Primary adherence
This study showed that the rate of primary adherence to remote e-prescriptions was suboptimal, as only (35.5%) of the prescriptions were ultimately dispensed. This figure is somewhat lower than those reported in other studies. A previous study from Poland on 119,880 e-prescriptions found the rate of medication adherence to be nearly (79%).
38 Another study from Spain on 2.9 million prescriptions reported that the adherence rate for all prescriptions was (53.6%).
39 The discrepancy between the results of the present study and those of prior studies indicates that primary adherence is a significant issue. One possible explanation is that primary adherence is a multifaceted challenge; it is patient- and medication-dependent throughout the process, from consultation to dispensation.
40
Primary adherence in both remote e-prescriptions and on-site prescriptions refers to the concept of patients filling their prescriptions after receiving them from their healthcare provider.
41,42 Previous studies that have compared primary adherence between e-prescriptions and on-site prescriptions showed that remote e-prescriptions have the potential to improve primary adherence.
43,44 A study conducted in the United State analyzed 423,616 prescriptions and found that e-prescriptions were associated with a higher likelihood of primary medication adherence (53%) compared to paper prescriptions (43%).
45 Similarly, another study conducted in the United States which analyzed 4318 prescriptions found that e-prescriptions had higher rates of medication adherence (80.2%) compared to paper prescriptions (62.8%).
46 These findings support the notion that remote e-prescriptions can be effectively enhance primary adherence, likely due to the convenience and automation they offer.
44,47,48 However, it is important to note that the rate of primary medication adherence observed in our study (35.5%) was still suboptimal compared to previous research findings.
In this study, patient age was significantly associated with primary adherence. The highest level of adherence was associated with patients between 3 and 16 years of age. Similarly, in a Massachusetts study, the highest adherence rate of all prescribed drugs (87%) was observed in children under the age of 18 years.
22 Additionally, a study from Sweden found an (82%) adherence rate for antidepressant prescriptions in individuals under 19 years of age.
49 A possible explanation for the higher adherence rate in children could be attributed to the parents’ eagerness to receive the medications and follow up on their children's medical conditions.
50
In this study, certain types of diseases and drugs were also associated with primary adherence. With respect to these factors, the highest adherence rates were observed in patients with respiratory diseases (45%) and those taking antibacterial drugs (43%). Potential explanations for the higher rate of adherence in patients with respiratory diseases include that these types of conditions, especially asthma, require the continued use of medications to achieve successful disease control and better therapeutic outcomes.
51,52 The antibiotic medication adherence finding aligns with results from other studies. In a prior study in Poland, the lowest non-adherence rate (14.3%) was observed in patients who were prescribed antibiotics.
38 Additionally, a previous study in Spain found that 76.88% of filled prescriptions were for penicillin.
39
In terms of time stages, the adherence rate was significantly higher during the curfew stage, from March 2 to June 20. A previous study from Germany showed that primary adherence during the pandemic (March 2020) was significantly higher than that prior to the pandemic (March 2019).
53 In the United States, during the beginning of the COVID-19 pandemic (from January to March 2020), it was found that patients with respiratory illnesses showed increased medication adherence during the last week of March 2020 compared to the first 7 days of January 2020.
54 The comparison of studies regarding primary adherence is summarized in Supplementary material 4.
Improving primary medication adherence is a multifaceted issue that required system improvements as well as the establishment of strong patient–provider relationships.
40 It is important to address the root causes of primary non-adherence and develop tailored solutions that address individual patient needs. In Saudi Arabia, the Anat system specifies that remote e-prescriptions can be dispensed up to 3 days after the date of prescribing.
30 This short period may limit patients’ access to their medications, especially during the COVID-19 pandemic, when it can be difficult to fill prescriptions in a timely manner. This may contribute to the low adherence rate found in the present study. Therefore, efforts should be made to revise the current policy and increase the prescription timeframe to improve access to medication and decrease non-adherence rates. This revision would align with approaches used in other countries such as the United States, United Kingdom, and Australia, where prescriptions are valid for 6 to 12 months, depending on the medication type (controlled or non-controlled) and pharmacist's clinical judgment.
55–57 Implementing other strategies such as offering medication home delivery service and prescription pick-up reminders could also be effective in facilitating medication access and improving adherence rates and ultimately lead to better health outcomes for patients.
58–60 Furthermore, affordability and out-of-pocket medication costs may have played a role in the present study's low medication adherence rate, as insurance companies do not cover expenses for medications that are prescribed through the Anat platform.
30 Exploring options for reducing the cost of medications such as working with insurance companies to cover prescriptions issued from Anat system and utilizing generic medication name when possible can help address financial barriers that may contribute to primary non-adherence.
61 Additionally, healthcare providers can also play a crucial role in addressing medication adherence issues.
41,62 They should prioritize open discussions with patients regarding medication adherence, provide education on how to obtain medications, and implement effective follow-up measures. By establishing a strong patient–provider relationship and actively involving patients in their treatment plans, healthcare providers can improve patient outcomes and reduce the burden of medication non-adherence on the healthcare system.
41,60,62,63
Antibiotic prescribing
The present study showed that male gender was associated with higher antibiotic e-prescription rates. A study from Eritrea found that the largest proportion of prescriptions (53%) comprised antibiotic prescriptions. The study also reported that males were more likely to receive antibiotic prescriptions than females.
64 This finding may reflect differences in the types of consultations and the infectious diseases between genders. Some infectious diseases affect males and females differently; in particular, urinary tract infections are more common in female patients, while respiratory diseases are more common in male patients.
65 These studies provide evidence that there may be gender disparities in antibiotic prescribing, with males being more likely to receive prescriptions than females. However, it's important to note that prescribing practices can vary depending on a variety of factors and more research is needed to fully understand the reasons behind these disparities in antibiotic e-prescriptions in Saudi Arabia.
Additional findings include children and genitourinary system diseases. Children from 3 to 16 years of age were more likely to receive antibiotics than any other age group. One possible explanation involves the roles of parents, as increased parental demand for antibiotics may lead to overprescribing.
66,67 Furthermore, genitourinary system diseases have been linked to antibiotic use in children. A previous study from Saudi Arabia reported that urinary tract infections were the most common type of infection in children <5 years old.
68 The prevalence rates of urinary tract infections in Saudi Arabia were 25% among all age groups and 26% among children between 4.5 and 5 years of age.
69,70
The present study also found that certain specialties were associated with the prescribing of antibiotics. Interestingly, radiologists were more likely to prescribe antibiotics than other specialties. Several studies have reported the roles of radiologists in prescribing antibiotics; most interventional radiologists prescribe antibiotics as preventive treatments (prophylaxes) in procedures.
71–73 However, their role in prescribing medication in outpatient's clinic setting is not very clear. More research is required to elucidate the reasons for this increase, and further training on remote e-prescribing and reviewing the prescribing privileges for controlled medications is recommended. The comparison of studies regarding antibiotic prescribing is summarized in Supplementary material 5.
In the study, Antibiotics were the most frequently prescribed type of drug. Antibiotic overuse and misuse are major contributors to antibiotic resistance, which is a growing global health threat.
19,24,74The Saudi MOH has developed guidelines for the appropriate use of antibiotics in healthcare facilities to combat antibiotic resistance and promote the rational use of antibiotics.
75–77 Additionally, the SFDA regulates the import and sale of antibiotics in the country to ensure their safety and efficacy.
78–80 Unfortunately, there is no specific information available regarding Saudi Arabia's antibiotics guideline for remote e-prescriptions. However, it is reasonable to assume that the guidelines for appropriate antibiotic use in healthcare facilities would also be applicable to remote e-prescriptions.
77 It is essential to recognize that remote e-prescriptions have the potential to improve the accuracy and efficiency of prescribing antibiotics. Nevertheless, it is crucial to consider that the process in which remote e-prescriptions are utilized, such as prescribing over the phone or through videoconferencing without direct patient assessment, may require tailored guidelines. While remote e-prescriptions offer many benefits, the appropriate use and monitoring of antibiotics remain vital in preventing antibiotic resistance. It is important for healthcare providers to exercise caution and adhere to best practices when prescribing antibiotics via remote e-prescriptions, ensuring that patient assessments and clinical considerations are appropriately addressed, striking a balance between the benefits and potential limitations associated with the remote e-prescribing process.
Limitations and strengths of the study
The present study employed a relatively large, real-world population and analyzed both prescription and dispensing data. The interpretation of the findings may contribute to a greater understanding of primary adherence and antibiotic e-prescribing issues in the Saudi population.
While the study used an electronic prescription database to determine antibiotic prescribing rates, no information about the practitioners’ gender or experience was provided. Further, it was not possible to compare primary adherence between 2019 and 2020 due to the lack of data.
Future research should prioritize investigating practitioner medical specialties in relation to remote e-prescriptions and on-site prescriptions in Saudi Arabia. This research is crucial to understand the unique challenges and advantages that different therapeutic areas present in remote e-prescribing. Identifying medical specialties that predominantly utilize remote e-prescriptions will provide valuable insights into prescribing practices across healthcare specialties. Studying the impact of remote e-prescriptions and on-site prescriptions in different therapeutic areas can pinpoint domains where remote e-prescriptions offer significant benefits and cost-effectiveness. This comprehensive understanding will inform the implementation and adoption of remote e-prescribing practices, assisting healthcare providers, policymakers, and stakeholders in making informed decisions and developing tailored strategies to optimize remote e-prescription use in Saudi Arabia. Furthermore, exploring the impact of antibiotic remote e-prescriptions on patient outcomes and revising the current antibiotic guidelines to effectively accommodate the unique aspects of remote e-prescriptions is essential. By comprehensively understanding the potential benefits and challenges associated with remote e-prescriptions in different contexts, healthcare providers and policymakers can make well-informed decisions, leading to improved patient care and reduced healthcare costs.