lance Data

Th e de l ive r i es o f HS m T t o t he t wo su rve i l l e d wa rds

c o r r e s p o n d e d t o 0 . 5 0 D D D / b e d - d a y i n 1 9 75 . D u r i n g

t he su rve i l l a nc e pe r i od t he a c t ua l u se wa s l owe r

(p < 0 .001) , a s t he 936 dose s t a ke n by t he pa t i e n t s

c o r r e s p o n d e d t o o n ly 0 .2 2 D D D / b e d - d a y . T h e a v e r -a ge da i l y dose i nge s t e d c o r re sponde d t o 0 .93 DDD(687 DD D i n 736 da ys ) . The d rug pa t t e rn du r i ng t hesu rve i l l a nc e pe r i od b roa d l y c o r re sponde d t o t ha t

re f lec ted by de l ive r ies dur ing the ent i re yea r (Table

2).



186 U. Bergman et al.: Auditing Hospital Drug Utitisation

Table 3. Indications for hypnotics, sedatives and minor tranquil-

lisers in two medical wards March-June 1975

Indication Prescriptions by: Doses administered

when prescribed by:

Insomnia 32 50 40 29 72 43

Anxiet y/ago ny 31 12 22 33 7 24

Somatic disorder s 11 3 8 15 1 11

Abstin ence/ delir ium 13 - 7 18 - 12

Premedi cation 5 - 3 1 - 0

9 8 34 21 4 19 10

100 100 100 100 100 100

n = 104 90 196 a 611 314 936 a

a For two prescriptions (1%) and 1t doses (1%) neither indica-

tion nor prescriber was stated

n u m b e r o f

p r e s c r i p t i o n s

6 0 - m

40

0 2 3 4 5 6 7 8 - 5 4 ?

n u m b e r o f d o s e s u s e d

Fig. 2. Fre quenc y distribution of 196 prescriptio ns of hypnotics,

sedatives, and minor tranquillisers of which 936 doses (range

0-5 4) were given during the surveillance study. Median = 2, mean

= 5.3 doses per prescription, dotted line = single-dose prescrip -

tions (n = 14)

Discus s ion

E c o n o m y a n d s i m p li c it y a r e t h e m a j o r a d v a n t a g e s o fu s i n g d r u g - d e l i v e r y a n d o c c u p a n c y s t a t is t ic s t o m e a s -

u r e h o s p i t a l d r u g u t i l i s a ti o n , a s t h e s e d a t a a r e a l r e a d y

m a d e a v a il a b le f o r o t h e r p u r p o s e s . I n f o r m a t i o n o n

t h e i n d i c a t i o n s f o r t h e p r e s c r i b in g , v a r i a t i o n s i n i n d i -

v i d u a l d o s e a n d d r u g e f f e c t s m u s t b e s o u g h t s e p a -

r a t e ly . T h e " d e f i n e d d a i l y d o s e " i s a n e s t i m a t e d a v e r -

a g e m a i n t e n a n c e d o s e f o r t h e p r i nc i p a l i n d ic a t i o n o f

t h e d r u g [ 2]. A s s h o w n i n t h i s s tu d y , D D D - s t a t i s t i c s

c a n b e u s e d t o a s se s s d r u g u t i l i s a t io n i n h o s p i t a l s , as

w e l l a s fo r i n t e r n a t i o n a l c o m p a r i s o n s [ 3, 5 , 1 6 ] .T h e a v e r a g e d a i ly d o s e o f H S m T a c t u al l y g i v e n t o

t h e p a t i e n ts d u r i n g t h e s u rv e i ll a n c e s tu d y c o m p a r e d

w e l l w i t h t h e D D D . H o w e v e r , i t d i d d i f f e r c o n s i d e r -

a b l y f o r c e r t a i n d r u g s , e . g . d i a z e p a m , o f w h i c h 6 2 %

o f t h e D D D w a s a d m i n i s t e r e d . T h e s a m e g e n e r a l

a g r e e m e n t h a s b e e n f o u n d i n s t u d i e s o f p r e s c r i p t i o n s

f o r S w e d i s h o u t p a t i e n t s [ 6 , 1 6 ] . T h e d r u g p a t t e r n

d u r i n g t h e s u r v e i l l a n c e p e r i o d a l s o c o r r e s p o n d e d t ot h a t r e f l e c t e d b y t h e d e l i v e r i e s ( T a b l e s 1 , 2 ) .

H S m T w e r e p r e s c r i b e d f o r a l m o s t h a l f o f t h e

p a t i e n t s s u r v e i l l e d , b u t u s u a l l y o n l y a f e w d o s e s w e r e

g i v e n ( F ig . 3 ) . D u r i n g t h e s u r v e i l la n c e p e r i o d t h e

p a t i e n t s t o o k o n l y h a l f o f t h e m e a n a m o u n t o f H S m T

d e l i v e r e d d u r i n g 1 9 7 5 , a n d o n l y o n e - t h i r d o f t h e

a v e r a g e d e l i v e r i e s o f n i t r a z e p a m ( 0 .1 1 v s 0 . 3 1 D D D /

b e d - d a y ) . D u r i n g t h e s t u d y t h e p h y s i c ia n s p r o b a b l y

p a i d p a r t i c u l a r a t t e n t i o n t o t h e i r p r e s c r i b i n g h a b i t s ,

s i n c e t h e y h a d t o s p e c i f y t h e i n d i c a t i o n f o r e a c h d r u g

[ 4] . N u r s e s w e r e r e s p o n s i b l e f o r a b o u t h a l f o f t h e

p r e s c r i p t i o n s b u t f o r o n l y o n e - t h i r d o f t h e d o s e s , a n d

t h e i r p r e s c r i b i n g w a s a l m o s t e n t i r e l y f o r s l e e p i n g d i s-o r d e r s ( T a b l e 3 ) . T h e s u p e r v i s i o n a n d r e c o r d i n g o f

d r u g i n t a k e e x c l u d e d t h e p r e v i o u s h a b i t o f l e a v i n g

h y p n o t i c s a t t h e b e d - s i d e " i n c a s e o f n e e d " . S e a s o n a l

v a r i a t i o n i n d r u g u t i li s a t i o n [ 10 ] m a y a l s o h a v e c o n -

t r i b u t e d t o t h e l o w e r u s e d u r i n g t h e s u r v e i l l a n c e

p e r i o d .

A c e r t a i n a m o u n t o f w a s t a g e i s i n c l u d e d i n d e l i v -

e r y d a t a . U p t o 7 % o f a ll d ru g s d e l i v e r e d ( o n a c o s t

b a si s) h a v e b e e n r e p o r t e d t o b e d i s c a r d e d b e c a u s e o f

t h e e x p i r y d a t e l i m i t a t i o n [ 8 ] . H o w e v e r , d r u g - d i s -

p e n s i n g r o u t i n e s i n S w e d i s h h o s p i t a l s g i v e r i se t o

a d d i t i o n a l w a s t a g e , w h i c h i s n o t n o r m a l l y a c c o u n t e df o r . A l l d r u g s a r e d i s p e n s e d f r o m t h e w a r d s t o r e f o r

a t l e a s t 2 4 h i n a d v a n c e a n d d r u g s t h a t a r e n o t u s e d

c a n n o t b e r e t u r n e d . T h i s w a s t a g e c o r r e s p o n d e d to

a b o u t o n e - t e n t h o f a ll H S m T d e l i v e re d . A " u n i t

d o s e " d r u g - d e li v e r y s ys t e m w o u l d e l i m i n a t e m o s t o f

t h e s e p r o b l e m s .

I n 1 9 7 5 t h e d e l i v e r i e s o f H S m T t o t h e g e n e r a l

w a r d s f o r a d u l t s c o r r e s p o n d e d t o c o n t i n u o u s u s e o f

t h o s e d r u g s b y 3 0 to 8 0 % o f t h e p a t i e n ts . T h e

t h e r a p e u t i c r a t i o n a l e f o r t h e e x t e n s i v e u s e o f t h e s e ,

m a i n l y s y m p t o m a t i c d r u g s i n s o m e d e p a r t m e n t s c a n

b e q u e s t i o n e d . A s w e e x p e c t e d , t h e i r u s e d i f f e r e d

w i d e l y i n t h e D e p a r t m e n t s o f P e d i a t r i c s a n dP s y c h i a t r y [ 13 ]. C l i n ic a l l y m e a n i n g f u l c o m p a r i s o n s

h o w e v e r , c a n o n l y b e m a d e b e t w e e n s i m i l a r d i s c i -

p l i n e s [ 5 , 1 2 , 1 5 ] , o r w i t h i n d e p a r t m e n t s o v e r t i m e '

( F i g. 1 ). H o w e v e r , w e d a r e t o s p e c u l a t e t h a t t h e r e la -

t i v e l y h i g h u s a g e o f b a r b i t u r a t e s i n t h e O b s t e t r i c

D e p a r t m e n t m a y b e r e l a t e d t o t h e co n t r ov e r s ia l

r e p o r t s o f p o s s i b l e a d v e r s e e f f e c t s o n t h e f e t u s o f

n e w e r H S m T , a n d t h a t p s y c h i a t r i s t s a r e b i a s e d

a g a in s t b e n z o d i a z e p i n e s d u e t o t h e p u r p o r t e d a b u s e

r i sk s .

C o i n c i d i n g w i t h d i s c u s s io n o f r e s u lt s f r o m t h e s u r -

v e i l l a n c e s t u d y i n t h e D e p a r t m e n t o f M e d i c i n e i n



u . Bergman et al.: Auditing Hospital Drug Utilisation 187

J a nua r y 1976 , t he r e w a s a s i gn i f i c a n t de c r e a s e i n t he

u s e o f H S m T . A r e s tr i ct i o n i n " n u r s e p r e s c r i b i n g "

f r om 1977 d i d no t f u r t he r r e duc e t he i r u s e . S i m i la r ly ,

c o i n c i d e n t a l w i t h i n t e n s i v e i n f o r m a t i o n a n d d i s c u s -

s i o n o f d r u g - h a n d l i n g r o u t i n e s w i t h t h e s t a f f o f th e

D e p a r t m e n t o f G e n e r a l S u r g e r y , th e u t i li s at i on o fH S m T t h e r e d e c re a s e d b y 3 6 % i n 1 97 7 . T h e u s e o f

H S m T w a s a l so d i s c u s se d a t a g e n e r a l s t a f f m e e t i n g i n

t h e h o s p i ta l h e l d b y t h e P h a r m a c y a n d T h e r a p e u t i c s

C o m m i t t e e i n th e e a r l y 1 9 7 7 , a n d t h i s m a y h a v e c o n -

t r i b u t e d t o t h e d e c r e a s e i n m o s t d e p a r t m e n t s s e e n i n

t h a t y e a r ( F ig . 1 ). T h e m e t h o d u s e d t h u s a p p e a r s w e ll

s u i t e d f o r a s s e ss i n g t h e e f f e c t o f d r u g i n f o r m a t i o n

p r o g r a m s o n d r u g u t i l i s a t i o n .

I n a n A m e r i c a n s t u d y , d i f f e r e n c e s i n d r u g a v a il a -

b i l i ty a n d c h a n g e s i n t h e h o s p i t a l d r u g f o r m u l a r y

w e r e m o r e i m p o r t a n t d e t e r m i n a n t s o f d r u g p r e s c r ib -

i ng th a n r e c o m m e n d a t i o n s f r o m t h e P h a r m a c y a n d

T h e r a p e u t i c s C o m m i t t e e [ 1 0] , In o u r h o s p i ta l t h e

f o r m u l a r y d r u g s , j o i n t l y s e l e c t e d b y c l in i c ia n s , c li n ic a l

p h a r m a c o l o g i s t s a n d p h a r m a c i s ts , a c c o u n t e d f o r t h e

v a s t m a j o r i t y o f t h e H S m T u s e d . N o c h a n g e s w e r e

m a d e i n t h e d r u g f o r m u l a r y a n d a l l t h e d r u g s w e r e

c o n t i n u o u s l y a v a i la b l e d u r i n g 1 9 7 5 - 1 9 7 7 . R e c e n t

d a t a f r o m t h e N a t i o n a l C o r p o r a t i o n o f P h a r m a c i e s

r e v e a ls t h a t d e l i v e r i e s o f H S m T t o h o s p i t al s i n S w e -

d e n h a v e r e m a i n e d s t a b l e t h r o u g h o u t t h e s e t h r e e

y e a r s ( 0 . 46 , 0 .4 8 , 0 . 4 7 D D D / b e d - d a y ) . I n a g r e e m e n t

w i t h t e a c h i n g i n c li n ic a l p h a r m a c o l o g y , t h e r e h a s

b e e n a c h a n g e f r o m t h e u s e o f b a r b i t u r a t e s a n d c o m -

b i n a t i o n p r o d u c t s t o b e n z o d i a z e p i n e s a n d s e d a t i v ea n t i h i s t a m i n e s [ 1 1 ] .

W e b e l i e v e t h a t i n f o r m a t i o n a n d d i sc u s si o n o f t h e

u t il is a ti o n o f H S m T p o s i ti v e l y in f l u e n c e d t h e u s e o f

t h e s e d r u g s i n o u r h o s p i t a l . D r u g - d e l i v e r y st a ti s ti c s in

S w e d e n a r e n o w c o n v e r t e d t o D D D b y a c o m p u t e r -

i s e d r o u t i n e . T h i s s t a t i s t i c i s a v a i l a b l e t h r o u g h t h e

N a t i o n a l C o r p o r a t i o n o f P h a r m a c i e s t o a l l d o c t o r s ,

a n d t o p h a r m a c i s t s t h r o u g h t h e i r lo c a l P h a r m a c y a n d

T h e r a p e u t i c s C o m m i t t e e . T h e c o n t i n u o u s m o n i t o r in g

o f d r u g u t il i sa t io n e x p r e s s e d i n D D D / b e d - d a y s i s a n

i n e x p e n s i v e , s i m p l e , a n d v a l u a b l e b a s i s f o r d is c u s s io n

o f p h a r m a c o t h e r a p e u t i c r o u t i n e s , i . e . th e r a p e u t i c

a u d i t, i n P h a r m a c y a n d T h e r a p e u t i c s C o m m i t t e e s .W h e n p r o b l e m a r ea s a r e d et e c te d , m o r e e l a b o r a t e

s t u d i e s, s u c h a s p r o s p e c t i v e s u r v e i l l a n c e , c a n b e c o n -

d u c t e d t o g i v e th e d e t a i l e d i n f o r m a t i o n n e c e s s a r y f o r

a c l i n i c a l j u d g e m e n t o f t h e r a p e u t i c q u a l i t y .

A c k n o w l e d g e m e n t s . T h i s s t u d y w a s s u p p o r t e d b y t h e

N a t i o n a l C o r p o r a t i o n o f S w e d is h P h a r m a d e s . W e

a r e v e r y g r a te f u l t o M r s I n g r i d N o r d e n s t a m o f t h e

N a t i o n a l C o r p o r a t i o n o f S w e d i s h P h a r m a c i e s f o r

p r o v i d i n g d a t a o n t o t a l h o s p i t a l d r u g d e l i v e r i e s i n

S w e d e n , a n d t o M r s K e r s t i n J a c o b s e n , r e s e a r c h

n u r s e , f o r h e r v a l u a b l e h e l p i n t h e s u r v e i l l a n c e st u d y .

R e f e r e n c e s

1. Apo tekens lfikemedelsregister, 1974-19 75. Esselte DigitypeAB, Stockholm 1974. (A register of Swedish PharmaceuticalSpecialities)

2. Nordic statistics on m edicines 1975-1977 , parts I, II. Statisti-

cal reports of the Nordic countries no 35, 36. Helsinki andOslo: Nordic Council of M edicine, 19793. Bergm an, U., Elm es, P., Halse, M., Lunde, P. K. M., Sjrqvist,

F. , Wade, O ., Westerholm, B.: Th e measurement of drug con-sumption. Drugs fo r diabetes in Northern Ireland, Norway an dSweden. Eur. J. clin. Pharm acol. 8, 83-89 (1975)

4. Bergm an, U., Norlin, A., Wiholm , B.-E.: Inadeq uacies n hos-pital drug handling. Acta M ed. Scand. 205 , 79-85 (1979)

5. Bergman, U., Grimsson, A., Wahba, A . H. W., W esterholm,B. (ed s): Studies in drug utilization - metho ds and applica-tions. WHO Regional Publications, European Series no. 8,Copenhagen 1979

6. Bergman, U., Dahlstrrm, M., G unn arson, C. , and W es-terholm, B.: Why are psych otropic drugs prescribed to out-patients? A m ethodologicalstudy. Eur. J. Ctin. PharmacoL 15,249-256 (1979)

7. Crooks, J.: M ethods of "aud it" in drug use . In: Adva nces inpharmacology and therap eutics, Vol 6: Clinicalpharmacology,Duch rne-M arullaz, P. (ed.) pp. 189-195. O xford, New York:Pergamon Press 1978

8. Dolby , J., Ekblom, B.: Lfikemedelskassation sluten vfird enettfirsstudie rid Ullerfikers sjukhus. S vensk FarmaceutiskTidskrift 78, 324-329 (1974)

9. Ed itorial: Medical audit and continuing education. Br. Med. J.1978/II, 156

10. Franklin, E., May, M. S., Stewart, R., Cluff, L. E .: Dru g use inhospital. Evaluation of determ inants. Clin. Pharm acol. Ther.16, 834--845 (1972)

11. Koch -W eser, J., Green blatt, M.D.: Th e archaic barbituratehypnotics. N. Engl. J. M ed. 291 , 790-791 (1974)

12a. Lawson, D.H., J ick, H.: D rug prescribing in hospitals: An

international comparison. Am . J. P ublic Health 6 6, 644--648(1976)

12b. Lawson, D.H ., J ick, H.: Drug prescribing in hospitals: Aninternational comparison. In: Advan ces in pharm acology andtherapeutics, Vol. 6: Clinical pharm acology. Duch rne-M arul-laz, P. ed.) pp. 93-99. Oxford, New York: Pergamon Press1978

13. Morland, T.A ., Rylandse, G.W., Christoffer, L. J . , Stephen-sen, I. H.: Patterns of d rug prescribing for children in hospital.Eur. J. clin. Pharm acol. 14, 39-46 (1978)

14. Sicr, J.: Majo r d rug prescribing patterns in general hospitals.Clin. Pharm acoI. Ther. 18, 133-13 8 (19 75)

15. Westerholm , B.: Patterns of d rug utilization. Sources of infor-mation on drug usage in Sw eden. Clin. Phalmacot. Ther. 19,644-650 (1974)

16. Westerho lm, B., Kristensen, F., Schaffalitzkyde Muckadell,H .U ., Id~inpfi~in-Heikkil/i, ., Lahti, T., Grim sson, A., O lafs-son, O., M cMeek ing, C., Lund e, P. K. M., O ydvin, K.: Drugutilization - Geog raphical differencesand clinical m plications- Psychotropic drugs. In: Advances in pharmacology andtherapeutics, Vol. 6: Clinical pharm acology. Duchd ne-Ma rul-laz, P. (ed.), pp 11 3-121. Oxford, New York: Pergamon Press1978

Received: July 3, 1979accepted in revised form: Novem ber 12, 1979

Dr. Bengt-Erik WiholmDepartment of Clinical PharmacologyHuddinge University Hospital(S-14186) H uddinge, Sweden

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