Publications from Affiliated Sites
Publications from GW Faculty
India: Multi-Center Research Projects
Self Prescribing of Antibiotics
Antibiotic resistance has become a global health threat. Over 2 million illnesses a year occur in the United States because of antibiotic resistance each year (CDC, 2013). Misuse of antibiotics, both for conditions in which such medications are not needed and incorrect dosing regimens, have contributed to the problem of antibiotic resistance (Awad; Ventola). In the US for example, an average of 22 doses of antibiotics are prescribed per person annually (Van Boeckel). The Centers for Disease Control and Prevention estimates that in up to 50% of cases in which an antibiotic is prescribed, it was used inappropriately (CDC n.d; CDC 2013).
Worldwide, antibiotics are even more readily available. A systematic review of antibiotic use in low to medium income countries estimated an approximately 39% prevalence of antibiotic use, most commonly for febrile, respiratory or gastrointestinal illnesses (Ocan). India has one of the highest rates of antibiotic use in the world. A combination of poor access to clinicians and ease of attainability from pharmacists has contributed to the use of over the counter antibiotics in India. Antibiotics, such as carbapenems, are easily obtainable from pharmacies without a prescription (Laxminarayan). Recently India issued practice guidelines to help direct providers about the proper prescribing of antibiotics after increased resistance to carbapenems and other certain drug categories occurred in the critical care setting, as well as after the death of an American woman due to a multidrug resistant organism (Srivastava). In addition to ready access to approved antibiotics, a recent study showed that a third of antibiotic sales in India are of non-approved drug formulations (McGettigan).
Large scale studies in India of the prevalence of self- prescribed antibiotic use have been limited. In one study in Kerala, 18% of customers presenting to a sample of pharmacies had requested an antibiotic without a prescription. Authors estimated that 4 out of every 1000 persons in Kerala used antibiotics without a prescription, with lower education, lower income and lack of provider satisfaction being associated with a higher rate of self-prescribed antibiotic use (Saradamma).
Another study in Pondicherry demonstrated that 12% of residents surveyed reported self- medicating, with 10% of these patients taking antibiotics. Patients reported that time was a major factor in their decision to self-medicate; respondents often received advice from the pharmacist in reaching the decision on what medication to take (Selvaraj).
Despite its widespread use, the prevalence of antibiotic use in a population of patients presenting to the ED in India has not been previously studied. The objective of this study is to evaluate the prevalence of self-prescribed antibiotic use of patients presenting with febrile and infectious disease related complaints to EDs in a sample of xx emergency departments across India. In addition, we hope to understand the reasons for which antibiotics are used.
Emergency Room Patient Expectations
In the United States and other well-resourced countries, patients come to an Emergency Department with core expectations for comprehensive clinical care in a timely manner. These expectations have developed over the last 40 years and mirror the development of Emergency Medicine (EM) as a recognized and respected medical specialty that is practiced in well-staffed and well-resourced clinical settings (Emergency Rooms, ERs). In such settings, EM physicians are expected complete accredited residency or applicable training programs and to be formally credentialed to practice as EM physicians. In addition, clinical settings in which EM is practiced should comply with national standards for clinical care. EM care is considered a basic and essential component of a well-developed healthcare system and has repeatedly been shown to improve clinical outcomes in a variety of medical conditions and public health emergencies.
In less-resourced countries, EM care remains a poorly defined and an unregulated field of clinical practice. This despite evidence, such as that from The Global Disease and Priorities Project estimates that 45% of deaths and 36% of disability adjusted life years in low- and middle-income countries (LMICs) could be addressed by improved access to quality emergency care services (1). In light of these estimates, over the past 20 years, significant efforts have been made to improve access to emergency care in the developing world, including the development of formal residency training programs (2-4). The Indian Ministry of Health formally recognized EM as a specialty in 2009. Despite this, the central government recognized MD EM training programs only currently graduate 28 residents per year in a country of 1.3 billion people (5,6). Privately sponsored efforts across the country have sought to increase training in EM and improve access to emergency care (7,8). One such program, the Masters in Emergency Medicine, is a 3-year, western style, formal emergency medicine residency program affiliated with George Washington University. Started in 2010, the program now operates in 21 different hospitals, has 281 current residents, and has graduated over 300 emergency trained physicians
In India, where large segments of the population lack access to even the most basic medical services, the development of EM represents an opportunity to address health disparities and expand access to care. Despite the growth of EM in India over the past 10 years, it remains a new concept in India and it is possible that patients who present to
ERs for clinical care have variable understanding of what serves are available to them and it is possible that their expectations are not aligned with provided services. There is a paucity of data evaluating public attitudes and understanding of EM and the role of the emergency room in India. Identifying gaps in patient understanding and evaluating patient expectations will be crucial to the continued development of EM in India. Hence, in this study, we seek to better understand what the motivations, expectations, and understanding of available services by patients presenting to emergency departments for clinical services.