Changes in drug prescription over a decade in an Arctic child population

Introduction

Drug prescriptions and their utilization are some of the most debated health topics in terms of both increased public spending on drugs and general concern regarding drug safety and side effects [1]. Drug therapy is the predominant method of treatment in general practice, and a majority of drugs are prescribed to outpatients. Drugs are also commonly prescribed to children [2–11]. Research into drug prescription can provide an overview of drug use and help to identify therapeutic problems. It can also provide information needed to address disadvantageous prescription practices. In some diseases, drug prescription can also help provide estimates of disease prevalence. Even if the response and effects of drugs in children can differ from findings in adults, and might vary with age and development, off-label prescription to children is common [9].

Due to the organization of the healthcare system in Greenland, a unique possibility exists: to be able to study changes not only in drug prescription but also in drug use on an individual level in the child population in a given geographic area.

Greenland is an Arctic country with a population of 56 000 inhabitants. It has free access to healthcare, and all prescribed drugs are supplied by the healthcare system free of charge. No drugs meant for children can be bought over the counter. Shortly after birth, all citizens are registered in health services files by a unique personal registration code. The largest town in Greenland is the capital Nuuk, which has approximately 15 000 inhabitants. In Nuuk, nine general practitioners at the District Medical Clinic provide medical care 24 h a day to the entire population of the city. The clinic also houses the only pharmacy in the city.

The aim of this study was to compare drug prescription to 0 14-y-old outpatients in Nuuk, Greenland, in the years 1991 and 2001.

Material and methods

For the year 1991, all prescriptions to 0–14-y-old children from the District Medical Clinic in Nuuk, Greenland, were examined, and the following data were computerized: date of birth, sex, personal registration code, date of issue and pharmacotherapeutic drug category. The drugs were categorized according to the Anatomical Therapeutic Chemical (ATC) Classification Code. The 1991 data were computerized to the 2nd level for all drugs and to 5th level for antibiotics. Since 1996, all data on prescriptions from the District Medical Clinic have been computerized. For 2001 data, 5th-level ATC codes were extracted from this system. The ACT codes used in Greenland are given centrally by the Danish Medicines Agency. In 2001, 41 prescriptions were excluded due to a lack of ATC code.

Gender was unknown in 0.1% and 3.7% of prescriptions in 1991 and 2001, respectively, and these were excluded from the gender analysis. The age of the child was calculated as the age at first prescription in the year of investigation. The population was calculated as the mean number of children on 1 January and 31 December in each year. Individual use was estimated by aggregating the data.

For statistical evaluation, the χ²test and χ² for trend were used.

Results

Discussion

During the decade 1991–2001, the prescription rate rose from 2.0 to 2.2 drugs/child/year, and the proportion of children who received prescribed drugs increased from 61% to 70%. The total number of prescriptions found might seem high, but taking into account the fact that approximately 1/3 of all drugs prescribed might be bought over the counter in other countries, it is comparable to findings in Danish children [8].

The majority of drugs were prescribed in only a few therapeutic groups, and relatively few different drugs are prescribed in the majority of cases. This was most pronounced in the youngest children, and other studies confirm this uniformity [2,5,8]. In Greenland, the lack of OTC drugs and the use of a list of recommended drugs have contributed to these findings, but in 1991 the number of different diagnoses for the youngest outpatient children in Nuuk was only half that in schoolchildren [11]. In the youngest children, infections were diagnosed in 90% of visits; mostly upper respiratory infections such as common cold, bronchitis and otitis media, which made up about 50% of visits. In schoolchildren, infections was seen in 42% of visits, and upper respiratory infections accounted for 21% of all diagnoses [11].

Theoretically, a shift in prescription might be caused by a change in disease pattern, new prescription practices, or by a combination of these. Despite the increase in total prescriptions, drug prescription to the youngest children more than halved, and a reduction in all major groups, except anti-asthmatics, was found. This reduction in the number of prescriptions during only one decade is not likely to be caused by changes in disease pattern alone, but probably reflects a general focus on drug prescription to infants after the high prescription of drugs found in 1991 [3]. In contrast, prescriptions increased in all older age groups, and this was most pronounced in the schoolchildren. This increase is even more difficult to explain. However, as these children were to some extent the same children with a high number of prescriptions in 1991, it might be speculated that their drug use was influenced by earlier experiences as drug consumers. A change towards regarding drugs more as “consumer goods”, both by patients and doctors, might also have contributed. A relatively higher number of prescriptions to younger children has been found worldwide [4–6,8].

The increase in the number of children given anti-asthmatics was at the expense of other respiratory drugs. If the prescription of anti-asthmatics is thought to reflect disease prevalence in the population, then the prevalence more than doubled during 1991 – 2001, with a four-to fivefold increase in toddlers and preschool children. The mean number of prescriptions in 2001, however, is comparable to Danish figures [13]. An increased prevalence of atopy and asthma in recent years has been verified by a doubling of positive blood tests for common inhaled antigens from 1987 to 1998 [14]. The decrease in use of nasal preparations and agents against cough might partly reflect changes in disease patterns in Greenland, too, as lower morbidity from upper respiratory infections has recently been described elsewhere [2,12]. Less under-diagnosing of asthma or more focus on the lack of evidence of positive effects of agents against cough might also have contributed, but an over-prescription against cough of beta-2 agonists cannot be excluded.

The prescription of antibiotics is of worldwide concern. Guidelines in Greenland recommend phenoxymethylpenicillin as the drug of choice in airway infections in outpatients. According to the National Medical Laboratory in Nuuk, resistance to penicillin V is low, and no major changes in resistance pattern in commonly found bacteria were found during the study decade. Prescription of phenoxymethylpenicillin in more cases therefore reflects a prescription practice closer to recommended guidelines. The increased prescription of antibiotics was not at the expense of dermatological antibiotics. If a prescription of dermatological antibiotics is supposed to reflect one cure, the incidence of bacterial skin infections nearly tripled, with the highest increase in schoolchildren.

Prescription practices have been seen as a reflection of health professionals’ ability to discriminate between various choices of drugs and to determine which ones will be of most benefit to their patients [15]. This cross-sectional study has revealed changes in child prescriptions that cannot be explained by disease pattern, our knowledge of socio-economic changes, new guidelines or the implementation of new diagnostic tools alone. Unrecognized and partly unexplainable changes in prescription are probably also found elsewhere, and changes in prescription practices might need even more attention from health personnel.