Let us examine this study of geographic distribution by McDonald and Jalbert more closely. The researchers used a pharmacy database to quantify the number of schedule II stimulants prescribed during 2008 for the treatment of ADHD. Prescription data were provided by 37,000 pharmacies, representing 76% of all retail pharmacies in the United States. According to the researchers, most (97%) of all stimulant prescriptions in the United States are filled in retail pharmacies.
To exclude the transient use of stimulants, the researchers counted only prescriptions that were filled for at least a 60-day supply. They focused on prescriptions during March 2008 specifically because previous research has found that the rate of ADHD treatment increases during the winter as children may develop problems in school.
The main study outcomes were differences in the prevalence of stimulant prescribing across different regions, states, and counties in the United States. The investigators also attempted to understand the determinants of any geographic differential in prescribing patterns, focusing on race/ethnicity, poverty, education, and physician supply. They used data from the American Medical Association and US Census Bureau to establish these criteria.
The overall prevalence of stimulant prescriptions was 4.5% for children and 1.2% for adults. There was little difference in prescription rates in different regions of the country, with the South having slightly higher rates of prescriptions for children and adults (2.4% and 0.5%, respectively) vs the Midwest (2.2% and 0.4%, respectively).
However, the variation in stimulant prescribing increased as the analysis focused on increasingly smaller geographic areas. Rates of ADHD treatment for children ranged between 0.4% and 5.1% across different states, with the highest rates of treatment found in South Carolina, Kentucky, and Delaware and the lowest rates identified in Alaska, California, and Hawaii. The high and low rates by state for adult treatment were 0.2% and 1.2%, with the highest rates of treatment in Delaware, Washington, DC, and Rhode Island and the lowest rates in the same 3 Pacific states that had the lowest rates for children.
The rate of variability of ADHD prescriptions was even more profound in the analysis by county. There was a 4.6-fold difference in comparing counties at the 25th and 75th percentiles of stimulant prescribing across the spectrum of counties. The respective difference in the state-to-state analysis was only 2.0, but both of these measures are approximately 10-fold higher than those found for other health interventions.
Why the Variability?
Why was there such profound variability in stimulant prescribing for ADHD? Socioeconomic variables explained approximately 60% of the difference in prescribing habits. Physician availability was another major influence. A lack of pediatricians and family physicians was particularly associated with lower prescription rates among children, but the supply of psychiatrists was more important among adults.
Other factors associated with lower rates of ADHD treatment among children included rural location, higher proportions of nonwhite children, higher overall educational levels, lower poverty rates, and lower average expenditures for special education programs in schools. Variables associated with lower rates of treatment among adults were generally similar but included lower educational levels. Of note, the presence of state prescription monitoring programs did not affect the rates of stimulant medications.
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