What Drives Prescribing of Asthma Medication to Children? A Multilevel Population-Based Study

Mira G. P. Zuidgeest; Liset van Dijk; Peter Spreeuwenberg; Henriëtte A. Smit; Bert Brunekreef; Hubertus G. M. Arets; Madelon Bracke; Hubert G. M. Leufkens

doi:10.1370/afm.910

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Overtreating Asthma in Preschool Children: Is it a Public Health Problem?
Herberto J Chong Neto

Published on: 16 March 2009
How to explain these findings?
Johannes C van der Wouden

Published on: 29 January 2009

Published on: (16 March 2009)
Page navigation anchor for Overtreating Asthma in Preschool Children: Is it a Public Health Problem?
Overtreating Asthma in Preschool Children: Is it a Public Health Problem?
Herberto J Chong Neto, Curitiba, Brazil
Other Contributors:
To the Editor
Wheezing is the most common symptom of asthma. Asthma diagnosis is difficult especially in preschool children. As asthma in childhood, the prevalence of wheezing in infants has a high variability according few cohort studies. After ruling out possible causes of chronic respiratory symptoms the next step is to assess severity and frequency of symptoms in order to initiate controller therapy. Inhale...
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To the Editor
Wheezing is the most common symptom of asthma. Asthma diagnosis is difficult especially in preschool children. As asthma in childhood, the prevalence of wheezing in infants has a high variability according few cohort studies. After ruling out possible causes of chronic respiratory symptoms the next step is to assess severity and frequency of symptoms in order to initiate controller therapy. Inhaled corticosteroids are the first line medication for asthma management in all age groups under an appropriate diagnosis(1). There is no consensus in how to treat recurrent recurrent wheezing in children under 1 year old.
Zuidgeest et al., have been showed that all 3 evaluated parties (patient, family, and General Pratictioner-GP) have a significant influence on whether children are given a prescription for asthma medication. They found a much higher variance among GPs when prescribing to children younger than 6 years compared with older children, which they consider to be a result of the diagnostic complexities especially present in preschool children with asthmatic symptoms. Diagnostic uncertainties may result in more physician and family driven prescribing irrespective of the clinical context, a feature not always in the interest of the child(2).
We have conducted a cross-sectional study (as a part of multicentre study EISL, from spanish: Estudio Internacional de Sibilancias en Lactantes) aimed to verify prevalence, risk factors and treatment of wheezing/recurrent wheezing in the first twelve months of life. We have applied a standardized and validated questionnaire to parents of infants and found that 45.4% have at least one wheezing episode and 22.6% have had 3 or more wheezing episodes. Wheezing infants in the first year of life have used inhaled β2-agonists (84.6%), inhaled steroids (18.5%), oral steroids (24.3%), and leukotrienes modifiers (5.4%)(3,4).
Stratifying wheezing infants more than 3 episodes and less than 3 episodes we found that inhaled β2-agonists and inhaled steroids have been used more frequently than those with less than 3 wheezing episodes. Oral steroids and leukotriene modifiers were similar used between wheezer infants. We concluded that pediatricians frequently prescribe controller asthma medication, demonstrating that evidence-based guidelines are little utilized in clinical practice and free access to medication can change decision in asthma management and could also influence the pattern of prescriptions in our population(5).
In conclusion, as asthma is a multifactor disease, its treatment seems to be multilevel and probably a problem of public health.
REFERENCES
1- Bacharier LB, Boner A, Carlsen K-H, Eigenmann PA, Frischer T, Götz M et al. Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report. Allergy 2008: 63: 5–34.
2- Zuidgeest MGP, van Dijk L, Spreeuwenberg P, et al. What drives prescribing of asthma medication to children? A multilevel population- based study. Ann Fam Med 2009; 7: 32-40.
3- Chong Neto HJ, Rosario NA, Dela Bianca AC, Sole D, Mallol J. Validation of a questionnaire for epidemiologic studies of wheezing in infants. Pediatr Allergy Immunol 2007; 18: 86-7.
4- Chong Neto HJ, Rosario NA, Sole D, Mallol J. Prevalence of recurrent wheezing in infants. J Pediatr (Rio J.) 2007; 83: 357-62.
5- Rosario NA, Chong Neto HJ. Are we overtreating recurrent wheezing in infants? Allergol Immunopathol 2009, forthcoming.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (29 January 2009)
Page navigation anchor for How to explain these findings?
How to explain these findings?
Johannes C van der Wouden, Rotterdam, The Netherlands
Other Contributors:
This paper provides new insights based on sophisticated analyses of an impressive database. We would like to address some of the findings, and offer some suggestions for explanation.
GPs with a large proportion of children among their patients were less likely to prescribe asthma medication to the average child. We wonder what possible mechanism could be responsible for this finding. Could it be the amount of expe...
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This paper provides new insights based on sophisticated analyses of an impressive database. We would like to address some of the findings, and offer some suggestions for explanation.
GPs with a large proportion of children among their patients were less likely to prescribe asthma medication to the average child. We wonder what possible mechanism could be responsible for this finding. Could it be the amount of experience with the natural (benign) course of many respiratory problems? We invite the authors to offer competing explanations.
The positive relationship between the number of contacts with a GP and the chance of receiving asthma medication is thought provoking, as the causal direction of this relationship may be different from what the authors seem to put forward. As the time relationship between the event of prescribing and its determinants was not evaluated, the GP may have asked the children to return to see whether the prescribed medication shows any benefit. In this way, the prescribing event may have caused the increased contact rate.
Finally, the relation between gender and prescribing needs further study. We know that the prevalence of asthma is higher among boys, but also that parents do consult a doctor earlier in case of a boy than a girl. Whether boys really do get prescribed asthma medication more often, all other things being equal, remains unclear.
Competing interests: None declared
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Competing Interests: None declared.