Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, Rome, 112 - 00147, Italy.
Laboratory of Epidemiology of Developing Age, Department of Medical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.
BMC Pediatr. 2023 Apr 1;23(1):151. doi: 10.1186/s12887-023-03968-5.
In Italy, inhaled corticosteroids (ICSs) are inappropriately prescribed to provide relief in URTI symptoms. Extreme variation in ICS prescribing has been described at regional and sub-regional level. During 2020, extraordinary containment measures were implemented in attempt to halt Coronavirus, such as social distancing, lockdown, and the use of mask. Our objectives were to evaluate the indirect impact of the SARS-CoV-2 pandemic on prescribing patterns of ICSs in preschool children and to estimate the prescribing variability among pediatricians before and during the pandemic.
In this real-world study, we enrolled all children residing in the Lazio region (Italy), aged 5 years or less during the period 2017-2020. The main outcome measures were the annual ICS prescription prevalence, and the variability in ICS prescribing, for each study year. Variability was expressed as Median Odds Ratios (MORs). If the MOR is 1.00, there is no variation between clusters (e.g., pediatricians). If there is considerable between-cluster variation, the MOR will be large.
The study population consisted of 210,996 children, cared by 738 pediatricians located in the 46 local health districts (LHDs). Before the pandemic, the percentage of children exposed to ICS was almost stable, ranging from 27.3 to 29.1%. During the SARS-CoV-2 pandemic, the ICS prescription prevalence dropped to 17.0% (p < 0.001). In each study year, a relevant (p < 0.001) variability was detected among both LHDs and pediatricians working in the same LHD. However, the variability among individual pediatricians was always higher. In 2020, the MOR among pediatricians was 1.77 (95% CI: 1.71-1.83) whereas the MOR among LHDs was 1.29 (1.21-1.40). Furthermore, MORs remained stable over time, and no differences were detected in ICS prescription variability before and after pandemic outbreak.
If on one hand the SARS-CoV-2 pandemic indirectly caused the reduction in ICS prescriptions, on the other the variability in ICS prescribing habits among both LHDs and pediatricians remained stable over the whole study time span (2017-2020), showing no differences between pre- pandemic and pandemic periods. The intra-regional drug prescribing variability underlines the lack of shared guidelines for appropriate ICS therapy in preschool children, and raises equity issues in access to optimal care.
在意大利，人们不合理地使用吸入性皮质类固醇（ICS）来缓解上呼吸道感染（URTI）症状。ICS 处方的使用在地区和次地区层面存在极大差异。在 2020 年，为了阻止冠状病毒的传播，意大利实施了许多特殊的遏制措施，如保持社交距离、封锁和使用口罩。我们的目的是评估 SARS-CoV-2 大流行对学龄前儿童 ICS 处方模式的间接影响，并估计大流行前后儿科医生的处方差异。
在这项真实世界的研究中，我们纳入了 2017 年至 2020 年期间居住在拉齐奥地区（意大利）、年龄在 5 岁及以下的所有儿童。主要观察指标为每个研究年度的 ICS 处方流行率和 ICS 处方的变异性。变异性用中位数优势比（MOR）表示。如果 MOR 为 1.00，则表示各聚类（如儿科医生）之间没有差异。如果存在较大的聚类间差异，则 MOR 将较大。
研究人群由 210996 名儿童组成，由 46 个地方卫生区（LHD）的 738 名儿科医生负责治疗。在大流行之前，暴露于 ICS 的儿童比例基本稳定，范围在 27.3%至 29.1%之间。在 SARS-CoV-2 大流行期间，ICS 处方的流行率降至 17.0%（p<0.001）。在每个研究年度中，在 LHD 和在同一 LHD 工作的儿科医生之间均检测到显著的（p<0.001）变异性。然而，个体儿科医生之间的变异性始终更高。在 2020 年，儿科医生之间的 MOR 为 1.77（95%CI：1.71-1.83），而 LHD 之间的 MOR 为 1.29（1.21-1.40）。此外，MOR 随时间保持稳定，在大流行爆发前后，ICS 处方变异性无差异。
一方面，SARS-CoV-2 大流行间接导致 ICS 处方减少，另一方面，LHD 和儿科医生的 ICS 处方习惯变异性在整个研究期间（2017-2020 年）保持稳定，大流行前后无差异。区域内药物处方的变异性突出表明，在为学龄前儿童提供适当的 ICS 治疗方面缺乏共识指南，并引发了获得最佳治疗的公平性问题。
