General practitioners' prescribing behaviour as a determinant of poor persistence with inhaled corticosteroids in children with respiratory symptoms: mixed methods study

BMJ Open. 2013 Apr 3;3(4):e002310. doi: 10.1136/bmjopen-2012-002310. Print 2013.


Objectives: To evaluate general practitioners' (GPs') prescribing behaviour as a determinant of persistence with and adherence to inhaled corticosteroids (ICS) in children.

Design: Prospective observational study of persistence with and adherence to ICS followed by a focus group study of the GPs prescribing this treatment.

Setting: 7 primary care practices in the area of Zwolle, the Netherlands.

Participants: 134 children aged 2-12 years had been prescribed ICS in the year before the study started by their 19 GPs.

Main outcome measures: Patterns and motives of GPs' prescribing behaviour and the relationship with persistence with and adherence to ICS.

Results: GPs' prescribing behaviour was characterised by prescribing short courses of ICS to children with various respiratory symptoms without follow-up for making a diagnosis of asthma. This was driven by the GPs' pragmatic approach to deal with the large number of children with respiratory symptoms, and by beliefs about ICS which differed from currently available evidence. This prescribing behaviour was the main reason why 68 (51%) children did not persist with the use of ICS. In children with persistent use of ICS and a GP's advice to use ICS on a daily basis, the median (IQR) adherence was 70% (41-84%), and was similar for patients with persistent asthma and children lacking a diagnosis or symptoms of asthma.

Conclusions: Inappropriate prescription of ICS to children by GPs is common and drives the lack of persistence with ICS therapy in primary care. This finding should be taken into account when interpreting data from large prescription database studies. Improving primary healthcare providers' knowledge and competence in diagnosing and managing asthma in children is needed.