PHYSICIAN-PATIENT COMMUNICATION REGARDING PRESCRIBED MEDICATION IN AN AMBULATORY CARE SETTING IN KATHMANDU, NEPAL

Physician-patient interactions often lead to prescription of medicines. Safety andcompliance in the use of these medicines are largely dependent on proper verbal aswell as written communication between prescriber and patient. However, severalpublished reports suggest that such communication is often inadequate. The presentstudy indicated suboptimal doctor-patient communication at a tertiary care hospitalin Nepal. Fifty-two (21.7%) of the 240 patients/caregivers interviewed after out-patientconsultation claimed that doctors did not provide any information on prescribedmedicines. Nearly a quarter of the 188 patients/caregivers who did report havingreceived information could not recall what they had been told, and in more than halfof these cases the lack of recall was attributed to problems in communication. Frequentuse of the English language and Latin abbreviation in prescribed dosing schedulesindicated a need for improvement in written communication as well.Key Words: prescribing information; communication; physician-patient interaction; Nepal.

Antibiotic dispensing by drug retailers in Kathmandu, Nepal

OBJECTIVES To assess over-the-counter antimicrobial dispensing by drug retailers in Kathmandu, Nepal, for rationality, safety, and compliance with existing government regulations.

METHODS

Standardized cases of dysuria in a young adult male and acute watery diarrhoea in a child were presented by a mock patient to retailers at 100 randomly selected pharmacies. Questions asked by retailers and advice and medications given at their initiative were recorded.

RESULTS

All retailers engaged in diagnostic and therapeutic behaviour beyond their scope of training or legal mandate. Historical information obtained by retailers was inadequate to determine the nature or severity of disease or appropriateness of antimicrobial therapy. 97% (95% CI = 91.5-99.4%) of retailers dispensed unnecessary antimicrobials in diarrhoea, while only 44% (95% CI = 34.1-54.3%) recommended oral rehydration therapy and only 3% (95% CI = 0.6-8.5%) suggested evaluation by a physician. 38% (95% CI = 28.5-48.2%) gave antimicrobials in dysuria, yet only 4% (95% CI = 1.1-9.9%) adequately covered cystitis. None covered upper urinary tract or sexually transmitted infections, conditions which could not be ruled out based on the interviews, and only 7% (95% CI = 2.9-13. 9%) referred for a medical history and physical examination necessary to guide therapy.

CONCLUSIONS

Although legislation in Nepal mandates a medical prescription for purchase of antibiotics, unauthorized dispensing is clearly problematic. Drug retailers in our study did not demonstrate adequate understanding of the disease processes in question to justify their use of these drugs. Risks of such indiscretion include harm to individual patients as well as spread of antimicrobial resistance. More intensive efforts to educate drug retailers on their role in dispensing, along with increased enforcement of existing regulations, must be pursued.

Pediatric telephone triage protocols: standardized decisionmaking or a false sense of security?

STUDY OBJECTIVE

To determine whether implementation of a set of standardized pediatric telephone triage protocols results in consistent triage dispositions when applied by different operators.

METHODS

A descriptive study with interrater comparisons was performed. Telephone interviews simulated the setting of a triage station in a university hospital-based pediatric emergency department. A mock parent presented 15 standardized respiratory cases in random order to 12 pediatric ED nurses. Nurses assigned patients' complaints to severity categories using 9 respiratory complaint protocols extracted from a commercially available pediatric telephone triage tool. Protocol selection and severity endpoints were recorded. Interobserver agreement among nurses was analyzed by the kappa statistic. Comparisons of operator characteristics and triage results were carried out by ANOVA.

RESULTS

Interrater agreement in triage disposition among nurses was poor (kappa,.11; 95% confidence interval,.02 to.20). Protocol selection varied; the group used a mean of 3 different disposition-generating protocols per case. Disposition also varied, with up to 4 different severity endpoints per protocol in a given case. A post-hoc comparison of the mean disposition severity between nurses did not reach significance at an adjusted level (P =.04). Fifty-eight percent of the nurses felt confined by the protocols, and 42% admitted to at least 1 intentional deviation from them.

CONCLUSION

It may not simply be assumed that the use of protocols will standardize care. This is particularly important in the case of triage, with current trends toward medical decisionmaking by less skilled providers with diminishing patient contact. Although triage protocols may be useful to guide clinical thinking, their consistency must be validated before they may be safely disseminated for general use.