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NATIONAL MEDICAL CARE STATISTICS 2010

Chapter 6 | MANAGEMENT OF MORBIDITY

6.1 Prescribed

Anatomical Therapeutic Chemical (ATC) Classification System

The drugs prescribed in a primary care setting were coded according to the ATC classification, which categorises the active ingredients into different groups according to the body system or organ on which they exert their effects as well as their chemical, pharmacological and therapeutic properties.

According to the code, each drug is classified at five different levels. first Level is the main group, which consists of mostly organs or body systems. Each of the 14 main groups in Level 1 are divided at 2nd Level according to their pharmacological and therapeutic effects, which are further subdivided at 3rd and 4th levels based on their chemical, pharmacological and therapeutic properties. The 5th Level of the code indicates the chemical substance1.

An example of ATC classification for amlodipine is shown below. The full ATC code for plain amlodipine products is thus C08CA01.

Levels ATC Code ATC Description

1 C Cardiovascular system 2 C08 channel blockers 3 C08C Selective calcium channel blockers with mainly vascular effects 4 C08C A Dihydropyridine derivatives 5 C08C A01 Amlodipine

Types of Drugs Prescribed

A total of 54,532 drugs were prescribed in NMCS 2010, out of which 54,204 drugs (99.4%) were coded according to the ATC classification. The remaining 328 drugs could not be coded due to illegible writing or spelling errors.

In this report, data is being presented according to the main groups (ATC Level 1 – Table 6.1) and main therapeutic groups (ATC Level 2 – Table 6.2) followed by a list of Top 100 most prescribed , in descending order (Table 6.3).

Overall, drugs were the highest prescribed (R – 24.1%), with an average of 59.8 encounters (95%CI 59.7 – 59.9) being given a drug from this group in every 100 encounters. This is followed by drugs for alimentary tract and metabolism (A – 18.5%) and drugs for nervous system (N – 14.2%) (Table 6.1).

Antihistamines for systemic use (R06 – 13.4%) were the most frequently prescribed main therapeutic group (ATC Level 2), followed by analgesics (N02 – 12.0%), antibacterials for systemic use (J01 – 11.1%), anti-inflammatory and antirheumatic products (M01 – 9.3%) and and cold preparations (R05 – 4.3%). All 78 ATC Level 2 Codes identified in NMCS 2010 are listed in Table 6.2.

Among all the 54,204 coded drugs, paracetamol (11.1%) was the most prescribed drug, far outnumbering combination products (4.3%), chlorphenamine (or chlorpheniramine – 3.8%), mefenamic (3.4%) and amoxicillin (3.3%) (Table 6.3).

Reference

1. WHO Collaborating Centre for Drug Statistics Methodology, Guidelines for ATC classification and DDD assignment 2011. Oslo, 2010. Management of Morbidity 6

17 NATIONAL MEDICAL CARE STATISTICS 2010

Table 6.1 Distribution of prescribed medications by ATC Level 1 in NMCS 2010, in descending order

Proportion 95 % CI Rate per 100 ATC of prescribed No ATC level 1 Description Number* encounter L1 medications (%)** (N = 21,868) Lower Upper (n = 54,204)

1 R Respiratory system 13,068 24.11 59.76 59.66 59.86

2 A Alimentary tract and metabolism 10,039 18.52 45.91 45.82 46.00

3 N Nervous system 7,710 14.22 35.26 35.19 35.34

4 M Musculo-skeletal system 7,239 13.36 33.10 32.02 33.18

5 J Antiinfectives for systemic use 6,657 12.28 30.44 30.37 30.51

6 C Cardiovascular system 3,340 6.16 15.27 15.22 15.33

7 D Dermatologicals 2,478 4.57 11.33 11.29 11.38

Systemic hormonal preparations, 8 H 1,239 2.29 5.67 5.63 5.70 excl. sex hormones and insulins

9 B Blood and blood forming organs 848 1.56 3.88 3.85 3.90

10 S Sensory organs 781 1.44 3.57 3.55 3.60

Genitourinary system and sex 11 G 478 0.88 2.19 2.17 2.21 hormones

Antiparasitic products, 12 P 317 0.58 1.45 1.43 1.47 insecticides and repellents

13 V Various 8 0.01 0.04 0.03 0.04

Antineoplastic and 14 L 2 0.00 0.01 0.01 0.01 immunomodulating agents

TOTAL CODED DRUGS 54,204 100.00 - - -

* frequency of total coded drugs ** calculated based on total coded drugs (n = 54,204)

18 NATIONAL MEDICAL CARE STATISTICS 2010

Table 6.2: Distribution of prescribed medications by ATC level 2 in NMCS 2010, in descending order

Proportion 95 % CI Rate per 100 of prescribed No ATC L2 ATC level 2 Descriptions Number* encounter medications (%)** (N = 21,868) Lower Upper (n = 54,204)

1 R06 for systemic use 7,191 13.35 32.88 32.80 32.96 2 N02 Analgesics 6,455 11.98 29.52 29.45 29.59 3 J01 Antibacterials for systemic use 5,992 11.12 27.40 27.33 27.47 Antiinflammatory and 4 M01 5,000 9.28 22.86 22.80 22.93 antirheumatic products 5 R05 Cough and cold preparations 2,316 4.30 10.59 10.55 10.63 6 A02 Drugs for acid related disorders 2,315 4.30 10.59 10.54 10.63 Drugs for functional 7 A03 2,144 3.98 9.80 9.76 9.85 gastrointestinal disorders Antidiarrheals, intestinal 8 A07 antiinflammatory / 1,764 3.27 8.07 8.03 8.10 antiinfective agents 9 R01 Nasal preparations 1,636 3.04 7.48 7.45 7.52 10 A11 Vitamins 1,560 2.90 7.13 7.10 7.17 11 H02 for systemic use 1,194 2.22 5.46 5.43 5.49 12 A10 Drugs used in diabetes 1,188 2.21 5.43 5.40 5.46 Drugs for obstructive airway 13 R03 1,104 2.05 5.05 5.02 5.08 diseases Corticosteroids, dermatological 14 D07 835 1.55 3.82 3.79 3.84 preparations 15 R02 Throat preparations1 821 1.52 3.75 3.73 3.78 Other drugs for disorders of the 16 M09 775 1.44 3.54 3.52 3.57 musculo-skeletal system2 17 M03 Muscle relaxants 728 1.35 3.33 3.30 3.35 18 C07 Beta blocking agents 718 1.33 3.28 3.26 3.31 19 C10 Lipid modifying agents 681 1.26 3.11 3.09 3.14 20 N05 Psycholeptics 663 1.23 3.03 3.01 3.05 21 C08 Calcium channel blockers 650 1.21 2.97 2.95 3.00 Agents acting on the 22 C09 633 1.17 2.89 2.87 2.92 renin-angiotensin system Topical products for 23 M02 596 1.11 2.73 2.70 2.75 joint and muscular pain 24 B03 Antianemic preparations3 573 1.06 2.62 2.60 2.64 for 25 D01 499 0.93 2.28 2.26 2.30 dermatological use 26 S01 Ophthalmologicals 492 0.91 2.25 2.23 2.27 27 A12 supplements 427 0.79 1.95 1.93 1.97 Management of Morbidity 4

28 N07 Other nervous system drugs 416 0.77 1.90 1.88 1.92 6

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Table 6.2: Distribution of prescribed medications by ATC level 2 in NMCS 2010, in descending order (CONT)

Proportion 95 % CI Rate per 100 of prescribed No ATC L2 ATC level 2 Descriptions Number* encounter medications (%)** (N = 21,868) Lower Upper (n = 54,204)

29 C03 404 0.75 1.85 1.83 1.87 and chemotherapeutics 30 D06 371 0.69 1.70 1.68 1.71 for dermatological use 31 J07 Vaccines 326 0.61 1.49 1.47 1.51 , incl. antihistamines, 32 D04 312 0.58 1.43 1.41 1.44 , etc. Sex hormones and modulators of 33 G03 268 0.50 1.23 1.21 1.24 the genital system 34 A01 Stomatological preparations 264 0.49 1.21 1.19 1.22 35 B01 Antithrombotic agents 237 0.44 1.08 1.07 1.10

36 A06 Laxatives 207 0.38 0.95 0.93 0.96

37 P01 Antiprotozoals 204 0.38 0.93 0.92 0.95 38 D02 Emollients and protectives 190 0.35 0.87 0.86 0.88 Ophthalmological and 39 S03 170 0.32 0.78 0.77 0.79 otological preparations 40 J02 Antimycotics for systemic use 168 0.31 0.77 0.76 0.78 and , 41 D08 161 0.30 0.74 0.72 0.75 topical

42 G04 Urologicals 160 0.30 0.73 0.72 0.74

43 M04 Antigout preparations 133 0.25 0.61 0.60 0.62 44 J05 Antivirals for systemic use 127 0.24 0.58 0.57 0.59 45 S02 Otologicals 119 0.22 0.54 0.53 0.55 46 C05 Vasoprotectives 115 0.21 0.53 0.52 0.54 47 N06 Psychoanaleptics 106 0.20 0.48 0.48 0.49

48 C01 Cardiac therapy5 78 0.14 0.36 0.35 0.36 Ectoparasiticides, incl. scabicides, 49 P03 61 0.11 0.28 0.27 0.29 insecticides and repellents 50 C02 Antihypertensives 60 0.11 0.27 0.27 0.28 51 A13 Tonics 55 0.10 0.25 0.24 0.26 52 P02 Anthelmintics 52 0.10 0.24 0.23 0.24 Gynecological antiinfectives 53 G01 48 0.09 0.22 0.21 0.23 and antiseptics Antiobesity preparations, excl. 54 A08 47 0.09 0.21 0.21 0.22 diet products 55 H03 Thyroid therapy 43 0.08 0.20 0.19 0.20 56 J04 Antimycobacterials 43 0.08 0.20 0.19 0.20

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Table 6.2: Distribution of prescribed medications by ATC level 2 in NMCS 2010, in descending order (CONT)

Proportion 95 % CI Rate per 100 of prescribed No ATC L2 ATC level 2 Descriptions Number* encounter medications (%)** (N = 21,868) Lower Upper (n = 54,204)

57 N03 Antiepileptics 43 0.08 0.20 0.19 0.20

58 D10 Anti- preparations 42 0.08 0.19 0.19 0.20

Other alimentary tract and 59 A16 36 0.07 0.16 0.16 0.17 metabolism products

60 D11 Other dermatological preparations 27 0.05 0.12 0.12 0.13

61 B02 Antihemorrhagics 22 0.04 0.10 0.10 0.10

62 D05 Antipsoriatics 22 0.04 0.10 0.10 0.10

63 A09 Digestives, incl. 19 0.04 0.09 0.08 0.09

Blood substitutes and 64 B05 16 0.03 0.07 0.07 0.08 perfusion solutions

65 N04 Anti-parkinson drugs 16 0.03 0.07 0.07 0.08

66 A05 Bile and liver therapy 11 0.02 0.05 0.05 0.05

Preparations for treatment of 67 D03 11 0.02 0.05 0.05 0.05 and ulcers

68 N01 Anesthetics 11 0.02 0.05 0.05 0.05

69 D09 Medicated dressings 8 0.01 0.04 0.03 0.04

70 V06 General nutrients 8 0.01 0.04 0.03 0.04

Drugs for treatment of 71 M05 7 0.01 0.03 0.03 0.03 diseases

72 A04 Antiemetics and antinauseants 2 0.00 0.01 0.01 0.01

73 G02 Other gynecologicals6 2 0.00 0.01 0.01 0.01

74 H05 Calcium homeostasis7 2 0.00 0.01 0.01 0.01

75 C04 Peripheral vasodilators 1 0.00 0.00 0.00 0.01

76 J06 Immune sera and immunoglobulins 1 0.00 0.00 0.00 0.01

77 L02 Endocrine therapy 1 0.00 0.00 0.00 0.01

78 L04 Immunosuppressants 1 0.00 0.00 0.00 0.01

* frequency of total coded drugs ** calculated based on total coded drugs (n = 54,204)

1. Refers to preparations for common minor of mouth and throat, consisting of mainly lozenges 2. Refers to drugs for musculoskeletal system other than anti-inflammatory and antirheumatic products, topical products for joint and muscle pain, antigout preparations and drugs for bone diseases. For example, enzymes preparations and injections 3. Includes preparations, vitamin B12 and folic acid, and other antianemic preparations 4. Refers to drugs for nervous system other than anaesthetics, analgesic, anti-parkinson drugs, anti-epileptics, psycholeptics and psychoanaleptics, e.g. antivertigo preparations 5. Includes cardiac glycosides, antiarrhythmics, cardiac stimulants and vasodilators for cardiac diseases 6. Includes intrauterine devices Management of Morbidity

7. Includes calcitonin preparations 6 21 NATIONAL MEDICAL CARE STATISTICS 2010

Table 6.3: Top 100 most prescribed medications in NMCS 2010, in descending order

Proportion 95 % CI Rate per 100 of prescribed No ATC Code ATC Description Number* encounter medications (%)** (N = 21,868) Lower Upper (n = 54,204)

1 N02BE01 Paracetamol (plain) 6,000 11.07 27.44 27.37 27.51

2 R06AA52 Diphenhydramine, combinations 2,312 4.27 10.57 10.53 10.62

3 R06AB04 Chlorphenamine 2,078 3.83 9.50 9.46 9.54

4 M01AG01 Mefenamic acid 1,827 3.37 8.35 8.32 8.39

5 J01CA04 Amoxicillin 1,769 3.26 8.09 8.05 8.13

6 M01AB05 1,720 3.17 7.87 7.83 7.90

7 R01BA52 , combinations 1,498 2.76 6.85 6.82 6.88

8 A03BB01 Butylscopolamine (hyoscine) 1,077 1.99 4.93 4.90 4.95

9 J01DB01 Cefalexin 861 1.59 3.94 3.91 3.96

10 H02AB06 839 1.55 3.84 3.81 3.86

11 M09AB Enzymes 775 1.43 3.54 3.52 3.57

12 R06AB02 Dexchlorpheniramine 712 1.31 3.26 3.23 3.28

Magnesium compounds, 13 A02AA10 656 1.21 3.00 2.98 3.02 combinations;

14 R06AE07 Cetirizine 636 1.17 2.91 2.89 2.93

Oral rehydration 15 A07CA 624 1.15 2.85 2.83 2.88 formulations

16 M03BC51 Orphenadrine, combinations1 585 1.08 2.68 2.65 2.70

17 A10BA02 Metformin 575 1.06 2.63 2.61 2.65

18 J01FA01 572 1.06 2.62 2.59 2.64

Ordinary salt combinations 19 A02AF02 569 1.05 2.60 2.58 2.62 and antiflatulents

20 R05CB02 565 1.04 2.58 2.56 2.60

21 R06AX13 543 1.00 2.48 2.46 2.50

Opium alkaloids and 22 R05DA20 derivatives, combinations; 542 1.00 2.48 2.46 2.50 cough suppressants

23 R03CC02 Salbutamol; for systemic use 498 0.92 2.28 2.26 2.30

Preparations with 24 M02AC derivatives; topical products for 491 0.91 2.25 2.23 2.27 joint and muscular pain

25 A11GA01 Ascorbic acid (vit C) 468 0.86 2.14 2.12 2.16

26 M01AE01 452 0.83 2.07 2.05 2.09

27 C07AB03 Atenolol 451 0.83 2.06 2.04 2.08

22 NATIONAL MEDICAL CARE STATISTICS 2010

Table 6.3: Top 100 most prescribed medications in NMCS 2010, in descending order (CONT)

Proportion 95 % CI Rate per 100 of prescribed No ATC Code ATC Description Number* encounter medications (%)** (N = 21,868) Lower Upper (n = 54,204)

28 J01CF02 430 0.79 1.97 1.95 1.99

Vitamin B1 in combination with 29 A11DB 427 0.79 1.95 1.93 1.97 vitamin B6 and/or vitamin B12

30 R06AA02 Diphenhydramine 390 0.72 1.78 1.77 1.80

31 A07DA03 Loperamide 376 0.69 1.72 1.70 1.74

32 R05DA09 369 0.68 1.69 1.67 1.71

33 J01CR02 Amoxicillin and inhibitor 364 0.67 1.66 1.65 1.68

Silicones; for functional bowel 34 A03AX13 355 0.65 1.62 1.61 1.64 disorder

35 A07DA01 Diphenoxylate2 354 0.65 1.62 1.60 1.64

36 A02BA01 Cimetidine 345 0.64 1.58 1.56 1.59

37 D07AC01 ; topical 343 0.63 1.57 1.55 1.59

38 C08CA01 Amlodipine 340 0.63 1.55 1.54 1.57

39 A03FA01 Metoclopramide 326 0.60 1.49 1.47 1.51

40 N05AB04 Prochlorperazine 318 0.59 1.45 1.44 1.47

41 D04AX Other antipruritics; topical3 310 0.57 1.42 1.40 1.43

Chloramphenicol; 42 S01AA01 299 0.55 1.37 1.35 1.38 ophthalmologicals

43 C10AA02 Lovastatin 297 0.55 1.36 1.34 1.37

Sulfamethoxazole and 44 J01EE01 280 0.52 1.28 1.27 1.30 trimethoprim

45 M01AC06 Meloxicam 275 0.51 1.26 1.24 1.27

46 C08CA05 Nifedipine 274 0.51 1.25 1.24 1.27

47 R06AD02 274 0.51 1.25 1.24 1.27

48 N07CA02 Cinnarizine 237 0.44 1.08 1.07 1.10

49 B03BB01 Folic acid 230 0.42 1.05 1.04 1.07

50 A03FA03 Domperidone 224 0.41 1.02 1.01 1.04

51 R02A Throat preparations4 224 0.41 1.02 1.01 1.04

52 A07BA01 Medicinal charcoal 223 0.41 1.02 1.00 1.03

53 A11EA Vitamin B-complex, plain 218 0.40 1.00 0.98 1.01 Management of Morbidity 54 A10BB09 Gliclazide 214 0.39 0.98 0.97 0.99 6

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Table 6.3: Top 100 most prescribed medications in NMCS 2010, in descending order (CONT)

Proportion 95 % CI Rate per 100 of prescribed No ATC Code ATC Description Number* encounter medications (%)** (N = 21,868) Lower Upper (n = 54,204)

55 A10BB01 Glibenclamide 213 0.39 0.97 0.96 0.99

56 C03AA03 Hydrochlorothiazide 212 0.39 0.97 0.96 0.98

Imidazole and 57 D01AC20 derivatives, combinations 206 0.38 0.94 0.93 0.96 with corticosteroids

58 C09AA04 Perindopril 204 0.38 0.93 0.92 0.95

59 C10AA01 Simvastatin 204 0.38 0.93 0.92 0.95

Paracetamol, combinations 60 N02BE51 203 0.37 0.93 0.92 0.94 excluding psycholeptics

61 B01AC06 Acetylsalicylic acid 202 0.37 0.92 0.91 0.94

62 J01AA02 202 0.37 0.92 0.91 0.94

63 P01AB01 199 0.37 0.91 0.90 0.92

64 A02BA02 Ranitidine 198 0.37 0.91 0.89 0.92

65 A11BA Multivitamins, plain 188 0.35 0.86 0.85 0.87

66 A02BC01 Omeprazole 180 0.33 0.82 0.81 0.84

67 R03DA04 Theophylline 179 0.33 0.82 0.81 0.83

68 A02BA03 Famotidine 177 0.33 0.81 0.80 0.82

69 A12AA05 174 0.32 0.80 0.78 0.81

70 M01AE02 Naproxen 174 0.32 0.80 0.78 0.81

71 J01MA02 172 0.32 0.79 0.77 0.80

72 A12BA02 citrate 171 0.32 0.78 0.77 0.79

73 M01AC01 170 0.31 0.78 0.77 0.79

74 J01DB05 Cefadroxil 162 0.30 0.74 0.73 0.75

Dexamethasone; 75 H02AB02 154 0.28 0.70 0.69 0.72 for systemic use

76 C07AB02 Metoprolol 152 0.28 0.70 0.68 0.71

77 R05CB06 147 0.27 0.67 0.66 0.68

Dexamethasone and 78 S03CA01 antiinfectives combinations; 147 0.27 0.67 0.66 0.68 opthalmologicals and otologicals

Dequalinium; throat 79 R02AA02 145 0.27 0.66 0.65 0.67 preparations5

80 D07AA02 ; topical 144 0.27 0.66 0.65 0.67

81 R03AC02 Salbutamol; inhalation 144 0.27 0.66 0.65 0.67

24 NATIONAL MEDICAL CARE STATISTICS 2010

Table 6.3: Top 100 most prescribed medications in NMCS 2010, in descending order (CONT)

Proportion 95 % CI Rate per 100 of prescribed No ATC Code ATC Description Number* encounter medications (%)** (N = 21,868) Lower Upper (n = 54,204)

Other cold combination 82 R05X 143 0.26 0.65 0.64 0.66 preparations6

83 R05DB21 141 0.26 0.64 0.63 0.66

84 J01FA09 Clarithromycin 140 0.26 0.64 0.63 0.65

Other emollients and 85 D02AX 131 0.24 0.60 0.59 0.61 protectives7

86 J07AM01 Tetanus toxoid 131 0.24 0.60 0.59 0.61

87 R03CC03 Terbutaline; for systemic use 131 0.24 0.60 0.59 0.61

88 B03AA02 Ferrous fumarate 130 0.24 0.59 0.58 0.60

Betamethasone and antibiotics 89 D07CC01 124 0.23 0.57 0.56 0.58 combinations; topical

90 D06AX01 ; topical 123 0.23 0.56 0.55 0.57

Betamethasone; 91 H02AB01 116 0.21 0.53 0.52 0.54 for systemic use

Triamcinolone; 92 A01AC01 113 0.21 0.52 0.51 0.53 for local oral treatment

93 R05CA10 Expectorant, combinations 112 0.21 0.51 0.50 0.52

Other antiseptics; 94 R02AA20 109 0.20 0.50 0.49 0.51 throat preparations8

95 C09AA02 Enalapril 108 0.20 0.49 0.48 0.50

96 G04BX Other urologicals 106 0.20 0.48 0.48 0.49

97 M01AH05 Etoricoxib 106 0.20 0.48 0.48 0.49

98 R02AX Other throat preparations9 106 0.20 0.48 0.48 0.49

99 R05CB03 106 0.20 0.48 0.48 0.48

100 J02AB02 ; for systemic use 104 0.19 0.48 0.47 0.48

TOTAL CODED DRUGS 54,204 100.00

* frequency of total coded drugs ** calculated based on total coded drugs (n = 54,204)

1. Including combinations with paracetamol 2. Including combinations with 3. Excluding topical anthistamines and anaesthetics 4. Unspecified lozenges 5. Refers to lozenges 6. Including cough and cold preparations which were neither expectorants nor cough suppressants, such as methol inhalations, traditional remedies 7. Including soft paraffin and fat products with high water content (creams) such as aqueous creams, emulsifying ointment

8. Refers to gargle Management of Morbidity

9. Refers to herbal lozenges 6 25 NATIONAL MEDICAL CARE STATISTICS 2010

6.2 Continuity of care

The majority of encounters were not followed up (74.7%) only 22.9% had follow ups while a small number (0.9%) of encounters were referred to other doctors/specialists, to hospitals (0.7%) and to others (0.8%). This survey did not capture which health indications were sent for referral.

Table 6.4: Follow up proposed by primary care practitioners in NMCS 2010

95 % CI Visit Disposition Number Total (%) Lower Upper

No follow up planned 15,803 74.73 74.62 74.85

Follow up planned 4,872 23.04 22.98 23.10

Referral to other doctor / specialist1 185 0.87 0.86 0.89

Referral to hospital2 141 0.67 0.66 0.68

Others3 145 0.69 0.68 0.70

SUBTOTAL 21,146* 100 - -

* includes presence of missing data

1. Includes referral to other doctors (e.g. doctors in government clinics), physicians, specialists 2. Includes referral to hospital emergency department and hospital follow up 3. Includes referral for procedures (e.g. x-ray, mammogram), allied health professionals (e.g. physiotherapist), others but not specified

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