Protected: Qi09 – ADHD medications v0.2

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Operationalisation

Denominator

The number of individuals in the age group ( / 1,000) alive at the end of the year.

Numerator

All defined in the denominator who were dispensed amfetamine (ATC N06BA01), dexamfetamine (N06BA02), methylphenidate (N06BA04), atomoxetine (N06BA09), lisdexamfetamine (N06BA12) or guanfacine (C02AC02) at least once during the examined year.

Exclusions (Numerator, denominator)

  • Individuals who die or emigrate during the examined year.

Notes

N/A

Sources of Data

  • Population register
  • Outpatient medication dispensations register

Information about the indicator set

Purpose

  • The quality indicator set is intended for comparison of effectiveness and/or safety aspects of prescribing across Nordic countries and subnational regions.
  • Further comparisons across population subgroups (e.g., socioeconomic position, immigration background) can inform equity considerations.
  • Further comparisons in relation to expenditures can inform efficiency considerations

Limitations

  • The indicators in the set use medication dispensings and/or sales data as a proxy for appropriate prescribing and medication use. This is to allow comparisons using register data, which have the advantage of being readily available and comprehensive in terms of population coverage and over time (5–7).
  • Register data are not without limitations. Medications may have been prescribed, but not collected from the pharmacy by the user. Collected medications may not have been (appropriately) used by the patient. Sales data may not be fully comparable across countries.
  • Register data are collected primarily for other purposes than quality assessment. Thus, discontinuities over time due to, e.g., legislative changes and administrative reforms need to be acknowledged in the interpretation of the results.
  • Indicators need to be updated regularly because clinical guidelines and the range of available medications change over time.
  • ATC-codes are based on WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD Index version 2024

Background and literature related to the proposed indicator

Clinical guidelines

 Finnish Current Care guideline on ADHD (26)

  • Pharmacotherapy is an important part of managing ADHD and the need for it should be assessed when the diagnosis is confirmed.
  • It is recommended that medication was initiated by a specialist or a doctor with expertise on ADHD and child/youth development (e.g., child of youth psychiatrist, pediatrician, or pediatric neurologist)
  • In most cases ADHD medication is not recommended to children aged below 6 years. If considered necessary, pharmacotherapy should be initiated in specialised care and monitored carefully.
  • Pharmacotherapies include stimulants (short-, medium-, and long-acting methylphenidate, dexamfetamine and lisdexamfetamine), atomoxetine and guanfacine.
  • Choice of pharmacotherapy is guided by the available medications, patients’ symptom profile and other relevant factors (e.g., risk of stimulant abuse by the patient or patient’s family members).
  • In most cases, the first choice is medium- or long-acting methylphenidate.

Similar or related indicators in Nordic or European quality assessment

Swedish Association of Local Authorities and Regions quality indicators (Vården i siffror)

  • Share of 0-17-year-olds with ADHD medication, per 1000 (27)

 Swedish National Guidelines (Nationella Riktlinjer: ADHD och autism) (28,29)

  • Among individuals with newly diagnosed ADHD who initiated stimulant medicines, the share of individuals who continued medication for up to one year. A high share is preferred.
  • Among individuals hospitalised with concomitant diagnoses of ADHD and substance abuse, the share of individuals who were dispensed stimulants at least twice during 365 days after the hospitalisation.

Similar or related indicators in international scientific literature

  • Inappropriate: Pharmacological ADHD/ADD treatment before age 6 years (before school), except in severe cases (30)
  • Children with ADHD requiring medication were first prescribed a stimulant medication (31)
  • Stimulant medication for the treatment of ADHD should not be initiated by GPs (32)

References

  1. Sayal K, Prasad V, Daley D, Ford T, Coghill D. ADHD in children and young people: prevalence, care pathways, and service provision. Lancet Psychiatry. 2018 Feb 1;5(2):175–86.
  2. Faraone SV, Banaschewski T, Coghill D, Zheng Y, Biederman J, Bellgrove MA, et al. The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder. Neurosci Biobehav Rev. 2021 Sep 1;128:789–818.
  3. Vertessen K, Luman M, Oosterlaan J. ADHD medication adherence: the importance of adequate prescribing. Lancet Psychiatry. 2024 Jan 1;11(1):2–3.
  4. Rosenau PT, Dietrich A, Matthijssen AFM, Kleine-Deters R, van de Loo-Neus GHH, Buitelaar JK, et al. Adherence to Clinical Guidelines for Dose Finding and Monitoring Methylphenidate Use: A Medical Record Audit in Child and Adolescent Mental Health Care and Pediatric Settings. J Child Adolesc Psychopharmacol. 2023 Jun;33(5):183–9.
  5. Xu G, Strathearn L, Liu B, Yang B, Bao W. Twenty-Year Trends in Diagnosed Attention-Deficit/Hyperactivity Disorder Among US Children and Adolescents, 1997-2016. JAMA Netw Open. 2018 Aug 31;1(4):e181471.
  6. Kazda L, Bell K, Thomas R, McGeechan K, Sims R, Barratt A. Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review. JAMA Netw Open. 2021 Apr 12;4(4):e215335.
  7. Massuti R, Moreira-Maia CR, Campani F, Sônego M, Amaro J, Akutagava-Martins GC, et al. Assessing undertreatment and overtreatment/misuse of ADHD medications in children and adolescents across continents: A systematic review and meta-analysis. Neurosci Biobehav Rev. 2021 Sep 1;128:64–73.
  8. Brikell I, Yao H, Li L, Astrup A, Gao L, Gillies MB, et al. ADHD medication discontinuation and persistence across the lifespan: a retrospective observational study using population-based databases. Lancet Psychiatry. 2024 Jan 1;11(1):16–26.
  9. Gimbach S, Vogel D, Fried R, Faraone SV, Banaschewski T, Buitelaar J, et al. ADHD medicine consumption in Europe after COVID-19: catch-up or trend change? BMC Psychiatry. 2024 Feb 9;24(1):112.
  10. Kolari TA, Vuori M, RÄttÖ H, Varimo EA, Aronen ET, Saastamoinen LK, et al. Incidence of ADHD medication use among Finnish children and adolescents in 2008–2019: a need for practice changes? Scand J Public Health. 2024 Feb 29;14034948231219826.
  11. Vuori M, Koski-Pirilä A, Martikainen JE, Saastamoinen L. Gender- and age-stratified analyses of ADHD medication use in children and adolescents in Finland using population-based longitudinal data, 2008–2018. Scand J Public Health. 2020 May 1;48(3):303–7.
  12. Sørensen AMS, Wesselhöeft R, Andersen JH, Reutfors J, Cesta CE, Furu K, et al. Trends in use of attention deficit hyperactivity disorder medication among children and adolescents in Scandinavia in 2010–2020. Eur Child Adolesc Psychiatry. 2023 Oct 1;32(10):2049–56.
  13. Madsen KB, Ersbøll AK, Olsen J, Parner E, Obel C. Geographic analysis of the variation in the incidence of ADHD in a country with free access to healthcare: a Danish cohort study. Int J Health Geogr. 2015 Aug 22;14(1):24.
  14. Wallach-Kildemoes H, Skovgaard AM, Thielen K, Pottegård A, Mortensen LH. Social Adversity and Regional Differences in Prescribing of ADHD Medication for School-Age Children. J Dev Behav Pediatr. 2015 Jun;36(5):330.
  15. Sjöström D, Rask O, Welin L, Petersson MG, Gustafsson P, Landgren K, et al. The Winding Road to Equal Care: Attitudes and Experiences of Prescribing ADHD Medication among Pediatric Psychiatrists: A Qualitative Study. Int J Environ Res Public Health. 2023 Jan;20(1):221.
  16. Lasten ja nuorten ADHD-diagnoosien yleisyys 2022. 2022;
  17. Aalto-Setälä T, Vuori M. Lasten ADHD-lääkehoidon yleistymiskehitys ei näytä tasaantuvan. Lääketieteellinen Aikakauskirja Duodecim. 22(139):1811–3.
  18. Widding-Havneraas T, Markussen S, Elwert F, Lyhmann I, Bjelland I, Halmøy A, et al. Geographical variation in ADHD: do diagnoses reflect symptom levels? Eur Child Adolesc Psychiatry. 2023 Sep 1;32(9):1795–803.
  19. Vuori M, Martikainen JE, Koski-Pirilä A, Sourander A, Puustjärvi A, Aronen ET, et al. Children’s Relative Age and ADHD Medication Use: A Finnish Population-Based Study. Pediatrics. 2020 Oct 1;146(4):e20194046.
  20. Halldner L, Tillander A, Lundholm C, Boman M, Långström N, Larsson H, et al. Relative immaturity and ADHD: findings from nationwide registers, parent- and self-reports. J Child Psychol Psychiatry. 2014;55(8):897–904.
  21. Karlstad Ø, Furu K, Stoltenberg C, Håberg SE, Bakken IJ. ADHD treatment and diagnosis in relation to children’s birth month: Nationwide cohort study from Norway. Scand J Public Health. 2017 Jun 1;45(4):343–9.
  22. Sayal K, Chudal R, Hinkka-Yli-Salomäki S, Joelsson P, Sourander A. Relative age within the school year and diagnosis of attention-deficit hyperactivity disorder: a nationwide population-based study. Lancet Psychiatry. 2017 Nov 1;4(11):868–75.
  23. Laugesen K, Ludvigsson JF, Schmidt M, Gissler M, Valdimarsdottir UA, Lunde A, et al. Nordic Health Registry-Based Research: A Review of Health Care Systems and Key Registries. Clin Epidemiol. 2021 Dec 31;13:533–54.
  24. Furu K, Wettermark B, Andersen M, Martikainen JE, Almarsdottir AB, Sørensen HT. The Nordic countries as a cohort for pharmacoepidemiological research. Basic Clin Pharmacol Toxicol. 2010 Feb;106(2):86–94.
  25. Rasmussen L, Wettermark B, Steinke D, Pottegård A. Core concepts in pharmacoepidemiology: Measures of drug utilization based on individual-level drug dispensing data. Pharmacoepidemiol Drug Saf. 2022;31(10):1015–26.
  26. ADHD (aktiivisuuden ja tarkkaavuuden häiriö) [Internet]. [cited 2024 Aug 8]. Available from: https://www.kaypahoito.fi/hoi50061#s1
  27. ADHD-behandling bland barn och unga [Internet]. [cited 2024 Aug 8]. Available from: https://vardenisiffror.se/indikator/b2c88b08-4a40-49b1-b139-c775d920f74d?datefrom=2022-11-01&dateto=2023-04-30&gender&relatedmeasuresbyentry=keyword&relatedmeasuresbyid=lakemedelsbehandling&showtarget=false&units=se&units=08&units=17&units=18&units=25&units=24&units=23&units=06&units=22&units=19&units=05&units=20&units=12&units=07&units=01&units=03&units=21&units=09&units=14&units=13&units=04&units=10
  28. Adhd och autism: prioriteringsstöd till dig som beslutar om resurser i hälso- och sjukvården eller socialtjänsten: nationella riktlinjer 2024. Stockholm: Socialstyrelsen; 2024. 108 p.
  29. Indikatorer för vård och stöd vid adhd och autism.
  30. Sadozai L, Sable S, Le Roux E, Coste P, Guillot C, Boizeau P, et al. International consensus validation of the POPI tool (Pediatrics: Omission of Prescriptions and Inappropriate prescriptions) to identify inappropriate prescribing in pediatrics. PloS One. 2020;15(10):e0240105.
  31. Braithwaite J, Hibbert PD, Jaffe A, White L, Cowell CT, Harris MF, et al. Quality of Health Care for Children in Australia, 2012-2013. JAMA. 2018 Mar 20;319(11):1113.
  32. Gill PJ, O’Neill B, Rose P, Mant D, Harnden A. Primary care quality indicators for children: measuring quality in UK general practice. Br J Gen Pract J R Coll Gen Pract. 2014 Dec;64(629):e752-757.