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LETTER TO THE EDITOR
Year : 2013  |  Volume : 57  |  Issue : 4  |  Page : 280-281  

Overuse of non-evidence based pharmacotherapies in coronary heart disease in India


1 Senior Consultant and Director Research, Department of Medicine, Fortis Escorts Hospital, Jaipur, Rajasthan, India
2 Research Scholar, Department of Medicine, Fortis Escorts Hospital, Jaipur, Rajasthan, India
3 Consultant, Jaipur Heart Watch Foundation, Jaipur, Rajasthan, India
4 Senior Consultant, Department of Medicine, Fortis Escorts Hospital, Jaipur, Rajasthan, India

Date of Web Publication18-Dec-2013

Correspondence Address:
Rajeev Gupta
Senior Consultant and Director Research, Department of Medicine, Fortis Escorts Hospital, Malviya Nagar, JLN Marg, Jaipur - 302 017, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.123241

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How to cite this article:
Gupta R, Sharma KK, Ahuja S, Khedar RS. Overuse of non-evidence based pharmacotherapies in coronary heart disease in India. Indian J Public Health 2013;57:280-1

How to cite this URL:
Gupta R, Sharma KK, Ahuja S, Khedar RS. Overuse of non-evidence based pharmacotherapies in coronary heart disease in India. Indian J Public Health [serial online] 2013 [cited 2019 Nov 13];57:280-1. Available from: http://www.ijph.in/text.asp?2013/57/4/280/123241

Sir,

Limited literature exists regarding overuse of medications in patients suffering from various medical conditions. [1] In controlled health-care financing environments, such as government or insurance funded, there are restrictions on the use of medications and procedures by physicians. However, there is a little restriction in most low-income countries with out-of-pocket payment healthcare systems. [2] To determine the use of low- or non-evidence based therapies in patients with stable coronary heart disease (CHD) we performed a prescription audit at tertiary, secondary and primary care in Rajasthan to identify the use of low- and non-evidence based therapies (multivitamins, anti-oxidants etc.). Details of methodology have been reported. [3] We evaluated prescriptions of 2282 CHD patients. A total of 688 patients were at tertiary care, 1306 at secondary care and 288 at primary care. The mean age of patients was 60.5 ± 14 years, nearly 50% of patients were 45-65 years of age and 71% of patients were men. The median time after diagnosis was 30 months (inter-quartile range: 18-54 months). Aspirin was prescribed in 2030 (88.9%), beta blockers in 1491 (65.3%), angiotensin converting enzyme inhibitors or angiotensin receptor blockers in 1927 (84.4%), statins in 1441 (63.1%) and other lipid modifying drugs in 263 (11.5%). Any one of these four evidence based drugs were prescribed in all, any 2 in 2211 (96.9%), any 3 in 1720 (75.4%) and all 4 in 681 (29.8%) (P < 0.001). When compared to tertiary care physicians, the prescriptions at secondary and primary care respectively were lower for aspirin (94.6 vs. 90.8 and 67.0%), statins (82.4 vs. 62.3 and 20.8%), or use of 2 drugs (96.3 vs. 97.5 and 85.1%), 3 drugs (58.4 vs. 55.3 and 27.8%), or all 4 drugs (43.5 vs. 27.7 and 6.6%) (P < 0.01). Use of other drugs was, nitrates in 920 (40.3%), dihydropyridine calcium channel blockers (CCBs) in 629 (27.5%) and non dihydropyridine CCBs in 393 (17.2%). Use of low evidence based drugs was potassium channel openers in 465 (20.4%) and metabolic modulators in 411 (18.0%). Use of non-evidence based drugs such as antioxidants was in 251 (11.0%) and multivitamins in 794 (34.8%). Use of antioxidants was greater at tertiary care (12.6%) Vs. secondary (11.3%) or primary (5.9%) while use of multivitamins was significantly greater at primary care (46.5%) when compared to tertiary (25.6%) or secondary (37.1%) care (P < 0.01). The present study shows a high use of low-evidence based therapies in CHD.

Three categories of quality-related issues in health care exist: Underuse is lack of provision of necessary care, misuse is the provision of wrong care and overuse in the provision of medical services with no benefit or for which harms outweigh benefits. All the three are widely prevalent. [4] In India, the focus so far has been on underuse of drugs and technologies. [5] Only a few studies in acute illnesses have reported misuse or overuse of drugs. The present study is one of the first from India focused on medication overuse in chronic disease viz., CHD. This study shows inappropriately high use of prescription multivitamins and antioxidants for stable CHD patients. Use of low-evidence based drugs such as potassium channel openers and metabolic modulators is also high. A meta-analysis of 172 studies reported inappropriate or overuse of medical care in different disease conditions. [1] Overuse of pharmacotherapy was studied for inappropriate antibiotic use in respiratory diseases and ranged from 2% to 90% for antibiotics and 12-80% for bronchodilators. A low rate of overuse for coronary angiography (8-22%), coronary revascularization (2-14%) and cartotid endarterectomy (9-11%) was reported. There were no studies that evaluated pharmacotherapy in stable CHD. A study at a tertiary medical center in US showed overuse of statin therapy in primary prevention and underuse in secondary prevention. [1] No studies have reported overuse of vitamins in the US, but use of alternative medicines is high. [1],[4]

Considering the resources that are wasted on inappropriate use of drugs, many interventions are advised. Approaches that have proved effective include standard treatment guidelines, essential drugs lists, pharmacy and therapeutics committees, problem-based basic professional training, and targeted in-service training of health workers. [4] Some other interventions, such as training of drug sellers, education based on group processes and public education, need further evaluation. Two issues that will require long-term strategic approaches are improving prescribing in all sectors of health-care (especially the private sector) and monitoring the impacts of health sector reform. [5] Sufficient evidence is now available to persuade policy-makers that it is possible to promote rational drug use. If such effective strategies are followed, the quality of health-care can be improved and drug expenditures reduced.

 
   References Top

1.Korenstein D, Falk R, Howell EA, Bishop T, Keyhani S. Overuse of health care services in the United States: An understudied problem. Arch Intern Med 2012;172:171-8.  Back to cited text no. 1
    
2.Lim SS, Gaziano TA, Gakidou E, Reddy KS, Farzadfar F, Lozano R, et al. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: Health effects and costs. Lancet 2007;370:2054-62.  Back to cited text no. 2
    
3.Sharma KK, Gupta R, Agrawal A, Roy S, Kasliwal A, Bana A, et al. Low use of statins and other coronary secondary prevention therapies in primary and secondary care in India. Vasc Health Risk Manag 2009;5:1007-14.  Back to cited text no. 3
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4.Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998;280:1000-5.  Back to cited text no. 4
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5.Reddy KS, Patel V, Jha P, Paul VK, Kumar AK, Dandona L, et al. Towards achievement of universal health care in India by 2020: A call to action. Lancet 2011;377:760-8.  Back to cited text no. 5
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