Article Figures & Data
Tables
Child Characteristics Children Without an Asthma Prescription (n = 42,997) Children Prescribed Asthma Medication (n = 3,374) OR (95% CI) CI = confidence interval; GP = general practitioner; ICPC = International Classification for Primary Care; OR = odds ratio; URTI = upper respiratory tract infection. a Significant values P<.05. b Average number of prescriptions issued per patient during 1 year. c Average number of contacts with GP during 1 year. d Referrals for respiratory complaints/diseases or to a lung specialist. e Dichotomous variables of the ICPC codes R02 (shortness of breath/dyspnea), R03 (wheezing), R05 (cough), R74 (acute upper respiratory tract infection), R78 (acute bronchitis/bronchiolitis), R81 (pneumonia), R96 (asthma), and R97 (allergic rhinitis). Mean age (SD; range), y 9.1 (4.8; 1–17) 7.7 (4.9; 1–17) 0.94a (0.93–0.95) Age <6 y, No. (%) 11,948 (25.8) 1,386 (41.1) 1.82a (1.69–1.96) Sex, male, No. (%) 21,798 (50.7) 1,922 (57.0) 1.29a (1.20–1.39) Antibiotic prescriptions, No. (SD; range)b 0.2 (0.6; 0–13) 0.6 (1.0; 0–12) 1.85a (1.77–1.93) Oral corticosteroid prescriptions, No. (SD; range)b 0.003 (0.11 ;0–12) 0.046 (0.26;0–5) 4.69a (3.59–6.12) Contacts with GP, No. (SD; range)c 2.1 (2.6; 0–35) 5.2 (4.0; 0–34) 1.30a (1.29–1.31) Children with 0 contacts in registration year, No. (%) 13,786 (32.1) 129 (3.8) — Referrals, No. (%)d 93 (0.3) 94 (3.6) 13.0a (12.2–13.9) Registered diseases and complaints,e No. (%) Asthma 227 (0.5) 1,739 (51.5) 260a (221–305) Shortness of breath/dyspnea 92 (0.2) 144 (4.3) 21.1a (15.9–28.1) Wheezing 16 (0.0) 63 (1.9) 55.2a (30.7–99.2) Cough 2082 (4.8) 873 (25.9) 6.90a (6.26–7.59) Acute bronchitis/ bronchiolitis 769 (1.8) 622 (18.4) 13.5a (11.9–15.3) Acute URTI 3,267 (7.6) 674 (20.0) 3.06a (2.78–3.38) Pneumonia 241 (0.6) 133 (3.9) 7.24a (5.74–9.15) Allergic rhinitis 1,029 (2.4) 252 (7.5) 3.24a (2.78–3.77) Age-Groups, Years Medication Type 1–2 n = 5,293 3–5 n = 8,041 6–8 n = 8,335 9–11 n = 8,350 12–14 n = 8,196 15–17 n = 8,156 Total n = 46,371 ICS = inhaled corticosteroids; LABA = long-acting β2-agonists; SABA = short-acting β2-agonists. a We calculated percentage of children using some sort of asthma medication, not percentage of total population; therapy groups therefore add up to 100%. Therapy groups are defined as follows: SABA = monotherapy with short-acting β2-agonists; ICS = monotherapy with inhaled corticosteroids; SABA+ICS = combination therapy of these 2 medication groups (10.3% of children in this group also received 1 or more other asthma medicines, of which 82% were LABA); other medicines = all other therapies. All asthma medication, % 10.9 10.1 7.0 6.1 5.7 5.2 7.3 Medication groups, % SABA 8.0 7.0 4.9 4.5 4.5 3.6 5.3 ICS 5.9 7.0 4.8 4.0 3.2 3.0 4.5 LABA 0.1 0.3 0.5 0.7 0.6 0.6 0.5 Cromones 0.8 0.5 0.1 0.1 0.1 0.1 0.2 Montelukast 0.0 0.1 0.1 0.1 0.0 0.1 0.1 Therapy groups, %a SABA 38.6 25.7 29.2 32.4 41.9 39.1 33.4 ICS 20.7 24.7 24.3 18.7 15.1 21.9 21.3 SABA+ICS 33.2 43.2 40.9 40.4 36.2 30.2 38.1 Other medicines 7.5 6.5 5.6 8.6 6.8 8.8 7.2 Family Characteristics No Child With Asthma Medication Within Family (n = 22,456) ≥1 Child Within Family With Asthma Prescription (n = 3,081) OR (95% CI) CI = confidence interval; ICPC = International Classification for Primary Care; OR = odds ratio; SES = socioeconomic status. a Ethnicity based on the country of birth. b The highest SES of parent(s) using the International Socio-Economic Index of Occupational Status. c At least 1 parent with registered ICPC code for asthma during the study period. d Significant values P<.05. 1 or both parents non-Western cultural background, No. (%)a 1,834 (10.6) 275 (11.1) 1.01 (0.87–1.17) Mean SES highest (SD; range)b 50.4 (15.5;16–87) 49.5 (15.4;16–87) 1.00 (0.99–1.00) Parental asthma, No. (%)c 821 (3.7) 256 (8.3) 2.33d (1.90–2.85) GP Characteristics GPs Prescribing Asthma Medication Average and Below Average (n = 58)a GPs Prescribing Asthma Medication Above Average (n = 51)a OR (95% CI) CI = confidence interval GP = general practitioner; FTE = full-time equivalent; OR = odds ratio. a To display the GP characteristics, we divided the GPs into 2 groups: those who prescribed asthma medicaton to the average percentage of children or less, and those who prescribed above average (which, on the GP level, is 7.4%) within their childhood patient population. b As classified by Statistics Netherlands on a 5-point scale, in which 1 = high level of urbanizaton and 5 = low urbanization. c Full-time or part-time working in number of FTEs. d Authorized or required by the Health Authority to provide pharmaceutical services to his/her patients. e Total number of patients divided by the number of FTEs per 1,000 patients. f Average number of prescriptions issued per patient during 1 year. g Significant values P<.05. h GPs with 25% or more of their total patient population of children aged 0–17 years. Mean age (SD; range), y 47.6 (5.7; 36–59) 46.2 (6.2; 33–56) 1.00 (0.99–1.01) Sex, male, No. (%) 50 (86.2) 37 (72.6) 0.83 (0.69–1.00) Practice type, solo, No. (%) 27 (46.6) 20 (39.2) 0.88 (0.75–1.02) Urban practice location, mean (SD; range)b 2.8 (1.4;1–5) 3.1 (1.0;1–5) 1.03 (0.98–1.10) Mean FTE (SD; range)c 0.91 (0.15; 0.5–1.0) 0.88 (0.17; 0.5–1.0) 0.79 (0.48–1.28) Dispensing doctor, No. (%)d 5 (8.6) 3 (5.9) 0.97 (0.73–1.29) Workload, mean (SD; range)e 2.8 (0.7;1.4–5.5) 2.6 (0.6;1.3–4.8) 0.89 (0.80–1.00) Prescribing volume, mean (SD; range)f 1.5 (0.5; 0.05–2.7) 1.8 (0.5; 0.9–3.2) 1.55g (1.38–1.75) ≥25% of patients 0–17 y, No. (%)h 15 (25.9) 6 (11.8) 0.77g (0.64–0.93) Children with an asthma diagnosis, % (SD; range) 3.5 (1.4; 0.8–7.3) 5.4 (2.1; 1.9–11.6) 1.10g (1.07–1.14) - Table 5.
Multilevel Logistic Regression Analyses With 3 Levels: Child, Family, and General Practitioner (GP)
Explanatory Variables Empty Model Intercept (SE) Model 1a Intercept (SE) Model 2a,b Intercept (SE) Model 3a,b Intercept (SE) CI = confidence interval; GP = general practitioner; OR = odds ratio; SE = standard error. a Model 1 (age-groups), model 2 (age-groups, child characteristics), model 3 (age-groups, child characteristics, family characteristics, GP characteristics). b In these models we corrected for the presence of an asthma diagnosis in the child (model 2: OR = 262; 95% CI, 219–312; model 3: OR = 264; 95% CI, 221–315). c The variance at the lowest level (children) is not determined because the outcome is dichotomous. d Correlation between the variances of the 2 defined age-groups on the GP level. e ICC between the 2 upper levels (families and GPs). ICC is the relative contribution of GP to sum of family and GP variance. Age 1–17 y −2.580 (0.039) Age 1–5 y −2.210 (0.054) −3.629 (0.100) −3.645 (0.091) Age 6–17 y −2.779 (0.039) −3.573 (0.071) −3.605 (0.060) OR (95% CI) OR (95% CI) Sex, male 1.25 (1.13–1.39) 1.25 (1.13–1.39) Shortness of breath/dyspnea 20.7 (14.3–29.9) 20.2 (13.9–29.2) Wheezing 51.5 (24.7–107) 49.7 (23.8–104) Cough 6.51 (5.68–7.47) 6.46 (5.64–7.40) Acute bronchitis/bronchiolitis 9.04 (7.57–10.8) 8.91 (7.45–10.6) Acute upper respiratory tract infection 1.47 (1.26–1.72) 1.47 (1.26–1.72) Pneumonia 2.10 (1.44–3.07) 2.11 (1.44–3.09) Allergic rhinitis 2.12 (1.68–2.69) 2.10 (1.66–2.67) No. of contacts with GP 1.10 (1.08–1.12) 1.10 (1.08–1.12) Presence of parental asthma 1.74 (1.41–2.15) Prescribing volume of GP 1.99 (1.60–2.47) Patients 0–17 y ≥25% per GP 0.59 (0.44–0.78) Percentage of children with asthma diagnosis per GP 0.88 (0.83–0.93) Variance (SE)c Variance (SE) Variance (SE) Variance (SE) Between-family variance 0.567 (0.071) 0.535 (0.071) 0.474 (0.112) 0.471 (0.111) Between-GP variance Age 1–17 y 0.119 (0.022) Age 1–5 y 0.209 (0.042) 0.751 (0.134) 0.547 (0.106) Age 6–17 y 0.097 (0.022) 0.384 (0.071) 0.214 (0.047) Covariance 0.118 (0.025) 0.479 (0.083) 0.284 (0.058) Correlations Correlations Correlations Correlations Correlation of GP variance between age-groupsd – 0.83 0.89 0.83 Intraclass correlatione Age 1–17 y 0.17 Age 1–5 y 0.38 0.72 0.64 Age 6–17 y 0.29 0.65 0.51
Additional Files
The Article in Brief
What Drives Prescribing of Asthma Medication to Children? A Multilevel Population-Based Study
Mira G. P. Zuidgeest , and colleagues
Background Asthma in children is a major clinical and public health problem. Because diagnosing and treating the condition is a challenge, there are differences in the prescribing of asthma medication. The aim of this study is to investigate how and to what degree patient, family, and doctor characteristics influence the prescribing of asthma medication in children.
What This Study Found The patient, family, and doctor have a significant influence on prescribing asthma medication in children. Prescribing is strongly related to children's asthma and symptoms and to other respiratory diseases, such as bronchitis. The presence of asthma in the parents is also associated with prescribing asthma medication to children. In addition, in this study, every extra family contact with the doctor led to a 10% extra chance of receiving asthma medication. There is more variation between doctors in prescribing for children younger than the age of 6 years compared with older children. This may be due to the complexities in diagnosing asthma in young children.
Implications
- Uncertainties in diagnosing asthma may result in more prescribing that is influenced by family and doctors.
- Despite the ongoing search for better ways to diagnose asthma in children, there is still a diagnostic gap, especially in preschool children. This gap contributes to differences between doctors in prescribing asthma medication, based on personal preferences and general attitudes toward prescribing.
