Adult Attention-Deficit Hyperactivity Disorder: A Database Analysis of South African Private Health Insurance

By Schoeman, Renata; de Klerk, Manie | South African Journal of Psychiatry, March 2017 | Go to article overview

Adult Attention-Deficit Hyperactivity Disorder: A Database Analysis of South African Private Health Insurance


Schoeman, Renata, de Klerk, Manie, South African Journal of Psychiatry


Introduction

Attention-deficit hyperactivity disorder (ADHD) has received increased scientific, clinical and public attention over the past few decades. ADHD is the most common psychiatric disorder in children, affecting 2.0% to 16.0% of the school-age population. (1) It is now widely accepted that an estimated 60.0% to 70.0% of patients' symptoms persist into adulthood, with estimates of the prevalence of adult ADHD between 2.5% and 4.3%. (2)

ADHD is a costly, chronic disorder, with significant impact on the quality of life (QOL) of patients and their families. The burden of disease (BOD) is significant, with the disability-adjusted life years (DALYs) calculated as 424 per 100 000.3 Comorbidity, estimated at more than 50% with ADHD, contributes to the BOD and reduced QOL of patients with ADHD. (4,5)

In an analysis of all medical, pharmaceutical and disability claims in an administrative database (N > 100 000), resource utilisation of individuals with ADHD and their family members was contrasted with a matched control sample of patients without ADHD. The direct costs of ADHD in terms of annual average expenditure per patient, outpatient costs, inpatient costs and prescription drug costs were two- to threefold the costs of matched controls. (6)

ADHD causes significant personal, interpersonal and social burden, impacting negatively on overall QOL. Many studies have confirmed the efficacy and effectiveness of both stimulant and non-stimulant medication in the treatment of ADHD in children, adolescents and adults. Although pharmacotherapy plays a primary role in the treatment of ADHD, psychosocial interventions (psycho-education, cognitive behavioural therapy, supportive coaching or assistance with daily activities) are an integral part of management. (7,8,9,10,11)

Despite the known efficacy of treatment and the substantial costs of untreated ADHD, access to health care and treatment is not a given for many patients in emerging markets. This holds true for SA where research indicates poor identification and treatment of common mental disorders at primary health care level and limited access to specialist resources with a service delivery and treatment gap of up to 75%. (12,13) Medication options are often limited in emerging markets, and in SA, psychiatrists and patients do not have access to the medicines available in established markets.

The lifetime prevalence of ADHD in SA is unknown. Extrapolating the known international prevalence information to the South African context, the expected number of adults aged between 20 and 50 affected by ADHD would be between 771 264 (3%) and 1 285 439 (5%).

In SA, funding for treatment for children with ADHD is private, either via medical schemes or via the state sector (limited). However, adults with ADHD have even less access to care. Some medical schemes that cover for childhood ADHD often do not provide benefits for the treatment of adult ADHD, and patients can often not afford private treatment in addition to their monthly contributions to these funds.

Our study, the first in the field in SA, aimed to establish the current situation with regard to the psychiatric management of and funding for treatment of adult ADHD in the private sector as the basis for a proposal for a new funding model in order to improve access to treatment and QOL for adults with ADHD in emerging markets such as SA.

Methods

A triangulated study was conducted consisting of a retrospective claims database analysis, a survey and in-depth interviews. In this article, we report on findings on the quantitative analysis of a retrospective claims database using medical data, pharmacy data and enrolment information as captured for the largest administrator of medical schemes in SA, representing 3 million beneficiaries (29% of all beneficiaries across 17 medical schemes).

Inclusion criteria

To be included, claims submitted to the medical scheme had to be:

* for adult beneficiaries (aged 18-60)

* who had one or more outpatient medical claims for ADHD as indicated by relevant ICD-10 codes between 1 July 2011 and 30 June 2013 (14)

* who had received scripts or claimed for methylphenidate (MPH) derivatives, atomoxetine or bupropion as indicated by relevant National Pharmaceutical Product Index (NAPPI) codes. …

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