Thirty most common diagnoses managed in private clinics in 2014

80 National Medical Care Statistics 2014

CHAPTER 9: MEDICATIONS

During primary care encounters, patients were prescribed medications for their conditions as deemed necessary by the respective healthcare providers. The providers were instructed to record the medications prescribed in generic or brand names, the dosage form, route of administration, dose, frequency and duration of therapy. Note that NMCS 2014 captured only the medications prescribed and not the medications dispensed. Hence, the data presented here do not reflect the actual consumption of medications in the primary care setting. 9.1 w x y BER OF MEDICATIONS PRESCRIBED PER ENCO x NTER Number o z encounters with medical prescription Table 9.1.1 presents the number of encounters with and without medical prescription in primary care clinics in 2014. • A total of 292,906 89.9 encounters were prescribed with at least one medication. • The percentage of encounters during which medications were prescribed was higher in private clinics compared to public clinics 92.1 versus 86.6, respectively. Table 9.1.1: Number { z encounters with and without medical prescription in primary care clinics in 2014 Number | } encounters ~ nweighted count Weighted count Percent | } encounters  €  CI Overall With medication 24,523 292,906 89.9 88.9–90.9 Without medication 3,064 32,912 10.1 9.1–11.1 Public With medication 13,387 114,048 86.7 84.8–88.5 Without medication 2,083 17,576 13.4 11.5–15.2 Private With medication 11,136 178,857 92.1 91.0–93.2 Without medication 981 15,337 7.9 6.8–9.0 Number o z medications prescribed Table 9.1.2 shows the total number of medications prescribed and the prescription rates by encounters and by diagnoses in primary care clinics in 2014. • A total of 864,552 medications were prescribed, of which 37.8 were prescribed in the public sector while the remaining 62.2 were prescribed in the private sector. • The medication prescribing rate in the public sector was 248.5 medications per 100 encounters, which was lower compared to the private sector, which recorded a rate of 276.8 medications per 100 encounters. • The public-private difference was even greater when the prescription rate per diagnosis was examined. For every 100 diagnoses, approximately 70 more medications were prescribed in the private sector than in the public sector 230.8 medications versus 160.4 medications, respectively. • • • • ≥ 81 • • 89.9 10.1 86.7 13.4 92.1 7.9 • • • Chapter 9 : Medications Table 9.1.2: Number ‚ ƒ medications prescribed in primary care clinics in 2014 Number „ … medications † nweighted count Weighted count Percent „ … prescribed medications 95 ‡ CI n ˆ ‰ Š‹ Œ 552 Rate per 100 encounters 95 ‡ CI n ˆ Ž  Œ ‰ ‰ ‘ Rate per 100 diagnoses 95 ‡ CI n ˆ ‹  ŠŒ 743 Overall 70,711 864,552 100.0 265.3 256.7–274.0 198.0 190.8–205.1 Public 38,296 327,087 37.8 31.8–43.8 248.5 236.7–260.3 160.4 156.5–164.4 Private 32,415 537,465 62.2 56.2–68.2 276.8 265.3–288.2 230.8 221.7–239.9 Number o ƒ medications prescribed per encounter Below is the pattern of prescription in the public and private sectors as presented in Figure 9.1.1. • Generally, the primary care prescription pattern observed in NMCS 2014 was similar to the pattern observed in NMCS 2012. 1 • More encounters in the public sector 13.4 were not prescribed with any medication compared to the private sector 7.9. This may be explained by the fact that the public sector had more diagnostic, screening and preventive encounters, which most likely did not require any medication. • Nearly 60 of the encounters in private clinics were prescribed with three or more medications, compared to 45.8 in the public sector. • The highest number of medications prescribed per encounter was 15 and 13 in the public and the private sectors, respectively. Figure 9.1.1: Number ‚ƒ medications prescribed per encounter in primary care clinics in 2014 Nil One Two Three ≥ Four Public 13.4 18.5 22.4 20.1 25.7 Private 7.9 12.5 21.1 27.0 31.5 5 10 15 20 25 30 35 40 ’ “ ” • “ ˜ ™ š › “ ˜ • š œ ˜ ™ “ ”  ž Ÿ ¡¢£ ¤¥ ¦ §¨ £ ¥ ©ª«¬­ ª § ®¯ °¥ ¦ ¥ ® « § ¢ ®­¥ ¦ 82 National Medical Care Statistics 2014 Age- and gender-spec ± ² ± ³ prescription rate Age- and gender-specific prescription rates per 100 encounters in public and private clinics are presented in Figure 9.1.2. • The prescription rates were higher in the private sector for patients who were less than 40 years old compared to those in the public sector regardless of the gender. The trends were reversed for patients aged 40 years and above for both genders. • The lowest prescription rate was recorded in the infant age group less than one year old for both sectors. Nevertheless, the prescription rate for infants was more than two times higher in the private sector compared to the public sector for both genders. • No marked differences in prescription rate were observed between genders in different age groups for both sectors, except for the 20–39 and the 60 and above age groups in the public sector. In these two age groups, the differences were approximately 40 medications per 100 encounters. Similar trends were observed in NMCS 2012. 1 • For both sectors, elderly females aged 60 years and above were prescribed more medications than their male counterparts: 353.8 versus 312.8 medications per 100 encounters in public clinics and 295.0 versus 268.3 medications per 100 encounters in private clinics. • Of all age and gender groups, the elderly female patients in public clinics had the highest prescription rate 353.8 medications per 100 encounters, as reported above. Figure 9.1.2: Age- and gender- speci ² ic prescription rates per 100 encounters by sector in 2014 97.4 ´ µ ¶ ·¸ ¸ ¹ · µ ´ º ´ ·¸ 211.4 ¶ » ¸ ·´ 227.2 295.0 50 100 150 200

250 300

350 400 1 1–4 5–19 20–39 40–59 ≥ 60 R a te pe r 1 e n c o u n te rs Age group years Public; male Public; female Private; male Private; female • • • • • • 83 • • • • • ≥ Chapter 9 : Medications

9.2 TYPES OF MEDICATIONS PRESCRIBED

The implication of the escalating healthcare costs in Malaysia, driven by the rising burden of chronic diseases and the hike in drug prices, has been the subject of much discussion. Table 9.2.1 shows the distribution of medications prescribed to primary care patients by the Anatomical Therapeutic Chemical ATC classification in 2014. The medications are reported according to their anatomical main group ATC level 1, pharmacological subgroup ATC level 3 and chemical substance ATC level 5 in decreasing order of frequency. Only medications which accounted for at least 0.5 of all prescribed medications were included in the table. • Consistent with our findings in NMCS 2012, 1 the most common medications prescribed were respiratory system agents 22.4 of all medications, and systemic antihistamines contributed to more than half of all respiratory agents prescribed. • The second most frequently prescribed drugs were the alimentary tract and metabolism agents 20.2 of all medications, which were prescribed at a rate of 53.6 medications per 100 encounters. Blood glucose lowering agents like metformin, gliclazide and glibenclamide, which were prescribed at a rate of 14.3 per 100 encounters, represented 26.7 of the alimentary tract and metabolism agents prescribed. • Medications for cardiovascular system were prescribed at a rate of 41.0 per 100 encounters, making them the third most commonly prescribed drugs. This group of drugs constituted 15.4 of all medications prescribed in primary care clinics. Table 9.2.2 and Table 9.2.3 present the distribution of the prescribed medications according to the ATC level 1 index classification in the public and private sectors, respectively. • The top three medications prescribed in public clinics were cardiovascular agents 34.1, alimentary tract and metabolism agents 24.7 and respiratory system agents 14.1. Among these three categories, oral hypoglycaemic agents, lipid modifying agents and calcium channel blockers were the predominant therapeutic agents prescribed in public clinics see Table 9.3.1. • Respiratory medications were the most frequently prescribed medications in private clinics, accounting for 27.4 of all medications prescribed in private clinics. This was followed by alimentary tract and metabolism agents at 17.4 48.2 per 100 encounters and musculoskeletal medications at 15.5 43.0 per 100 encounters. • Prescription drugs for cardiovascular system were recorded at a rate of 11.3 medications per 100 encounters, amounting to 4.1 of all medications prescribed in private clinics. The prescription patterns in both public and private clinics were reflective of the types of diseases managed in the respective spheres of primary care, where chronic diseases such as dyslipidaemia, hypertension and diabetes were the predominant diagnoses managed in public clinics, while respiratory and cardiovascular diseases were the most common diagnoses in private clinics see Chapter 8.