Wednesday, July 28, 2010

U.S. Leads World in Prescription Drug Use

It’s complicated.

Wait, wait, it’s a good thing. Mostly.  Or maybe.

While the headline may suggest a story that is either shocking or self-evident, depending upon your point of view, the British study it refers to is based on the level of uptake of prescription drugs for 14 different diseases in 14 different countries. It is not a study of prescription drug abuse, but rather a look at legitimate medical treatment of diseases like cancer, multiple sclerosis, and Hepatitis C.

Measured by volume of use per capita, Americans consume more prescription drugs than any other country.  We’re number one! They can’t touch us! (Spain ranked second, and France was third. New Zealand, Sweden, and Germany ranked at the bottom.)

Seriously, though, we mostly knew that about America already. Another way to look at these numbers is to turn the question around: Why, for example, is the UK in 10th place for cancer drug usage, despite near-universal health coverage? Why aren’t other countries dispensing larger amounts of recognized medications for such diseases as Hepatitis C and rheumatoid arthritis? So, one question the report seems to raise is: why do other developed countries have worse access to prescription drugs than we do?

UK Health Secretary Andrew Lansley, quoted in an article for Nature News, stressed that “high usage does not necessarily equal good performance, nor does low usage indicate a failing.” At the same time, however, Lansley announced a new government fund of 50 million English pounds  “to increase access to cancer drugs.”

With those caveats in mind, we find that the report concludes… well, in the end, the report acknowledges the wide variations in international usage, but concludes that “there does not appear to be a consistent pattern between countries or for different disease areas or categories of drug.”  The study group did not find any uniform patterns that held across drug categories or disease regions. In fact, the report invites interested stakeholders to submit their best thoughts on the matter to

Despite this absence of firm conclusions or hypotheses, the report does manage to note some common themes:

-- “Differences in health spending and systems do not appear to be strong determinants of usage.” But even here, the report goes on to offer some thoughts on the dominance of the U.S. “For example, ‘supplier-induced demand’ was felt to be a greater issue in the USA because of the payment structures in that country: where suppliers can charge more for delivering a particular treatment, this may provide perverse incentives to prescribe those drugs.” And: “The majority of countries reviewed provide (almost) universal coverage, with residence in the given country being the most common basis for entitlement to healthcare. The USA is the only country not offering universal access to healthcare; entitlement to publicly funded services is dependent on certain conditions…”

--“Clinical culture and attitudes towards treatment remain important determinants in levels of uptake.” The same reasoning would apply to the U.S., as psychotherapists have struggled for a foothold in the brave new world of medications for diseases with strong mental and emotional components.

--“A country that spends more on healthcare or a country which operates few controls on prescribing could be expected to use more drugs.” But I thought the report said that differences in health spending and systems didn’t make any difference…

Here is the problem with attempts at surveys of this kind. (Departments at the United Nations do a lot of them, as do individual countries.) Mike Richards, the UK’s National Cancer Director, compiled the report--“Extent and causes of international variations in drug usage”—and further qualified the findings: “For some disease areas, high usage may be a sign of weaknesses at other points in the care pathway and low usage a sign of effective disease prevention.”

It is similar to the problem of quantifying addiction. The amount of addictive drug consumed often tells us very little about the problem, or the prospects for amelioration.  However, in a survey like this one, I think coming out on the top is, on balance, better than coming out on the bottom.

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