Discussion
In the present study, Mashhad’s DPIC activity for ten years was evaluated. Overall, 100997 calls were received by MDPIC since 2007 until 2017. The number of calls recorded in 2017 was 17781, which shows approximately a 10 times increase in the number of calls compared with 1668 calls received in 2007. The reason for such an increase may be the completion of MDPIC’s staff and equipment through these years and increased public awareness about services provided by MDPIC. Although the number of calls has significantly increased during these ten years, it still seems to be low considering the population who are under MDPIC supervision, based on the latest report available on the health information exchange (HIX) system (about 5’087’992 persons) (21). Thus, new policies regarding introducing MDPIC to the public should be implemented.
Majority of the calls (95.11%) were made by the general public, and 4.89% of the calls were related to the health care professionals. This pattern is consistent with other reports in Iran (5, 11 and 20). The low rate of health care professionals’ engagement with DPICs indicates that there is a need for implementation of informing programs to improve the health care professionals’ awareness about DPIC’s services. Among health care professionals, pharmacists made the majority of the calls (58.69%), followed by general practitioners (21.68%). This trend is similar to other studies in Iran (5, 11 and 20). More advertisement of DPICs in pharmacies may be the reason for this finding.
Queries were predominantly made by females (73.08%), which agrees with the findings of other studies conducted in Iran, Finland, and the Netherlands (5, 8, 9, 11, 20, 22 and 23). This may be the case because women have more free time in Iran as well as greater responsibility for family health. Moreover, most of the calls came from the age group of 18-60 years old, which is in line with previous studies in Iran (5, 8, 11 and 20). It seems that despite the excessive use of medication in the elderly population, they are not familiar with this telephone service and also, their pharmaceutical questions are may be asked from DPIC by their children.
Most of the received inquiries were related to therapeutic use (24.03%), followed by ADR (18.96%). These findings are in line with the previous reports in Iran, which could be due to the inappropriate drug consultation of physicians and community pharmacists to the patients in these areas (5, 9, 11, 20 and 23). Therefore, the drug information centers may have a critical role in improving patients’ awareness about their medicine. Moreover, providing the patients with accurate information regarding adverse drug reactions may deter undesirable health and economic consequences of ADRs, as they are the fourth to the sixth leading cause of death in the United States with an annual cost of $1.5-$4 billion to the health care system. According to the pharmacovigilance studies, ADRs are responsible for approximately 2.9-5% of hospital admissions, as well as more than 100,000 deaths per year in the United States (11, 24 and 25).
According to a worldwide survey on antibiotic usage, antibiotics account for the largest proportion of drug expenditure in developing countries, including Iran (26). Moreover, 58% of prescriptions in Iran contain at least one antibiotic (27). Given the overuse of antibiotics in Iran, the distribution of inquiries regarding antimicrobials (12.3%) in this study is consistent with the countrywide pattern of antibiotic use. Vitamin and minerals are in second place regarding the number of asked inquiries. This pattern is in accordance with other studies in Iran, which indicates a need to implement policies to increase public information about this category of drugs (5, 20). Such implementations may include designing scientific pamphlets providing the general public with practical information on vitamins and minerals.
According to the two surveys conducted in Imam Reza hospital, which is the only tertiary referral center for intoxicated patients in Khorasan Razavi province, the total number of hospital-referred poisoned patients evaluated during 1993-2000 and 2004-2013 were 71’589 and 49’189 cases, respectively (28, 29). In this study, the total number of poisoning cases called the center from 2007 to 2017 was 792, which is very low comparing to the total number of poisoning cases mentioned in the stated studies. This low rate of received poisoning cases in MDPIC is similar to the previous studies on other DPICs in Iran (9, 20, 30 and 31). This pattern may be related to the inadequate public awareness of DPIC as a reliable source of information and guidance for poisonings. Taking into account that DPICs have a crucial role in the management of poisoning cases, especially in early and pre-hospital phases, more efforts should be made to improve the laypersons’ education about these centers.
Among the poisoning cases recorded in Mashhad DPIC, pharmaceutical agents were responsible for the majority of the cases, which is in line with other reports in Iran (5, 9, 20, 29 and 30). This trend may be due to the high prevalence of self-medication (53%) in Iran, which is relatively more than in other countries in the world (32). For example, in the 2015 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS), analgesics (11.1%), household cleaning substances (7.54%), cosmetics/personal care products (7.41%), sedatives/hypnotics/antipsychotics (5.83%), and antidepressants (4.58%) were the most common substance classes that patients reported as poisoning cases (33). A report from the poison information center of Japan on accidental poisoning of children reported that most of the cases were with household products (34). Currently, the dispensing of prescription-only drugs without a prescription is prohibited by law in Iran. Nevertheless, the practice of self-prescription is already widespread in Iran because the law is not strictly run on the pharmacies (35). Therefore, there is a need for appropriate planning and implementing policies to address this problem.Moreover, worth mentioning that despite the widespread use of pesticides, we did not have too many questions about them. It may be due to their wide usage by the rural population and limited knowledge of them about DPIC center.
MDPIC aims to provide the public and health care professionals with evidence-based information in order to reduce medication errors, adverse reactions and prevent wasting resources. In an effort to deliver reliable drug and poison information, valid references such as Micromedex® and UptoDate® are used in MDPIC. The key resource used by our center to answer questions regarding drug information was Micromedex®, which is also used widely in other drug information centers in Iran and United States (9, 19, 20 and 36). A Canadian study aimed to determine users’ preferences among the most commonly used online drug information databases has shown that the Lexi-Comp® was of higher preference than Micromedex® (37). Lexi-Comp® provides the drug information available in UptoDate®. In a study on the performance of DPIC in southwestern Iran, most questions were answered by using UptoDate® (23). As regards the low rate of using UptoDate® in this study (6.32%), it should be mentioned that our center has started using this valuable evidence-based online resource since 2016. According to the recorded data in our center, the rate of usage of this database in 2016 and 2017 was 20% and 18%, respectively. Therefore, the absence of this online resource during 2007-2015 may account for its low rate of usage through this ten-year survey. Moreover, to address poisoning cases, our staff utilize poisindex® which is used in other poison information centers as well (14, 35).