Is more treatment better or a cause for concern?

Pediatric prescriptions on the rise

The nation’s spending on prescription drugs for children and young adults has soared 85% over the past five years, with spending in some categories of pediatric prescriptions jumping more than 600%, according to a report released by the pharmaceutical benefits manager Medco Health Solutions Inc., located in Franklin Lakes, NJ, and a subsidiary of the pharmaceutical giant Merck Inc.

According to the report, which reviewed the prescription drug use of a half million people younger than 19, pediatric patients are taking more — and more expensive — prescription medications for longer periods of time.

For patients younger than 19, the one-year rise in prescription spending per patient, a figure known as "drug trend," was 28%, compared to 23% in the 35-49 age group and less than 10% in the 65 and older age group.

"Increased diagnosis rates and new medicines are two key areas contributing to the higher cost and increased utilization of prescription drugs, providing more effective treatment and significantly improving the quality of life for America’s children," Robert Epstein, MD, Medco’s chief medical officer said in a statement released with the report. "Parents and pediatricians have become much more active in recognizing illness in children and pursuing treatment."

But newer drugs and therapies are more expensive. "Of particular concern now are the so-called orphan drugs, drugs that are the only ones on the market for a particular condition, that are very effective, but treat a condition that affects a small percentage of children, but are also very expensive," says Richard Walls, MD, FAAP, a pediatrician in La Jolla, CA, and a member of the Elk Grove Village, IL-based American Academy of Pediatrics Committee on Drugs.

Medco Health, which manages the pharmacy benefit for large companies and health plans, surveys its clients each year about prescription drug utilization and spending. Their findings were released on Sept. 24 in the Medco Health Solutions 2002 Drug Trend Report.

Researchers also reviewed current pediatric drug trend data and compared them to data obtained for pediatric prescriptions for the last five years. The comparison revealed significant increases in both cost and utilization:

  • Younger patients are taking 34% more medication than they were five years ago, based on days of therapy.
  • More than half of the increase in drug spending for children was due to an increase in the cost of drugs, including price inflation, and the introduction of new and more effective therapies.
  • Spending on proton pump inhibitors to treat heartburn and other gastrointestinal disorders in children, a class of drugs whose use was virtually nonexistent in that age group five years ago, has increased by 660%.
  • An increase in pediatric asthma diagnosis and treatment and the introduction of new allergy medications has contributed to a 211% rise in spending.
  • Spending on therapies for attention-deficit-hyperactivity disorder increased by 122% over the past four years.
  • Spending on antibiotics increased by 42%; however, recent studies have shown that physician prescribing in this category is on the decline.

The three primary drivers of the spending increases were treatments for asthma, allergy, and anti-infectives, closely followed by neurological/ psychological treatments and dermatologics.

For some classes of drugs, new medicines drove increases in spending up by more than 600% since 1997.

Though the findings primarily indicate improved treatment options for childhood illnesses, they are cause for concern because increased medication prices and spending threaten to send costs out of reach for many, says Epstein.

"While we should certainly take advantage of the tremendous advances in modern medicine, we must realize that fiscal innovation and therapeutic practicality are the most effective tools in managing the rising costs of prescription drug care."

By and large, the increased number of prescriptions and increased spending represent the greater number of options available to treat childhood illnesses, says Walls.

The past few years have seen more clinical trials of medications in younger patients. Pediatricians now have good data upon which to base decisions about use of prescription medications in children.

In particular, long-acting antihistamines now are being studied in children as young as 2; previously, the youngest children studied were 12, he says.

There are now many treatment modalities to address cough and cold problems in younger children.

For the past few years, there has also been a push in the pediatric medical community to more aggressively diagnose and treat asthma in children, which is reflected in the report of higher numbers of prescribed asthma medications, Walls explains.

"For many years, there were no nationally accepted diagnostic criteria for asthma in children, so it was difficult to do studies comparing different populations," he says.

But with the development of standardized criteria, pediatricians have made an effort to accurately diagnose asthma and initiate treatment at an earlier stage — before children begin to need hospitalization for exacerbations of the illness.

The trend is reflected in the Medco study, which found significant increases in prescriptions for asthma medications, but also found reductions in the number of pediatric hospital visits due to the illness.

Another factor that is likely influencing the trend, is the availability of newer classes of anti-depressants, particularly SSRIs (selective serotonin reuptake inhibitors), that can be used to treat adolescent and childhood depression, he adds.

According to the Medco study, the use of antibiotics is still on the rise in pediatric patients, but both the researchers and Walls say this is likely beginning to decline.

"I predict in the next few years, you will see far fewer prescriptions for antibiotics in children," Walls says. "Especially with the availability of the longer-acting antihistamines and similar drugs."

To control spiraling costs, Medco is advising its clients to make better use of generic equivalents of medications and to implement software-based medical and prescribing programs to identify potential prescribing errors.

Clients using such software systems have reduced their drug costs by as much as three percent and cut hospital spending by up to 5%, says Epstein.

Walls also recommends use of home delivery pharmacies and well-designed formularies of approved pharmaceuticals to limit spending.

In addition, smart rules to monitor appropriate prescribing patterns and health management programs to encourage treatment compliance would also help control costs.

Generic equivalents can be a good alternative, but in his experience, many generics are not truly the same medication as the original product and, often, they are not much lower in price.

"I have found that the generic manufacturers need to recoup costs for research and development, too — their [profit] margin is not as large as some people think," he notes.

Rising costs are definitely a concern, he admits. Families seen in his practice often pay more at the pharmacy for their drugs than they do for the office visit.

However, although Medco reported concern that spending by older people for their medications had not spiked as rapidly as that for younger patients, Walls emphasized that many young patients do not take the medications long-term, the way that the geriatric population often does.

"The pediatric approach is different in that when you put children on a medication, you expect to take them off that medication at some point," he notes. "It’s different in geriatrics. When an older person starts a medication, they usually stay with it. You have some people who have 10 or 15 medications they are taking at once. That is definitely still cause for concern."

Sources

  • Medco Health Solutions, 100 Parsons Pond Drive, Franklin Lakes, NJ 07417-9991. Web site: www.medcohealth.com.
  • Richard Walls, MD, 7300 Girard Ave., #106, La Jolla, CA 92037.