Variance in Medication Prescribing Practices
An article on public attitudes about attention-deficit/hyperactivity disorder (AD/HD) appeared in the May 2007 issue of Psychiatric Services. The authors, McLeod and associates, compare the estimated national prevalence of AD/HD with medication use and argue that AD/HD is underdiagnosed in the United States. They also observe that critics claim the disorder is overdiagnosed because of the tremendous increase in the use of AD/HD medications over the past decade. Missing from this analysis, however, is the more significant and difficult issue of the tremendous variance in medication utilization across the nation. Where a person lives seems to be important to whether that person receives medication for the treatment of AD/HD.
There are two published national studies documenting the significant variance in medication utilization across the country. The first, the result of 14 months of work by two reporters from a major metropolitan daily newspaper, gets little attention in the published research because of the source of the data and the journalistic credentials of the researchers. On May 6, 2001, the Cleveland Plain Dealer published a major study by reporters Sabrina Easton and Elizabeth Marchak entitled, "Ritalin Prescribed Unevenly in US." This study documented the use of medication to treat AD/HD in every county in the United States, using Drug Enforcement Administration (DEA) data.
Alarmingly, the Cleveland Plain Dealer study found that in some counties in the United States the number of people being prescribed medication for AD/HD was three times the expected prevalence rate, while in other counties not a single individual was receiving medication for the disorder. There are many possible reasons for this variance. CHADD believes that a major reason for the variance is inconsistency in the use of evidence-based diagnosis and treatment guidelines as published by the American Academy of Pediatrics (AAP) and American Academy of Child and Adolescent Psychiatry (AACAP). CHADD works closely with AAP and AACAP to more effectively implement these guidelines.
The second published study of medication use is a recognized professional study published in Pediatrics in February 2003. Despite controlling for age and gender, Cox and associates conclude that variation in stimulant use among children was second only to the variation in cough/cold/allergy prescription use among children. The authors state that the reasons for regional variation in stimulant treatment are not known. They postulate that "differences in state controlled substance abuse laws, anti-Ritalin campaigns, direct-to-consumer advertising, physician practice style, the values, beliefs, and expectations of adult caregivers" are the reasons. They define "physician practice style" as either the "professional uncertainty theory" of physician uncertainty about the nature of AD/HD, and the "enthusiasm hypothesis" whereby some physicians are advocates of stimulant medication use.
Through CHADD’s advocacy with the U.S. Congress, the U.S. Centers for Disease Control and Prevention (CDC) is currently funding two community-based studies to learn more about the prevalence and treatment patterns of AD/HD. (U.S. OMB. Federal Register, April 5, 2007; 72:65, 16789-16791)
When you consider a physician or other medication prescribing professional, ask if he or she practices the American Academy of Pediatrics evidence-based guidelines. Ask if he or she practices the American Academy of Child and Adolescent Psychiatry evidence-based guidelines. Try to probe his or her philosophy and understanding about what the U.S. National Institute of Mental Health (NIMH) states is a neurobiological lifespan disorder. You need to be comfortable with the doctor’s medication training and philosophy, preferably before you go into the appointment. This is possibly a long-term partnership between you and the professional.
While CHADD’s concern is with the variance of prescribing practice in the United States, you might be interested to know about worldwide patterns.
A March/April 2007 Health Affairs article by Sheffler and associates documents the significant variance between countries in the use of medication to treat AD/HD. These authors state their premises up front: that AD/HD is “a syndrome with strong neurobiological origins” and that the prevalence of AD/HD is similar across nations. As of 2003, 55 nations officially recognize AD/HD and officially recognize medication as one treatment for AD/HD. The United States counts for 83.1% of AD/HD medication consumption in the world. Sheffler and associates conclude that use of AD/HD medications is positively related to per capita income and to the availability of medical specialists who understand AD/HD. This is true for most health conditions.
Canada, Great Britain, and Australia show medication-use patterns similar to the United States while France, Italy, Ireland, Austria, Japan, Sweden, and Finland use less AD/HD medication than predicted by per capita income. In addition to per capita income and availability of specialists, other factors identified by the authors as influencing these patterns include advertising, the definition of AD/HD and its differing focus on severity of the disorder, public educational policies and practices, and medication spending as a portion of overall health spending. France, for example, has highly restricted and narrow criteria before medication can be prescribed, requiring that only a hospital-based neurologist, psychiatrist, or pediatric specialist in AD/HD may prescribe AD/HD medications.
I hope you find this international information helpful and educational, and not a distraction from the important issue of treatment variance within the United States. CHADD will continue to work to close the variance of treatment within the United States by working with the professional community to implement evidence-based guidelines.