Cost-related medication nonadherence among elderly and disabled medicare beneficiaries: a national survey 1 year before the medicare drug benefit

Understanding social needs screening and demographic data collection in primary care practices serving Maryland Medicare patients

BACKGROUND

Health outcomes are strongly impacted by social determinants of health, including social risk factors and patient demographics, due to structural inequities and discrimination. Primary care is viewed as a potential medical setting to assess and address individual health-related social needs and to collect detailed patient demographics to assess and advance health equity, but limited literature evaluates such processes.

METHODS

We conducted an analysis of cross-sectional survey data collected from n = 507 Maryland Primary Care Program (MDPCP) practices through Care Transformation Requirements (CTR) reporting in 2022. Descriptive statistics were used to summarize practice responses on social needs screening and demographic data collection. A stepwise regression analysis was conducted to determine factors predicting screening of all vs. a targeted subset of beneficiaries for unmet social needs.

RESULTS

Almost all practices (99%) reported conducting some form of social needs screening and demographic data collection. Practices reported variation in what screening tools or demographic questions were employed, frequency of screening, and how information was used. More than 75% of practices reported prioritizing transportation, food insecurity, housing instability, financial resource strain, and social isolation.

CONCLUSIONS

Within the MDPCP program there was widespread implementation of social needs screenings and demographic data collection. However, there was room for additional supports in addressing some challenging social needs and increasing detailed demographics. Further research is needed to understand any adjustments to clinical care in response to identified social needs or application of data for uses such as assessing progress towards health equity and the subsequent impact on clinical care and health outcomes.

Challenges to medication adherence with intranasal corticosteroid irrigations

BACKGROUND

The purpose of this study was to investigate real-world adherence to intranasal corticosteroid irrigations using pharmacy data and assess factors associated with low adherence.

METHODS

Patients undergoing treatment with corticosteroid irrigations for any diagnosis during a 2-year period were prospectively recruited. Subjects completed a one-time set of questionnaires including the Barriers to Care Questionnaire (BCQ), 22-item Sino-Nasal Outcome Test (SNOT-22), and a questionnaire assessing their experience with corticosteroid irrigations. Pharmacy data was used to calculate the medication possession ratio (MPR), a measure of medication adherence graded from 0 to 1.

RESULTS

Seventy-one patients were enrolled. Patient diagnoses included chronic rhinosinusitis (CRS) without nasal polyps (n = 37), CRS with nasal polyps (n = 24), or a non-CRS diagnosis, most commonly chronic rhinitis (n = 10). The MPR for the overall group was 0.44 ± 0.33. Just 9.9% of patients had a perfect MPR of 1. Despite low MPR, only 19.7% of patients reported problems taking the medication when directly asked. Lower education resulted in lower MPR (unstandardized B = 0.065, p = 0.046). Increasing BCQ score, indicating higher barriers to care, was associated with lower MPR (unstandardized B = -0.010, p = 0.033). The lower the MPR, the worse the patient SNOT-22 scores (unstandardized B = -15.980, p = 0.036).

CONCLUSION

Adherence to corticosteroid irrigations was low and patients underreported issues with their medication. Education and barriers to care were associated with lower adherence, which, in turn, was associated with worse sinonasal quality of life.

Patient Adherence Following Knee Surgery: Evidence-Based Practices to Equip Patients for Success

Patient adherence with postoperative wound care, activity restrictions, rehabilitation, medication, and follow-up protocols is paramount to achieving optimal outcomes following knee surgery. However, the ability to adhere to prescribed postoperative protocols is dependent on multiple factors both in and out of the patient's control. The goals of this review article are (1) to outline key factors contributing to patient nonadherence with treatment protocols following knee surgery and (2) to synthesize current management strategies and tools for optimizing patient adherence in order to facilitate efficient and effective implementation by orthopaedic health care teams. Patient adherence is commonly impacted by both modifiable and nonmodifiable factors, including health literacy, social determinants of health, patient fear/stigma associated with nonadherence, surgical indication (elective vs. traumatic), and distrust of physicians or the health care system. In addition, health care team factors, such as poor communication strategies or failure to follow internal protocols, and health system factors, such as prior authorization delays, staffing shortages, or complex record management systems, impact patient's ability to be adherent. Because the majority of factors found to impact patient adherence are nonmodifiable, it is paramount that health care teams adjust to better equip patients for success. For health care teams to successfully optimize patient adherence, focus should be paid to education strategies, individualized protocols that consider patient enablers and barriers to adherence, and consistent communication methodologies for both team and patient-facing communication.

In the wake of a crisis: Caught between housing and healthcare

Objective

To measure the association between housing insecurity and foregone medication due to cost among Medicare beneficiaries aged 65+ during the Recession.

Methods

Data came from Medicare beneficiaries aged 65+ years from the 2006-2012 waves of the Health and Retirement Study (HRS). Two-wave housing insecurity changes are evaluated as follows: (i) No insecurity, (ii) Persistent insecurity, (iii) Onset insecurity, and (iv) Onset security. We implemented a series of four weighted longitudinal General Estimating Equation (GEE) models, two minimally adjusted and two fully adjusted models, to estimate the probability of foregone medications due to cost between 2008 and 2012.

Results

Our study sample was restricted to non-proxy interviews of non-institutionalized Medicare beneficiaries aged 65+ in the 2006 wave (n = 9936) and their follow up visits (n = 8753; in 2008; n = 7464 in 2010; and n = 6594 in 2012). Results from our fully adjusted model indicated that the odds of foregone medication was 64% higher among individuals experiencing Onset insecurity versus No insecurity in 2008, and also generally larger for individuals experiencing Onset Insecurity versus Persistent Insecurity. Odds of foregone medication was also larger among females, minority versus non-Hispanic white adults, those reporting a chronic condition, those with higher medical expenditures, and those living in the South versus Northeast.

Conclusion

This study drew from nationally representative data to elucidate the disparate health and financial impacts of a crisis on Medicare beneficiaries who, despite health insurance coverage, displayed variability in foregone medication patterns. Our findings suggest that the onset of housing insecurity is most closely linked with unexpected acute economic shocks leading households with little time to adapt and forcing trade-offs in their prescription and other needs purchases. Both housing and healthcare policy implications exist from these findings including expansion of low-income housing units and rent relief post-recession as well as wider prescription drug coverage for Medicare adults.

Prevalence and persistence of cost-related medication non-adherence before and during the COVID-19 pandemic among medicare patients at high risk of hospitalization

OBJECTIVE

To study cost-related medication non-adherence (CRN) for a 30-month period before and during the COVID-19 pandemic using a sample of Medicare patients at high risk of hospitalization.

DESIGN

A novel data set of quarterly surveys of CRN was used to evaluate CRN before and during the COVID-19 pandemic. Generalized Estimating Equation (GEE) analyses were conducted to evaluate the adjusted coefficients of change in CRN behaviors controlling for socio-demographic and health characteristics.

PARTICIPANTS

Six hundred seventy-seven Medicare beneficiaries at high risk of hospitalization who were alive on January 1, 2020 and followed up through quarterly surveys on CRN for 30 months before and during the COVID-19 pandemic.

MAIN OUTCOMES AND MEASURES

Two metrics of prevalence and persistence of CRN and their adjusted coefficients in GEE with binomial family distribution and log link function controlling for socio-demographic and health characteristics.

RESULTS

A total of 5,990 quarterly surveys were completed by the 677 patients during the 30-month study period. Among the 677 patients, 250 (37%) were men, 591 (87%) were African American, and 288 (42%) were Medicare-Medicaid dual eligible. The unadjusted prevalence of CRN before and during the COVID-19 pandemic was 31.1% and 25.7% respectively (p = 0.02 by Chi-squared test), and persistent CRN rates were 12.1% and 9.7% respectively (p = 0.17 by Chi-squared test). The adjusted odds ratio of CRN prevalence during the pandemic compared to the pre-pandemic level was 0.75 (p<0.01), and 0.74 (p = 0.03) for persistent CRN in GEE estimations.

CONCLUSION AND RELEVANCE

There are coherent evidence of a reversal of CRN rates during the COVID-19 pandemic among this high-need, high-cost resource utilization Medicare population. Patients' CRN behaviors may be responsive to exogenous impacts, and the behaviors changed in the same direction with similar magnitude in terms of prevalence (the extensive margin) and persistence (the intensive margin). More research is needed to advance the understanding of the driving forces behind patients' behavioral changes and to identify factors that may be informative for reducing CRN in the long run.

Characteristics associated with poor atrial fibrillation-related quality of life in adults with atrial fibrillation

PURPOSE

Few studies have examined the relationship between poor atrial fibrillation-related quality of life (AFQoL) and a battery of geriatric factors. The objective of this study is to describe factors associated with poor AFQoL in older adults with atrial fibrillation (AF) with a focus on sociodemographic and clinical factors and a battery of geriatric factors.

METHODS

Cross-sectional analysis of a prospective cohort study of participants aged 65+ with high stroke risk and AF. AFQoL was measured using the validated Atrial Fibrillation Effect on Quality of Life (score 0-100) and categorized as poor (<80) or good (80-100). Chi-square and t -tests evaluated differences in factors across poor AFQoL and significant characteristics ( P  < 0.05) were entered into a logistic regression model to identify variables related to poor AFQoL.

RESULTS

Of 1244 participants (mean age 75.5), 42% reported poor AFQoL. Falls in the past 6 months, pre/frail and frailty, depression, anxiety, social isolation, vision impairment, oral anticoagulant therapy, rhythm control, chronic obstructive pulmonary disease and polypharmacy were associated with higher odds of poor AFQoL. Marriage and college education were associated with a lower odds of poor AFQoL.

CONCLUSIONS

More than 4 out of 10 older adults with AF reported poor AFQoL. Geriatric factors associated with higher odds of reporting poor AFQoL include recent falls, frailty, depression, anxiety, social isolation and vision impairment. Findings from this study may help clinicians screen for patients with poor AFQoL who could benefit from tailored management to ensure the delivery of patient-centered care and improved well being among older adults with AF.

Changes in Prescription Drug and Health Care Use Over 9 Years After the Large Drug Price Increase for Colchicine

Importance

Prescription drug prices are a leading concern among patients and policy makers. There have been large and sharp price increases for some drugs, but the long-term implications of large drug price increases remain poorly understood.

Objective

To examine the association of the large 2010 price increase in colchicine, a common treatment for gout, with long-term changes in colchicine use, substitution with other drugs, and health care use.

Design, Setting, and Participants

This retrospective cohort study examined MarketScan data from a longitudinal cohort of patients with gout with employer-sponsored insurance from 2007 through 2019.

Exposures

The US Food and Drug Administration's discontinuation of lower-priced versions of colchicine from the market in 2010.

Main Outcomes and Measures

Mean price of colchicine; use of colchicine, allopurinol, and oral corticosteroids; and emergency department (ED) and rheumatology visits for gout in year 1 and over the first decade of the policy (through 2019) were calculated. Data were analyzed between November 16, 2021, and January 17, 2023.

Results

A total of 2 723 327 patient-year observations were examined from 2007 through 2019 (mean [SD] age of patients, 57.0 [13.8] years; 20.9% documented as female; 79.1% documented as male). The mean price per prescription of colchicine increased sharply from $11.25 (95% CI, $11.23-$11.28) in 2009 to $190.49 (95% CI, $190.07-$190.91) in 2011, a 15.9-fold increase, with the mean out-of-pocket price increasing 4.4-fold from $7.37 (95% CI, $7.37-$7.38) to $39.49 (95% CI, $39.42-$39.56). At the same time, colchicine use declined from 35.0 (95% CI, 34.6-35.5) to 27.3 (95% CI, 26.9-27.6) pills per patient in year 1 and to 22.6 (95% CI, 22.2-23.0) pills per patient in 2019. Adjusted analyses showed a 16.7% reduction in year 1 and a 27.0% reduction over the decade (P < .001). Meanwhile, adjusted allopurinol use rose by 7.8 (95% CI, 6.9-8.7) pills per patient in year 1, a 7.6% increase from baseline, and by 33.1 (95% CI, 32.6-33.7) pills per patient through 2019, a 32.0% increase from baseline over the decade (P < .001). Moreover, adjusted oral corticosteroid use exhibited no significant change in the first year, then increased by 1.5 (95% CI, 1.3-1.7) pills per patient through 2019, an 8.3% increase from baseline over the decade. Adjusted ED visits for gout rose by 0.02 (95% CI, 0.02-0.03) per patient in year 1, a 21.5% increase, and by 0.05 (95% CI, 0.04-0.05) per patient through 2019, a 39.8% increase over the decade (P < .001). Adjusted rheumatology visits for gout increased by 0.02 (95% CI, 0.02-0.03) per patient through 2019, a 10.5% increase over the decade (P < .001).

Conclusions and Relevance

In this cohort study among individuals with gout, the large increase in colchicine prices in 2010 was associated with an immediate decrease in colchicine use that persisted over approximately a decade. Substitution with allopurinol and oral corticosteroids was also evident. Increased ED and rheumatology visits for gout over the same period suggest poorer disease control.

Patient Characteristics Associated With Being Offered or Choosing Telephone vs Video Virtual Visits Among Medicare Beneficiaries

Importance

After the rapid expansion of telemedicine during the COVID-19 pandemic, there is debate about the role and reimbursement of telephone vs video visits. Missing is an understanding of what type of virtual visits clinicians may offer or patients may choose when given the option.

Objective

To evaluate characteristics of Medicare beneficiaries associated with practices and clinicians offering telephone visits only and patients receiving telephone visits only, when both telephone and video were available.

Design, Setting, and Participants

This survey study used 2019-2020 nationally representative Medicare Current Beneficiary Survey data. Participants included community-dwelling Medicare beneficiaries with a usual source of medical care who attended a practice offering telemedicine. Data were analyzed from May 3 to August 23, 2022.

Main Outcomes and Measures

Multivariable regression analysis was used to identify patient sociodemographic (age, sex, race, ethnicity, educational level, income, English proficiency, housing type, and number living at home), clinical (dementia, mental illness, self-rated health, hearing impairment, and vision impairment), and technology (technology access and prior use of video visits) factors associated with respondents' report of (1) practices offering telephone virtual visits only, (2) being offered telephone visits only when both video and telephone visits were available, and (3) receiving telephone visits only when both video and telephone visits were offered.

Results

Of 4691 respondents (representing 27 887 642 Medicare beneficiaries; mean [SD] age, 71.3[8.1] years; 55.0% female) reporting that their practice offered telemedicine, 1234 (23.3% weighted) reported that their practices offered telephone virtual visits only; factors associated with being in a practice offering telephone only included older age (adjusted odds ratio [aOR], 1.62 [95% CI, 1.10-2.39] for those aged ≥85 years vs 18-64 years), male sex (aOR, 1.36 [95% CI, 1.12-1.64]), Hispanic ethnicity (aOR, 1.41 [95% CI, 1.03-1.95]), lower income (aOR, 1.89 [95% CI, 1.43-2.49] for those with income ≤100% vs >200% of the federal poverty level), poor self-rated health (aOR, 1.25 [95% CI, 1.01-1.56]), and less technology access (aOR, 2.05 [95% CI, 1.61-2.60] for those with low vs high access). Of the 1593 patients in practices offering both video and telephone visits, 297 (16.7% weighted) were themselves offered telephone visits only; factors associated with being offered telephone only included Hispanic ethnicity (aOR, 1.96 [95% CI, 1.13-3.41]), limited English proficiency (aOR, 3.05 [95% CI, 1.28-7.31]), and less technology access (aOR, 1.68 [95% CI, 1.00-2.81] for those with low vs high access). Finally, of the 711 respondents who were themselves offered both video and telephone visits, 304 (43.1% weighted) had a telephone visit; factors associated with receiving telephone visits only were older age (aOR, 2.68 [95% CI, 1.21-5.92] for those aged 75-84 years vs 18-64 years) and less technology access (aOR, 2.65 [95% CI, 1.12-6.25] for those with moderate vs high access]). Among those who used video calls in other settings and were offered a choice, 122 (28.5%, weighted) chose telephone visits.

Conclusions and Relevance

In this survey study of Medicare beneficiaries, respondents often reported being offered or choosing telephone visits even when video visits were available. Study findings suggest that policy makers and clinical leaders should support the use of telephone visits to the extent that telephone is appropriate, while addressing both practice-level and patient-level barriers to video visits.

A Review of Factors Contributing to Adults' Adherence to Dysphagia Dietary Recommendations Through an Ecological Lens

PURPOSE

The purpose of this review was to identify the factors affecting adherence to dysphagia dietary recommendations, a necessary contributor to the effectiveness of this compensatory strategy.

METHOD

A rapid review of two electronic databases was conducted in April 2021. Studies were included based on the following criteria: (a) were empirical studies published in English, (b) included data from the adult population, and (c) measured adherence to dietary recommendations. The ecological model and the health belief model were used as frameworks during the analysis process.

RESULTS

The literature search resulted in 930 unique abstracts, of which 14 articles were included based on the final criteria. Across the literature, multiple factors were identified as having an influence on adherence, classified according to three unique levels: the individual (e.g., dissatisfaction), the caregiver (e.g., knowledge), and the environment (e.g., institutional policies and values).

CONCLUSIONS

Improving adherence to dysphagia dietary recommendations is crucial for the effectiveness of those recommendations. As suggested by the current review, increased adherence will require careful attention to the multiple levels of factors that likely play a role, acknowledging the multifaceted nature of this complex behavior. Furthermore, characterizing the multilevel factors that influence adherence can contribute to future theoretical models, which could help guide speech-language pathologists in their clinical practices.

Medication cost-reducing behaviors in older adults with atrial fibrillation: The SAGE-AF study

BACKGROUND

As patient prices for many medications have risen steeply in the United States, patients may engage in cost-reducing behaviors (CRBs) such as asking for generic medications or purchasing medication from the Internet.

OBJECTIVE

The objective of this study is to describe patterns of CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications among older adults with atrial fibrillation (AF) and examine participant characteristics associated with CRB.

METHODS

Data were from a prospective cohort study of older adults at least 65 years with AF and a high stroke risk (CHA2DS2VASc ≥ 2). CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications were evaluated using validated measures. Chi-square and t tests were used to evaluate differences in characteristics across CRB, and statistically significant characteristics (P < 0.05) were entered into a multivariable logistic regression to examine factors associated with CRB.

RESULTS

Among participants (N = 1224; mean age 76 years; 49% female), 69% reported engaging in CRB, 4% reported cost-related medication nonadherence, and 6% reported spending less on basic needs. Participants who were cognitively impaired (adjusted odds ratio 0.69 [95% CI 0.52-0.91]) and those who did not identify as non-Hispanic white (0.66 [0.46-0.95]) were less likely to engage in CRB. Participants who were married (1.88 [1.30-2.72]), had a household income of $20,000-$49,999 (1.52 [1.02-2.27]), had Medicare insurance (1.38 [1.04-1.83]), and had 4-6 comorbidities (1.43 [1.01-2.01]) had significantly higher odds of engaging in CRB.

CONCLUSION

Although CRBs were common among older adults with AF, few reported cost-related medication nonadherence and spending less on basic needs. Patients with cognitive impairment may benefit from pharmacist intervention to provide support in CRB and patient assistance programs.

Decreasing rates of cost-related medication non-adherence by age advancement among American generational cohorts 2004-2014: a longitudinal study

OBJECTIVES

The access barrier to medication has been a persistent and elusive challenge in the US healthcare system and around the globe. Cost-related medication non-adherence (CRN) is an important measure of medication non-adherence behaviours that aim to avoid costs. Longitudinal study of CRN behaviours for the ageing population is rare.

DESIGN

Longitudinal study using the Health and Retirement Study to evaluate self-reported CRN biennially.

SETTING

General population of older Americans.

PARTICIPANTS

Three cohorts of Americans aged between 50 and 54 (baby boomers), 65-69 (the silent generation) and 80 or above (the greatest generation) in 2004 who were followed to 2014.

INTERVENTION

Observational with no intervention.

PRIMARY AND SECONDARY OUTCOME MEASURES

Longitudinal CRN rates for three generational cohorts from 2004 to 2014. Population-averaged effects of a broad set of variables including sociodemographics, income, insurance status, limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and comorbid conditions on CRN were derived using generalised estimating equation by taking into account repeated measurements of CRN over time for the three cohorts, respectively.

RESULTS

The three cohorts of baby boomer, the silent generation and the greatest generation with 1925, 2839 and 2666 respondents represented 12.3 million, 8.2 million and 7.7 million people in 2004, respectively. Increasing age was associated with decreasing likelihood of reporting CRN in all three generational cohorts (p<0.05), controlling for demographics, income, insurance status, functional status and comorbid conditions. All three generational cohorts had a higher prevalence of diabetes, cancer, heart conditions, stroke, a higher percentage of respondents with Medicare-Medicaid dual eligibility and lower percentage with private insurance in 2014 compared with 2004 (p<0.05).

CONCLUSION

The paradox of decreasing CRN rates, independent of disease burden, income and insurance status, suggests populations' CRN behaviours change as Americans age, bearing implications to social policy.

Interventions for Adherence Improvement in the Primary Prevention of Cardiovascular Diseases: Expert Consensus Statement

Over the last 2 decades, the management of chronic disease in Korea has been improved, but it has gradually stagnated. In order to improve care and reduce cardiovascular morbidity and mortality, it is crucial to improve primary prevention of cardiovascular diseases. In recent international guidelines for hypertension, diabetes, hyperlipidemia, obesity, and other conditions, adherence issues have become more frequently addressed. However, in terms of implementation in practice, separate approaches by dozens of related academic specialties need to be integrated into a systematic approach including clinician’s perspectives such as the science behind adherence, clinical skills, and interaction within team approach.

In primary prevention for cardiovascular diseases, there are significant barriers to adherence including freedom from symptoms, long latency for therapeutic benefits, life-long duration of treatment, and need for combined lifestyle changes. However, to implement more systematic approaches, the focus on adherence improvement needs to be shifted away from patient factors to the effects of the treatment team and healthcare system. In addition to conventional educational approaches, more patient-oriented approaches such as patient-centered clinical communication skills, counseling using motivational strategies, decision-making by patient empowerment, and a multi-disciplinary team approach should be developed and implemented. Patients should be involved in a program of self-monitoring, self-management, and active counseling. Because most effective interventions on adherence improvement demand greater resources, the health care system and educational or training system of physicians and healthcare staff need to be supported for systematic improvement.

Affordability of Medical Care Among Medicare Enrollees

Importance

Cost-sharing requirements can discourage patients from seeking care and impose financial hardship. The Medicare program serves many older and disabled individuals with multimorbidity and limited resources, but little has been known about the affordability of care in this population.

Objective

To examine the affordability of medical care among Medicare enrollees, in terms of the prevalence of delaying medical care because of costs and having problems paying medical bills, and risk factors for these outcomes.

Design Setting and Participants

Cross-sectional analyses conducted from November 1, 2019, to October 15, 2021, used logistic regression to compare the probability of outcomes by demographic and health characteristics. Data were obtained from the 2017 nationally representative Medicare Current Beneficiary Survey (response rate, 61.7%), with respondents representing 53 million community-dwelling Medicare enrollees.

Main Outcomes and Measures

New questions about medical care affordability were included in the 2017 Medicare Current Beneficiary Survey: difficulty paying medical bills, ongoing medical debt, and contact by collection agencies. A companion survey question asked whether individuals had delayed seeking medical care because of worries about costs.

Results

Respondents included 10 974 adults aged 65 years or older and 2197 aged 18 to 64 years; 54.2% of all respondents were women. The weighted proportions of Medicare enrollees with annual incomes below $25 000K were 30.7% in the older population and 67.4% in the younger group. Self-reported prevalence of delaying care because of cost was 8.3% (95% CI, 7.4%-9.1%) among enrollees aged 65 years or older, 25.2% (95% CI, 21.8%-28.6%) among enrollees younger than 65 years, and 10.9% (95% CI, 9.9%-11.9%) overall. Similarly, 7.4% (95% CI, 6.6%-8.2%) of older enrollees had problems paying medical bills, compared with 29.8% (95% CI, 25.6%-34.1%) among those younger than 65 years and 10.8% (95% CI, 9.8%-11.9%) overall. Regarding specific payment problems, 7.9% (95% CI, 7.0%-8.9%) of enrollees overall experienced ongoing medical debt, contact by a collection agency, or both. In adjusted analyses, older adults with incomes $15 000 to $25 000 per year had odds of delaying care more than twice as high as those with incomes greater than $50 000 (odds ratio, 2.47; 95% CI, 1.82-3.39), and their odds of problems paying medical bills were more than 3 times as high (odds ratio, 3.37; 95% CI, 2.81-5.21). Older adults with 4 to 10 chronic conditions were more than twice as likely to have problems paying medical bills as those with 0 or 1 condition.

Conclusions and Relevance

The findings of this study suggest that unaffordability of medical care is common among Medicare enrollees, especially those with lower incomes, or worse health, or who qualify for Medicare based on disability. Policy reforms, such as caps on patient spending, are needed to reduce Medical cost burdens on the most vulnerable enrollees.

Exploring racial and ethnic disparities in medication adherence among Medicare comprehensive medication review recipients

Background

There has been a lack of evidence on whether there are racial and ethnic disparities in medication nonadherence among individuals receiving comprehensive medication review (CMR), a required component of the Medicare Part D medication therapy management (MTM) services.

Objectives

To explore racial/ethnic disparities in medication nonadherence among older MTM enrollees who received a CMR and to determine how much the identified disparities can be explained by observed characteristics.

Methods

The retrospective study used 100% of the 2017 Medicare claims, including MTM data. Linked Area Health Resources Files provided community characteristics. Nonadherence was defined as proportion of days covered <80%, and was measured for diabetes, hypertension, and hyperlipidemia medications. Racial/ethnic disparities were examined by logistic regressions that included racial/ethnic minority dummy variables. A nonlinear Blinder-Oaxaca decomposition method was applied to decompose the identified disparities.

Results

Compared with non-Hispanic Whites (Whites), Blacks were respectively 39% (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.33–1.45), 27% (OR = 1.27, 95% CI = 1.22–1.32), and 43% (OR = 1.43, 95% CI = 1.39–1.47) more likely to be nonadherent to diabetes, hypertension, and hyperlipidemia medications; Hispanics were 20% (OR = 1.20, 95% CI = 1.14–1.27) more likely to be nonadherent to hyperlipidemia medications. The total portion of disparity explained was 13.42%, 7.66%, 14.87%, and 10.69% respectively for disparities in Black-White (B–W) diabetes, B–W hypertension, B–W hyperlipidemia, and Hispanic-White hyperlipidemia. The top three contributors were the proportion of married-couple families, census region, and male gender.

Conclusions

A lower level of community affluence and social support, regional variations, and a lower proportion of males in Blacks and Hispanics may contribute to the disparities in medication nonadherence. The large unexplained portion of the disparity attests that nonadherence is a complex issue. The Medicare MTM program needs to implement measures to reduce disparities in medication adherence.

•

This retrospective study used 100% of the 2017 Medicare claims including MTM data.

•

Racial/ethnic disparity in medication adherence was identified among CMR recipients.

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Blacks were more likely than Whites to be nonadherent to all medications studied.

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Hispanics were more likely than Whites to be hyperlipidemia medication nonadherent.

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Observed characteristics explained close to 15% of the identified disparity.

Effectiveness of STOPP/START criteria in primary prevention of polypharmacy and under-treatment in older patients

AIM OF THE STUDY

STOPP/START criteria appear to be a useful tool to curb inappropriate prescribing (IP), which encompasses errors of both, over and under-treatment. This study aimed to find out whether application of STOPP/START reduces the IP effectively in primary care.

METHODS

This prospective cross-sectional study was conducted in two family health centers (FHCs) in Istanbul. All older adults who applied to FHCs between 01-07-2018 and 01-07-2020 were enrolled. The potential inappropriate medications (PIMs) and potential prescription omissions (PPOs) were identified according to STOPP/START version 2 criteria. Mean drug consumptions before and after STOPP/START were compared using Student's t-test.

RESULTS

Among 1023 participants there were 626 females and 397 males. The mean age was 73.33±7.30 years. The number of the patients seen at FHCs was 657 (64.2%) while 366 (35.8%) of them were visited at home. Of the patients, 383 (37.8) were 75 years old or older and 631 (62.2%) of them were under 75. Overall number of drugs consumed per patient was 5.49±3.93 while it was 6.01±3.71 and 4.55±4.138 for outpatients and home patients respectively (p<0.001). By application of STOPP criteria, among the 5616 medications consumed by the overall patients, 881(%15.6) of them were found to be potentially inappropriate. 424 (41.4%) patients were using at least one PIM. This ratio was 354 (53.8%) in outpatients and 70 (19%) in home patients. START criteria identified 380 (%7.4) PPOs. There were 246 (24.0%) patients with at least with one PPO; 155 (42.3%) of whom were home patients and 91 (13.8%) were outpatients. Regarding the age groups; PIM ratio was 35.5% in patients under 75 and 52.1% over 75 whereas PPO ratio was 22.5% under 75 and 26.8% over 75.

CONCLUSION

This study supports the data reporting the effectiveness of STOPP/START criteria in primary care units in implementing appropriate prescription criteria.

Effect of Cost-Related Medication Non-adherence Among Older Adults With Medication Therapy Management

Background: Medication therapy management (MTM) was established by the Center for Medicare and Medicaid Services (CMS) with the aim to improve medication adherence. However, the national prevalence of cost-related medication non-adherence (CRN) is still unknown and there is a literature gap in the association between MTM services and CRN.

Methods: A cross-sectional study was conducted. A nationally representative study sample from Medicare Current Beneficiary Surveys (MCBS) was used. Survey sampling weights were applied for national estimates of CRN. Weighted multivariable logistic regressions controlling for covariates were conducted to investigate the effect of the MTM on the CRN.

Results: The study identified 1,549 MTM-eligible beneficiaries. The prevalence of CRN was higher in MTM-eligible individuals than in non-MTM eligible individuals (24.14 vs. 13.44%; P < 0.001). According to the results of multivariable logistic regressions, we found that MTM eligibility was significantly associated with a higher prevalence of CRN (OR: 1.59; 95% CI: 1.28–1.96). Additionally, some other variables such as health status, with or without low-income subsidy are also associated with CRN.

Conclusions: Our findings suggest that the prevalence of CRN in MTM-eligible beneficiaries was higher than in non-MTM eligible beneficiaries. Further studies with the longitudinal design are warranted to clarify the relationship between MTM and CRN. Alternative strategies to improve CRN should be considered in future Medicare Part D Enhanced MTM Models.

Interventions supporting cost conversations between patients and clinicians: A systematic review

BACKGROUND AND AIM

Discussing cost during medical encounters may decrease the financial impact of medical care on patients and align their treatment plans with their financial capacities. We aimed to examine which interventions exist and quantify their effectiveness to support cost conversations.

METHODS

Several databases were queried (Embase; Ovid MEDLINE(R); Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily; the Cochrane databases; and Scopus) from their inception until January 31, 2020 using terms such as "clinician*", "patient*", "cost*", and "conversation*". Eligibility assessment, data extraction and risk of bias assessment were performed independently and in duplicate. We extracted study setting, design, intervention characteristics and outcomes related to patients, clinicians and quality metrics.

RESULTS

We identified four studies (1327 patients) meeting our inclusion criteria. All studies were non-randomised and conducted in the United States. Three were performed in a primary care setting and the fourth in an oncology. Two studies used decision aids that included cost information; one used a training session for health care staff about cost conversations, and the other directly delivered information regarding cost conversations to patients. All interventions increased cost-conversation frequency. There was no effect on out-of-pocket costs, satisfaction, medication adherence or understanding of costs of care.

CONCLUSION

The body of evidence is small and comprised of studies at high risk of bias. However, an increase in the frequency of cost conversations is consistent. Studies with higher quality are needed to ascertain the effects of these interventions on the acceptability, frequency and quality of cost conversations.

Cost-related nonadherence for prescription medications: a cross-sectional study in Jordan

Background: Cost-related nonadherence to medications is a commonly encountered problem posed by many patients, and specifically among elderly patients who use multiple chronic medications. This study aims to explore the prevalence of medication cost-related nonadherence and its predictors in Jordan.Method: A cross-sectional study was conducted between February 2019 and May 2019 in Jordan. The CRN questionnaire was used as a measure to assess the prevalence of cost-related nonadherence. Logistic regression was used to determine predictors of medication cost-related nonadherence.Results: The prevalence rate of CRN was 29.6% (95% CI: 27.0-32.3). Participants who are married or widowed were found to have higher odds of being non-adherent due to medication costs, with an odds ratio of 1.55 (95%CI: 1.19-2.00) and 1.95 (95%CI: 1.20-3.15), respectively. Lower educational level was associated with higher odds of being non-adherent 1.95 (95%CI: 1.25-3.05). Being retired was associated with higher odds of being non-adherent (2.20 (95%CI: 1.49-3.27)).Conclusion: Cost-related nonadherence is a common problem in Jordan and was most prevalent among those with hypertension and diabetes mellitus, low-income, and low levels of education. Our findings could help in developing interventions to improve cost-related medication nonadherence in developing countries.

Prevalence and Persistence of Cost-Related Medication Nonadherence Among Medicare Beneficiaries at High Risk of Hospitalization

IMPORTANCE

The unaffordability of drugs has been a persistent and elusive challenge in the US health care system. Little is known about the prevalence and persistence of cost-related medication nonadherence (CRN) in a population with high-cost, high-need resource utilization.

OBJECTIVE

To evaluate the prevalence and persistence of CRN among Medicare beneficiaries at high risk of hospitalization as well as the characteristics associated with CRN in this population.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used survey data from Medicare patients at high risk of hospitalization and with a life expectancy greater than 12 months at an urban academic medical center from November 6, 2012, to January 30, 2018. Patients were followed up for 12 months at 3-month intervals from baseline, for a total of 5 surveys. Data were analyzed from September 1, 2020, to January 5, 2021.

MAIN OUTCOMES AND MEASURES

Self-reported CRN, using a metric of persistence and transiency. Based on the results of the 5 surveys, CRN was categorized as persistent (3 or more surveys), intermittent (2), transient (1), and any (1 or more). Multiple logistic regression analyses were used to evaluate factors associated with persistent and transient CRN.

RESULTS

Of the 1655 Medicare beneficiaries followed up during the 15-month study period, 1036 (62.6%) were women and 1452 (87.7%) were Black or African American; 769 (46.5%) were younger than 65 years, and 886 (53.5%) were 65 years or older (mean [SD] age, 62.4 [15.9] years). A total of 374 patients (22.6%) reported CRN at baseline, 810 (48.9%) reported any CRN, and 230 (13.9%) reported persistent CRN (148 [19.2%] of those younger than 65 years and 82 [9.3%] of those 65 years or older). The 230 patients who had persistent CRN accounted for 28% of those who reported CRN at least once during the 15-month study period. Younger age (eg, <50 years vs 75 years: adjusted odds ratio [AOR], 3.07; 95% CI, 1.61-5.86; P = .001), worse self-reported health (AOR, 1.59; 95% CI, 1.10-2.31; P = .01), and depression (AOR, 1.58; 95% CI, 1.11-2.24; P = .01) were associated with greater likelihood of persistent CRN. The population-adjusted prevalence of CRN was 53.6% (887 patients).

CONCLUSIONS AND RELEVANCE

The findings suggest that CRN is prevalent, moderately persistent, and variable in the Medicare population at high risk of hospitalization despite coverage by insurance. Longitudinal follow-up and refined predictive modeling of CRN appear to be needed to identify and target more precisely those with persistent CRN and to develop effective interventions.

Asthma-chronic obstructive pulmonary disease overlap and cost-related medication non-adherence among older adults in the United States

BACKGROUND

Cost-related medication non-adherence (CRN) can negatively impact health outcomes in older adults with asthma and chronic obstructive pulmonary disease (COPD) overlap (ACO) by reducing access and adherence to essential medications. The objective of this study is to examine the association of ACO to any CRN and specific forms of CRN among a nationally representative sample of older (age ≥ 65 years) adults.

METHODS

We adopted a cross-sectional study design using data from pooled cross-sectional Medicare Current Beneficiary Surveys (MCBS) (2006-2013) and linked fee-for-service Medicare claims. Unadjusted and adjusted logistic regressions that accounted for the complex survey design examined the association of ACO to any CRN and specific forms of CRN.

RESULTS

Among older adults with ACO, 16% reported any CRN. The most common form of CRN was "failing to get prescription". As compared to older adults with no asthma and no COPD, those with ACO were more likely to report any CRN (adjusted odds ratios [AOR] = 1.50, 95%CI = [1.14, 1.96]) and all forms of CRN. However, when the number of unique medications was added to the model, there were no statistically significant differences in CRN between the two groups.

CONCLUSIONS

Older adults with ACO represent a vulnerable population with increased risk for CRN. Multiple factors can contribute to CRN including: a higher number of prescribed medications, multiple co-morbidities, and cost of therapies. Medication comprehensive review interventions have the potential of reducing the risk of CRN among the older Medicare beneficiaries with ACO.

Association between medication adherence and cardiovascular outcomes among acute coronary syndrome patients

BACKGROUND

Medication adherence to guideline-recommended therapy is important and associated with a lower rate of death and major adverse cardiovascular events (MACE) among patients with acute coronary syndrome (ACS).

OBJECTIVE

This retrospective study aimed to evaluate medication adherence in four classes of guideline-recommended medicines (antiplatelets, ACEIs/ARBs, beta-blockers, and statins) among patients discharged with ACS and to assess the association between patients' adherence to each medication and the occurrence of MACE including all causes of death, myocardial infarction, unstable angina, heart failure, stroke, atrial fibrillation or coronary revascularization.

METHODS

The electronic medical records of patients with ACS admitted at a tertiary teaching hospital in northern Thailand between January 1, 2010 and December 31, 2015 were reviewed. Medication adherence was evaluated from a hospital database of prescription refills using the medication gap technique with ≥90% as a cut-off for full adherence and <90% as partial adherence.

RESULTS

Of 256 patients, the mean age was 65.9 (±13.0) years. The median percentage of medication adherence in the dual antiplatelet group, ACEI/ARB group, beta-blocker group, and statin group were 94.7, 93.6, 93.1, and 93.1%, respectively. Sixty-two patients (24.2%) experienced MACE after a median follow-up of 1.5 years. Patients with ≥90% adherence of beta-blockers had a significantly lower risk of MACE than those with <90% adherence: HR = 0.47, 95% Cl, 0.26-0.87, p = 0.016, adjusted with potential confounders. No other significant associations were observed.

CONCLUSIONS

Medication adherence of each medication was above 90%. ACS patients with at least 90% adherence to beta-blockers had a lower risk of MACE than those having less than 90% adherence, but no other significant associations were found for other medications.

Cost-related Medication Nonadherence and Its Risk Factors Among Medicare Beneficiaries

BACKGROUND

Unaffordability of medications is a barrier to effective treatment. Cost-related nonadherence (CRN) is a crucial, widely used measure of medications access.

OBJECTIVES

Our study examines the current national prevalence of and risk factors for CRN (eg, not filling, skipping or reducing doses) and companion measures in the US Medicare population.

RESEARCH DESIGN

Survey-weighted analyses included logistic regression and trends 2006-2016.

SUBJECTS

Main analyses used the 2016 Medicare Current Beneficiary Survey. Our study sample of 12,625 represented 56 million community-dwelling beneficiaries.

MEASURES

Additional outcome measures were spending less on other necessities in order to pay for medicines and use of drug cost reduction strategies such as requesting generics.

RESULTS

In 2016, 34.5% of enrollees under 65 years with disability and 14.4% of those 65 years and older did not take their medications as prescribed due to high costs; 19.4% and 4.7%, respectively, experienced going without other essentials to pay for medicines. Near-poor older beneficiaries with incomes $15-25K had 50% higher odds of CRN (vs. >$50K), but beneficiaries with incomes <$15K, more likely to be eligible for the Part D Low-Income Subsidy, did not have significantly higher risk. Three indicators of worse health (general health status, functional limits, and count of conditions) were all independently associated with higher risk of CRN.

CONCLUSIONS

Changes in the risk profile for CRN since Part D reflect the effectiveness of targeted policies. The persistent prevalence of CRN and associated risks for sicker people in Medicare demonstrate the consequences of high cost-sharing for prescription fills.

Social capital and cost-related medication nonadherence (CRN): A retrospective longitudinal cohort study using the Health and Retirement Study data, 2006-2016

Prescription drug spending and other financial factors (e.g., out-of-pocket costs) partially explain variation in cost-related medication nonadherence (CRN). Indicators of social capital such as neighborhood factors and social support may influence the health and well-being of older adults as they may rely on community resources and support from family and peers to manage conditions. Previous research on the relationship of social capital and CRN has limited evidence and contradictory findings. Hence, our objective is to assess the relationship of social capital indicators (neighborhood social cohesion, neighborhood physical disorder, positive social support, and negative social support) and CRN using a longitudinal design, 2006 to 2016, in a nationally representative sample of older adults in the United States (US). The Health and Retirement Study is a prospective panel study of US adults aged ≥ 50 years evaluated every two years. Data was pooled to create three waves and fitted using Generalized Estimating Equation modelling adjusting for both baseline and timevarying covariates (age, sex, education, race, total household income, and perceived health status). The three waves consisted of 11,791, 12,336, and 9,491 participants. Higher levels of neighborhood social cohesion and positive social support were related with lower CRN (OR 0.92, 95% CI 0.88-0.95 and OR 0.77, 95% CI 0.70-0.84, p<0.01). In contrast, higher levels of neighborhood physical disorder and negative social support were related to higher CRN (OR 1.07, 95% CI 1.03-1.11 and OR 1.46, 95% CI 1.32-1.62, p<0.01). Interventions targeting social capital are needed, reinforcing positive social support and neighborhood social cohesion and diminishing neighborhood physical disorder and negative social support for older adults.

Patterns of healthcare utilization among patients with sickle cell disease hospitalized with pain crises

Background

Vaso‐occlusive crises (VOC) are the hallmark of sickle cell disease (SCD). Adults experiencing VOC often have high rates of unexpected healthcare utilization. We characterized prior and future healthcare utilization among adults hospitalized with VOC at an urban, academic medical center.

Methods

We identified 449 VOC hospitalizations among 63 patients from 2013 to 2016. Patients were categorized based on receiving established care at the medical center and prior utilization: (a) not established (n = 21); (b) newly established (n = 10); (c) established with low utilization in past 12 months (<4 VOC hospitalizations) (n = 22); and (d) established with high utilization in past 12 months (≥4 VOC hospitalizations) (n = 10). Patient and hospitalization characteristics and future utilization were compared across categories.

Results

Median age was 26 years (Q1 = 22, Q3 = 29) and 55.6% were female. Established patients with high prior utilization tended to have higher median pain scores at admission (10, P = .08). Thirty‐day readmissions were highest in established patients with high prior utilization (P = .06), but 30‐day clinic visits were highest in established patients with low prior utilization (P = .08). Adjusted linear regression found that newly established patients (β = −4.6, P < .01) and established patients with low prior utilization (β = −5.6, P < .01) had fewer VOC hospitalizations in the ensuing 12 months than established patients with high prior utilization.

Conclusion

Among patients with SCD hospitalized for VOC, there was heterogeneity in healthcare utilization, with persistence in utilization over time for some patients. Efforts are needed to shift care from the acute setting to the outpatient clinic, which may lead to improved outcomes.

Association Between Cost-Related Medication Nonadherence and Hypertension Management Among US Adults

BACKGROUND

Medication nonadherence is an important element of uncontrolled hypertension. Financial factors frequently contribute to nonadherence. The objective of this study was to examine the association between cost-related medication nonadherence (CRMN) and self-reported antihypertensive medication use and self-reported normal blood pressure among US adults with self-reported hypertension.

METHODS

Participants with self-reported hypertension from the 2017 National Health Interview Survey were included (n = 7,498). CRMN was defined using standard questions. Hypertension management included: (i) self-reported current antihypertensive medication use and (ii) self-reported normal blood pressure within the past 12 months. Adjusted prevalence and prevalence ratios of hypertension management indicators among those with and without CRMN were estimated.

RESULTS

Overall, 10.7% reported CRMN, 83.6% reported current antihypertensive medication use, and 67.4% reported normal blood pressure within past 12 months. Adjusted percentages of current antihypertensive medication use (88.6% vs. 82.9%, P < 0.001) and self-reported normal blood pressure (69.8% vs. 59.5%, P = 0.002) were higher among those without CRMN compared with those with CRMN. Adjusted prevalence ratios showed that, compared with those with CRMN, those without CRMN were more likely to report current antihypertensive medication use (odds ratio = 1.08, 95% confidence interval 1.04-1.12) and self-reported normal blood pressure (1.15 (1.07-1.23)).

CONCLUSIONS

Among US adults with self-reported hypertension, those without CRMN were more likely to report current antihypertensive medication use and normal blood pressure within the past 12 months. Financial barriers to medication adherence persist and impact hypertension management.

Association of Medication Adherence with Hospital Utilization and Costs Among Elderly with Diabetes Enrolled in a State Pharmaceutical Assistance Program

BACKGROUND

Medication adherence is crucial for the successful treatment among elderly patients with diabetes taking oral antidiabetic medications (OAMs). Cost of medications, lack of insurance coverage, and low income are major contributing factors towards medication nonadherence. State pharmaceutical assistance programs (SPAPs) provide medications at little or no cost to income-eligible patients and have potential to improve medication adherence among elderly patients. Despite this, limited research has focused on the association of medication adherence with health care utilization among elderly patients enrolled in SPAPs, and inclusion of health care costs as an outcome is even rarer.

OBJECTIVE

To evaluate the relationship between adherence to OAMs and hospital utilization and costs among elderly patients with diabetes who were enrolled in a SPAP.

METHODS

This retrospective observational study included elderly patients with diabetes enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PACE) program in 2015. Medication adherence was estimated as the proportion of days covered (PDC; adherent: PDC≥80%, nonadherent: PDC < 80%). Hospital utilization and costs were estimated using hospital discharge records from the Pennsylvania Health Care Cost Containment Council. Multiple adjusted regression analyses were used to examine the association of medication adherence with hospital utilization (all-cause and diabetes-related number of inpatient hospital visits and length of stay [LOS]) and costs.

RESULTS

Among 9,497 elderly PACE enrollees with diabetes, 81% were adherent, and 21% were hospitalized. Compared with adherent patients, patients who were nonadherent to OAMs had twice the odds of all-cause and diabetes-related hospitalization. Controlling for covariates, nonadherent patients had 27% more all-cause (95% CI = 9%-36%) and 21% more diabetes-related (95% CI = 5%-40%) hospital visits than adherent patients. Covariate-adjusted LOS for nonadherent patients was 24% longer than that of adherent patients for all-cause hospitalization (95% CI = 1.171-1.311) and 12.7% longer for diabetes-related hospitalization (95% CI = 1.036-1.227). Medication nonadherence was associated with significantly greater all-cause ($22,670 vs. $16,383; P < 0.0001) and diabetes-related ($13,518 vs. $12,634; P = 0.0003) hospitalization costs.

CONCLUSIONS

Among SPAP-enrolled elderly patients, nonadherence to OAMs was significantly associated with increased risk of hospitalization, longer hospital stays, and greater hospitalization costs. Attention is needed to improve medication adherence among elderly receiving financial assistance to pay their prescriptions to reduce economic burden on the health care system.

DISCLOSURES

No outside funding supported this study. The authors have nothing to disclose.

Pharmacists' Experiences, Perceptions, and Knowledge of Direct-to-Consumer Prescription Coupons

BACKGROUND

Despite widespread use of manufacturer-sponsored prescription drug coupons and pharmacy network discount cards (i.e., direct-to-consumer prescription coupons), little is known about community pharmacists' experiences, perceptions, and knowledge of coupon cards.

OBJECTIVE

To identify community pharmacists' experiences, perceptions, and knowledge of prescription coupons.

METHODS

An 11-item telephonic survey was conducted from August 2018 to March 2019. Eligible respondents included English-speaking pharmacists employed during the survey period in a community pharmacy physically located in Connecticut. Data were analyzed via descriptive statistics and one-way analysis of variance (ANOVA). One-way ANOVAs were conducted to test the relationship between the respondents' practice types, the average daily volume of coupons processed, and the average time needed to process each coupon. The responses were based on a 5-point Likert scale and dichotomized to enable interpretation of the results.

RESULTS

There were 240 surveys completed from an eligible pool of 691 community pharmacy sites (34.7% response rate). Respondents representing 60 different businesses located across 123 of the state's 282 major ZIP codes, representing 83.5% of the state's population. Respondents overwhelmingly held positive perceptions of the ability of prescription coupons to increase patients' medication access (91.7 %) and reduce out-of-pocket costs (93.3%). However, respondents also believed patients have trouble paying for prescriptions once coupons expire (70.8%). When questioned about privacy practices, 57.5% of respondents believed that it is illegal to "sell patients' information" (i.e., with no distinction made between protected health information and any other information), while another 25.8% declined to answer, citing they did not know. Only 20.8% (n = 50) of respondents knew that community pharmacies could see lowered reimbursement from accepting network drug discount cards, and 40.4% (n = 97) knew that pharmaceutical manufacturers can cover the difference in patients' copay costs. Approximately 10% of respondents believed (incorrectly) that discounts from pharmacy network discount cards were covered via patients' prescription insurance and/or the third-party discount card vendor companies (7.9% and 3.3%, respectively). Respondents believed patients received prescription coupons most often from the internet or mail (77.1%), their prescribers (62.9%), or from their own community pharmacies (33.3%). Finally, on average, respondents processed 14.6 (SD 19.8) coupons per day and required 4.8 (SD 4.3) minutes for each claim.

CONCLUSIONS

As far as we know, this is the first exploration of community pharmacists' experiences, perceptions, and knowledge of direct-to-consumer prescription coupons. Results show that, while community pharmacists overwhelmingly hold positive perceptions towards prescription coupons and drug discount cards, there is an opportunity to increase general understanding of the differences in business practices between manufacturer-sponsored prescription drug coupons and pharmacy network discount cards. Community pharmacies also spend a significant amount of time processing coupon claims.

DISCLOSURES

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors declare no relevant conflicts of interest or financial relationships. This study was presented as a poster at the 2019 American Society of Health Systems Pharmacists Midyear Clinical Meeting during December 8-12, 2019, in Las Vegas, NV.

Unfilled Prescriptions of Medicare Beneficiaries: Prevalence, Reasons, and Types of Medicines Prescribed

BACKGROUND

Despite the proven efficacy of prescription regimens in reducing disease symptoms and preventing or minimizing complications, poor medication adherence remains a significant public health problem. Medicare beneficiaries have high rates of chronic illness and prescription medication use, making this population particularly vulnerable to nonadherence. Failure to fill prescribed medication is a key component of nonadherence.

OBJECTIVES

To (1) determine the rates of self-reported failure to fill at least 1 prescription among a sample of Medicare beneficiaries in 2004, (2) identify the reasons for not filling prescribed medication, (3) examine the characteristics of Medicare beneficiaries who failed to fill their prescription(s), and (4) identify the types of medications that were not obtained.

METHODS

The study is a secondary analysis of the 2004 Medicare Current Beneficiary Survey (MCBS), an ongoing national panel survey conducted by the Centers for Medicare & Medicaid Services (CMS). Medicare beneficiaries living in the community (N = 14,464) were asked: "During the current year [2004], were there any medicines prescribed for you that you did not get (please include refills of earlier prescriptions as well as prescriptions that were written or phoned in by a doctor)?" Those who responded "yes" to this question (n = 664) were asked to identify the specific medication(s) not obtained. Rates of failure to fill were compared by demographic and income categories and for respondents with versus without self-reported chronic conditions, identified by asking respondents if they had ever been told by a doctor that they had the condition. Weighted population estimates for nonadherence were calculated using Professional Software for SUrvey DAta ANalysis for Multi-stage Sample Designs (SUDAAN) to account for the MCBS multistage stratified cluster sampling process. Unweighted counts of the prescriptions not filled by therapeutic class were calculated using Statistical Analysis Software (SAS).

RESULTS

In 2004, an estimated 1.6 million Medicare beneficiaries (4.4%) failed to fill or refill 1 or more prescriptions. The most common reasons cited for failure to fill were: "thought it would cost too much" (55.5%), followed by "medicine not covered by insurance" (20.2%), "didn't think medicine was necessary for the condition" (18.0%), and "was afraid of medicine reactions/contraindications" (11.8%). Rates of failure to fill were significantly higher among Medicare beneficiaries aged 18 to 64 years eligible through Social Security Disability Insurance (10.4%) than among beneficiaries aged 65 years or older (3.3%, P < 0.001). Rates were slightly higher for women than for men (5.0 vs. 3.6%, P = 0.001), for nonwhite than for white respondents (5.5% vs. 4.2%, P = 0.010), and for dually eligible Medicaid beneficiaries than for those who did not have Medicaid coverage (6.3% vs. 4.0% P = 0.001). Failure-to-fill rates were significantly higher among beneficiaries with psychiatric conditions (8.0%, P < 0.001); arthritis (5.2%, P < 0.001); cardiovascular disease (5.2%, P = 0.003); and emphysema, asthma, or chronic obstructive pulmonary disease (6.6%, P < 0.001) than among respondents who did not report those conditions, and the rate for respondents who reported no chronic conditions was 2.5%. Rates were higher for those with more self-reported chronic conditions (3.2%, 4.0%, 4.3%, and 5.9% for those with 1, 2, 3, and 4 or more conditions, respectively, P < 0.001). Among the prescriptions not filled (993 prescriptions indentified by 664 respondents), central nervous system agents, including nonsteroidal anti-inflammatory drugs, were most frequently identified (23.6%, n = 234), followed by cardiovascular agents (18.3%, n = 182) and endocrine/metabolic agents (6.5%, n = 65). Of the reported unfilled prescriptions, 8.1% were for antihyperlipidemic agents, 5.4% were for antidepressant drugs, 4.6% were for antibiotics, and 29.9% were for unidentified therapy classes.

CONCLUSION

Most Medicare beneficiaries fill their prescriptions, but some subpopulations are at significantly higher risk for nonadherence associated with unfilled prescriptions, including working-age beneficiaries, dual-eligible beneficiaries, and beneficiaries with multiple chronic conditions. Self-reported unfilled prescriptions included critical medications for treatment of acute and chronic disease, including antihyperlipidemic agents, antidepressants, and antibiotics.

DISCLOSURES

This study was funded by the U.S. Department of Education's National Institute on Disability and Rehabilitation Research, Field Initiated Research Grant H133G070055. However, the analysis and the interpretation of these findings do not necessarily represent the policy of the Department of Education and are not endorsed by the federal government. All authors contributed approximately equally to the study concept and design. Tuleu performed the majority of the data collection, with assistance from Kennedy. Kennedy interpreted the data, with assistance from Tuleu and Mackay. Kennedy and Mackay wrote the majority of the manuscript, with assistance from Tuleu. Kennedy made the majority of the changes in revision of the manuscript.

The Affordable Care Act and access to care across the cancer control continuum: A review at 10 years

Lack of health insurance coverage is strongly associated with poor cancer outcomes in the United States. The uninsured are less likely to have access to timely and effective cancer prevention, screening, diagnosis, treatment, survivorship, and end-of-life care than their counterparts with health insurance coverage. On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law, representing the largest change to health care delivery in the United States since the introduction of the Medicare and Medicaid programs in 1965. The primary goals of the ACA are to improve health insurance coverage, the quality of care, and patient outcomes, and to maintain or lower costs by catalyzing changes in the health care delivery system. In this review, we describe the main components of the ACA, including health insurance expansions, coverage reforms, and delivery system reforms, provisions within these components, and their relevance to cancer screening and early detection, care, and outcomes. We then highlight selected, well-designed studies examining the effects of the ACA provisions on coverage, access to cancer care, and disparities throughout the cancer control continuum. Finally, we identify research gaps to inform evaluation of current and emerging health policies related to cancer outcomes.

Risk Factors Associated With Food Insecurity in the Medicare Population

This analysis of survey data presents national estimates of food insecurity prevalence within the Medicare population.

Medication Burden for Patients With Bacterial Keratitis

PURPOSE

To understand medication use and patient burden for treatment of bacterial keratitis (BK).

METHODS

A retrospective study was conducted examining medical records of adult patients with BK in an academic cornea practice. Data collected included medications used in the treatment of BK, dosing of medications, and the number and total duration of clinical encounters. Costs of medications were estimated using the average wholesale pharmacy price. Linear regression analysis was used to investigate associations of medication use with patient demographics and corneal culture results and reported with beta estimates (β) and 95% confidence intervals (95% CIs).

RESULTS

Forty-eight patients with BK (56% female) were studied. Patients were treated for a median of 54 days with 10 visits, 5 unique medications, 587 drops, and 7 prescriptions. The estimated median medication cost was $933 (interquartile range: $457-$1422) US dollars. Positive bacterial growth was significantly associated with more visits (β: 6.16, 95% CI: 1.75-10.6, P = 0.007), more days of treatment (β: 86.8, 95% CI: 10.8-163, P = 0.026), more prescribed medications (β: 2.86, 95% CI: 1.04-4.67, P = 0.003), and more doses of medications (β: 796, 95% CI: 818-1412, P = 0.012) compared with patients who did not undergo corneal scraping. Patients were prescribed 132 more drops of medication for every 10 years of older age (β: 132, 95% CI: 18.2-246, P = 0.024). Sex and income were not associated with medication burden or treatment length.

CONCLUSIONS

Older patients and those with positive cultures incur the most medication burden in treatment of BK. Providers should be aware of medication usage and cost burden as it may affect compliance with treatment.

An Adapted Model of Cost-Related Nonadherence to Medications Among People With Disabilities

Despite emerging evidence on cost-related nonadherence (CRNA) to prescription medications, there is little conceptualization and exploration of this phenomenon with respect to disability. Specifically, there is a gap in the literature that explores factors influencing medication cost–adherence relationship among individuals living with a disability. To advance research on and policy for CRNA to medications among people with disabilities, we need a framework that can contribute towards guiding solutions to this problem. We examined the applicability of Piette and colleagues’ existing model for CRNA to the context of people with disabilities and suggested an adapted model (CRNA to medications for persons with disability [CRNA-d]) that can provide a more specific conceptualization of CRNA with respect to disability. The adapted CRNA-d model depicts that CRNA to prescription medications with respect to disability is a dynamic and multifaceted phenomenon, determined by various socioeconomic, disability-related, medication-related, prescriber-related, and system-related factors. We discuss how higher susceptibility to health complications, barriers to income and employment, additional health care costs, the complexity of medical regimens, limited access to physician services, and other policy-related factors increase the risk of persons with disabilities to face cost-related barriers to fulfill their necessary medications.

Cost-Related Medication Nonadherence and Cost-Reduction Strategies Among Elderly Cancer Survivors with Self-Reported Symptoms of Depression

How depression affects the medication cost burden for elderly cancer survivors has not been well studied. This study aims to investigate whether depression is associated with higher rates of cost-related medication nonadherence, and cost-reduction strategies among the elderly cancer survivors. Self-reports from survey files of the 2015 Medicare Current Beneficiary Survey-Medicare database were used to identify elderly cancer patients aged 65 years and older with and without depression. The 2 outcomes were cost-related nonadherence (CRN) and adoption of cost-reduction strategies. Bivariate analysis was used to describe the sample. Multivariable logistic regression was performed to examine the impact of depression on CRN and the use of cost-reduction strategies, after controlling for all other covariates. Among the 3765 elderly cancer survivors identified, 523 (14%) reported depression. In the group with depression, 26% reported CRN compared with 12% of the group without depression; 71% of individuals with depression reported having cost-reduction strategies while 65% of individuals with no depression reported such activity. In adjusted analyses, individuals with depression were significantly more likely to report CRN (adjusted odds ratio, 1.84; 95% confidence interval 1.33-2.54) and cost-reduction strategies (adjusted odds ratio, 1.37; 95% confidence interval, 1.07-1.76). Depression was associated with higher probabilities of both CRN and the adoption of cost-reduction strategies, indicating that depression can exacerbate the medication cost burden for elderly cancer survivors. It is important to detect and manage depression in elderly cancer survivors to reduce CRN and cost-reduction strategies.

Addressing Medication Costs During Primary Care Visits: A Before-After Study of Team-Based Training

BACKGROUND

Medications contribute to patients' out-of-pocket costs, yet most clinicians do not routinely screen for patients' cost-of-medication (COM) concerns.

OBJECTIVE

To assess whether a single training session improves COM conversations.

DESIGN

Before-after cross-sectional surveys of patients and qualitative interviews with clinicians and staff.

SETTING

7 primary care practices in 3 U.S. states.

PARTICIPANTS

In total, 700 patients were surveyed from May 2017 to January 2018: 50 patients per practice before the intervention and another 50 patients per practice after the intervention. Eligibility criteria included age 18 years or older and taking 1 or more long-term medications. Qualitative interviews with 45 staff members were conducted.

INTERVENTION

A single 60-minute training session for clinicians and staff from each practice on COM importance, team-based screening, and cost-saving strategies.

MEASUREMENTS

Patient data (demographics, number of long-term medications, total monthly out-of-pocket medication costs, and history of cost-related medication nonadherence) were obtained immediately before and 3 months after the intervention. Practice staff were interviewed 3 months after the intervention.

RESULTS

A total of 700 patient surveys were completed. Frequency of COM discussion improved in 6 of the 7 practices and remained unchanged in 1 practice. Overall, COM conversations with patients increased from 17% at baseline to 32% postintervention (P = 0.00). There was substantial heterogeneity among sites in before-after differences in patient-reported out-of-pocket COM. Qualitative analyses from key informant interviews showed wide variation in implementation of screening approaches, workflow, adoption of a team-based approach, and strategies for addressing COM.

LIMITATION

It is not known whether improvements in COM conversations were sustained beyond 3 months.

CONCLUSION

A single team training to screen and address patients' medication cost concerns improved COM discussions over the short term. Further research is needed to assess sustained effects and impact on patient costs and medication adherence and to determine whether more intensive, scalable interventions are needed.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation.

Cost-related Nonadherence to Medication Treatment Plans: Native Hawaiian and Pacific Islander National Health Interview Survey, 2014

BACKGROUND

Adherence to medication treatment plans is important for chronic disease (CD) management. Cost-related nonadherence (CRN) puts patients at risk for complications. Native Hawaiians and Pacific Islanders (NHPI) suffer from high rates of CD and socioeconomic disparities that could increase CRN behaviors.

OBJECTIVE

Examine factors related to CRN to medication treatment plans within an understudied population.

RESEARCH DESIGN

Using 2014 NHPI-National Health Interview Survey data, we examined CRN among a nationally representative sample of NHPI adults. Bonferroni-adjusted Wald test and multivariable logistic regression were performed to examine associations among financial burden-related factors, CD status, and CRN.

RESULTS

Across CD status, NHPI engaged in CRN behaviors had, on an average, increased levels of perceived financial stress, financial insecurity with health care, and food insecurity compared with adults in the total NHPI population. Regression analysis indicated perceived financial stress [adjusted odds ratio (AOR)=1.16; 95% confidence intervals (CI), 1.10-1.22], financial insecurity with health care (AOR=1.96; 95% CI, 1.32-2.90), and food insecurity (AOR=1.30; 95% CI, 1.06-1.61) all increase the odds of CRN among those with CD. We also found significant associations between perceived financial stress (AOR=1.15; 95% CI, 1.09-1.20), financial insecurity with health care (AOR=1.59; 95% CI, 1.19-2.12), and food insecurity (AOR=1.31; 95% CI, 1.04-1.65) and request for lower cost medication.

CONCLUSIONS

This study demonstrated health-related and non-health-related financial burdens can influence CRN behaviors. It is important for health care providers to collect and use data about the social determinants of health to better inform their conversations about medication adherence and prevent CRN.

Attitudes, Beliefs, and Cost-Related Medication Nonadherence Among Adults Aged 65 or Older With Chronic Diseases

INTRODUCTION

Cost-related medication nonadherence (CRN) can negatively affect chronic disease prevention and management in an aging population. Limited data are available on the interacting influences among such factors as availability of financial resources, attitudes and beliefs of patients, and CRN. The objective of this study was to examine the causal paths among financial resource availability, patient attitudes and beliefs, and CRN.

METHODS

We used a nationally representative sample (n = 4,818) from the 2015 National Health Interview Survey; selected respondents were aged 65 or older, had a diagnosis of hypertension or diabetes or both, and were prescribed medication for at least 1 of these conditions. We performed structural equation modeling to examine whether perceived medication affordability, access to health care, and patient satisfaction influenced the effects of financial resource availability on CRN (skipped doses, took less medicine, or delayed filling a prescription to save money).

RESULTS

Six percent of respondents reported CRN in the previous 12 months. The model showed a good to fair fit, and all paths were significant (P < .05) except for age. The effects of financial resource availability on CRN was mediated through perceived medication affordability, access to health care, and patient satisfaction with health care services.

CONCLUSION

This study suggests that patients' attitudes and beliefs can mediate the effects of financial resource availability on CRN. We call for senior-friendly public health interventions that can address these modifiable barriers to reduce CRN among older adults with chronic conditions.

Patterns of borrowing to finance out-of-pocket prescription drug costs in Canada: a descriptive analysis

BACKGROUND

Out-of-pocket drug costs lead many Canadians to engage in cost-related nonadherence to prescription medications, but our understanding of other consequences such as borrowing money remains incomplete. In this descriptive study, we sought to quantify the frequency of borrowing to pay for prescription drugs in Canada and characteristics of Canadians who borrowed money for this purpose.

METHODS

In partnership with Statistics Canada, we designed and administered a cross-sectional rapid-response module in the Canadian Community Health Survey administered by telephone to Canadians aged 12 years or more between January and June 2016. We restricted our analyses to participants who responded to the question regarding borrowing money to pay for prescription drugs and used logistic regression to identify characteristics associated with borrowing.

RESULTS

A total of 28 091 Canadians responded to the survey (overall response rate 61.8%). The weighted proportion of respondents who reported having borrowed money to pay for prescription drugs in the previous year was 2.5% (95% confidence interval 2.2%-2.8%), an estimated 731 000 Canadians. The odds of borrowing were higher among younger adults, people in poor health and people lacking prescription drug insurance. Other factors associated with increased adjusted odds of borrowing were having 2 or more chronic conditions, low household income and higher out-of-pocket prescription drug costs.

INTERPRETATION

Many Canadians reported borrowing money to pay for out-of-pocket prescription drug costs, and borrowing was more prevalent among already vulnerable groups that also report other compensatory behaviours to address challenges in paying for prescription drugs. Future research should investigate policy responses intended to increase equity in access to prescription drugs.

Identifying and Understanding Barriers and Facilitators to Medication Adherence Among Marshallese Adults in Arkansas

Background: Significant health disparities are present in Marshallese adults residing in the United States, most notably a high incidence of type 2 diabetes and other chronic conditions. There is limited research on medication adherence in the Marshallese population. Objective: This study explored perceptions of and experiences with medication adherence among Marshallese adults residing in Arkansas, with the aim of identifying and better understanding barriers and facilitators to medication adherence. Methods: Eligible participants were Marshallese adults taking at least one medication for a chronic health condition. Each participant completed a brief survey and semistructured interview conducted in Marshallese by a bilingual Marshallese staff member. Interviews were recorded, transcribed, and translated from Marshallese to English. Qualitative data were coded for a priori and emergent themes. Results: A total of 40 participants were included in the study. The most common contributing factor for nonadherence was forgetting to take medication (82%). A majority of participants (70%) reported difficulty paying for medicine, 45% reported at least one form of cost-related nonadherence, and 40% engaged in more than one cost-related nonadherence practice. Family support and medication pill boxes were identified as facilitators for medication adherence. The majority of the participants (76.9%) stated that they understood the role of a pharmacist. Participants consistently desired more education on their medications from pharmacy providers. Conclusion: This is the first study to explore barriers and facilitators to medication adherence among Marshallese patients. The findings can be used to develop methods to improve medication adherence among Marshallese.

Food Preferences and Coping Strategies among Diabetic and Nondiabetic Households Served by US Food Pantries

Limited access to healthy food caused by food insecurity makes diabetes mellitus (DM) self-management more challenging. Using data from Hunger in America 2014 (n = 60,122 US food pantry users), we sought to understand food preferences and coping strategy utilization (e.g. choosing between paying for food and medical care) among households seeking assistance from US food pantries with and without DM members. The prevalence of wanting and not obtaining fruits, vegetables, dairy, and protein was high among all households. After adjusting for sociodemographic characteristics, households with DM members were more likely to want and not obtain fruits, vegetables, and dairy, and were also more likely to use several coping strategies to increase food access, compared to households without DM members. These results highlight the high demand for healthy food items among clients from US food pantries, particularly among households with DM, as well as the extra burden DM may place on food insecure households.

Awareness of the Medicare Part D Low-Income Subsidy among Older non-Hispanic Blacks and Hispanics

Using nationally representative data from the Health and Retirement Study, this study examined (1) whether awareness of the Medicare Part D Low-Income Subsidy (LIS) varies by race and ethnicity among beneficiaries age 65 and older (N = 1,504), and (2) the impact of factors associated with health benefits knowledge and need for assistance on LIS awareness. Logistic regression results showed that compared with older non-Hispanic Whites, older non-Hispanic Blacks (odds ratio [OR] = .61, p < .001) and Hispanics (OR = .55, p < .01) were less likely to be aware of the LIS. Ethnic differences in LIS awareness were largely explained by language or Spanish-speaking preference (OR = 1.07, p = .808). However, accounting for demographics, health and socioeconomic status, and language did not reduce racial disparities (OR = .63, p < .01). Differences in LIS awareness among racial and ethnic minority groups highlight the need for culturally and linguistically sensitive community-based education, communication, programs, and services that increase knowledge of and access to this critical support.

The consequences of patient charges for prescription drugs in Canada: a cross-sectional survey

BACKGROUND

Many Canadians face substantial out-of-pocket charges for prescription drugs. Prior work suggests that this causes some patients to not take their medications as prescribed; however, we have little understanding of whether charges for prescription medicines lead patients to forego basic needs or to use more health care services. Our study aimed to quantify the consequences of patient charges for medicines in Canada.

METHODS

As part of the 2016 Canadian Community Health Survey, we designed and fielded cross-sectional questions to 28 091 Canadians regarding prescription drug affordability, consequent use of health care services and trade-offs with other expenditures. We calculated weighted population estimates and proportions, and used logistic regression to determine which patient characteristics were associated with these behaviours.

RESULTS

Overall, 5.5% (95% confidence interval 5.1%-6.0%) of Canadians reported being unable to afford 1 or more drugs in the prior year, representing 8.2% of those with at least 1 prescription. Drugs for mental health conditions were the most commonly reported drug class for cost-related nonadherence. About 303 000 Canadians had additional doctor visits, about 93 000 sought care in the emergency department, and about 26 000 were admitted to hospital at the population level. Many Canadians forewent basic needs such as food (about 730 000 people), heat (about 238 000) and other health care expenses (about 239 000) because of drug costs. These outcomes were more common among females, younger adults, Aboriginal peoples, those with poorer health status, those lacking drug insurance and those with lower income.

INTERPRETATION

Out-of-pocket charges for medicines for Canadians are associated with foregoing prescription drugs and other necessities as well as use of additional health care services. Changes to protect vulnerable populations from drug costs might reduce these negative outcomes.

Understanding the patient experience of cost-related non-adherence to prescription medications through typology development and application

Many patients report skipping doses, splitting pills, or not filling prescriptions due to out-of-pocket costs-a phenomenon known as cost-related non-adherence (CRNA). This study investigated CRNA from the patient's perspective, and, to our knowledge, is the first study to undertake a qualitative investigation of CRNA specifically. We report the results from 35 semi-structured interviews conducted in 2014-15 with adults in four Canadian cities across two provinces. We used framework analysis to develop a CRNA typology to characterize major factors in patients' CRNA decisions. Our typology identifies four major components: (1) the insurance reason driving the drug cost, (2) the individual's overall financial flexibility, (3) the burden of drug cost on the individual's budget, and (4) the importance of the drug from the individual's perspective. The first two components set the context for CRNA and the final two components are the drivers for the CRNA decision. We also found four major patterns in CRNA experiences: (1) CRNA in individuals with low financial flexibility occurred for all levels of drug importance and all but the lowest level of cost burden; (2) CRNA for high importance drugs only occurred when the drug cost had a high burden on an individual's budget; (3) CRNA in individuals with more financial flexibility primarily occurred in drugs with medium importance but high or very high cost burdens; and (4) CRNA for low importance drugs occurred at almost all levels of drug cost burden. Our study furthers the understanding of how numerous factors such as income, insurance, and individual preferences combine and interact to influence CRNA and suggests that policy interventions must be multi-faceted or encourage significant insurance redesign to reduce CRNA.

Cultural and emotional determinants of cervical cancer screening among older Hispanic women

Older adults are at highest risk of cancer and yet have the lowest rates of cancer screening participation. Older minority adults bear the burden of cancer screening disparities leading to late stage cancer diagnoses. This investigation, utilization data from the 2008 wave of the Health and Retirement study examined the cultural and emotional factors thought to influence cervical cancer screening among older Hispanic women. We utilized logistic regression models to conduct the analyses. Findings indicate that the emotional factors were not significant but the cultural factor, time orientation was a significant predictor for older Hispanics' cervical cancer screening behaviors.

Social considerations of inflammatory bowel disease in Southern Israel

Chronic diseases pose unique social challenges beyond traditional health considerations that require specific attention. In this report, we examine the case of a middle-aged woman with ulcerative colitis, living in Southern Israel. Trust between the patient and physician is shown to positively influence a variety of therapeutic outcomes and should be considered a fundamental component of successful care. In context of the military conflict between Israel and Gaza, the needs of patients with chronic diseases cannot be forgotten. The work environment is also identified as an area of particular concern, as a supportive work environment is essential in order to maintain satisfaction in the workplace and sustain a high quality of life. Out-of-pocket costs for medications are confirmed to be a significant barrier to adherence. Better understanding of patients’ financial capabilities, along with affordable therapeutic interventions, will alleviate healthcare-related financial burdens and improve health outcomes.

The differential rates in cost-related non-adherence to medical care by gender in the US adult population

BACKGROUND

Cost-related non-adherence (CRN) to medical care is a persistent challenge in healthcare in the US. Gender is a key determinant of many healthcare behaviors and outcomes. Understanding variation in CRN by gender may provide opportunities to reduce disparities and improve outcomes.

AIMS

This study aims to examine the differential rates in CRN by gender across a spectrum of socio-economic factors among the adult population in the US.

METHOD

Data from the 2015 National Financial Capability Study (NFCS) were used for this study. CRN is identified if a respondent indicated not filling a prescription for medicine because of the cost and/or skipping a medical test, treatment, or follow-up recommended by a doctor because of the cost in the past 12 months. The differential rates in CRN by gender were assessed across socio-economic strata. A multivariable logistic regression analysis was performed to evaluate the difference in CRN rates by gender, controlling for potential confounders.

RESULTS

A total of 26,287 adults were included in the analyses. Overall, the weighted CRN rate in the adult population is 19.8% for men and 26.2% for women. There was a clear pattern of differential rates in CRN across socio-economic strata by gender. Overall, men were less likely to report CRN (AOR = 0.74; 95% CI = 0.69-0.79), controlling for other risk factors.

CONCLUSIONS

More research is needed to understand the behavioral aspects of gender difference in CRN. Patient-centered healthcare needs to take gender difference into account when addressing cost-related non-adherence behavior.

Closing the Medicare Doughnut Hole: Changes in Prescription Drug Utilization and Out-of-Pocket Spending Among Medicare Beneficiaries With Part D Coverage After the Affordable Care Act

BACKGROUND

The Affordable Care Act (ACA) include provisions that reduce beneficiaries' cost sharing and eventually closes the coverage gap-known as the "doughnut hole"-that was originally part of Medicare prescription drug coverage implemented in 2006.

OBJECTIVES

This study examines changes in overall prescription drug utilization and out-of-pocket spending as well as by manufacturer type (brand vs. generic), through 2013 as a result of the doughnut hole provisions of the ACA.

MATERIALS AND METHODS

This analysis is based on data from Medical Expenditure Panel Survey and the sample for this analysis includes all individuals 55 years of age and older. A difference-in-differences methodology was adopted to measure changes in drug utilization and out-of-pocket spending among both the treatment group and the comparison group after the ACA.

RESULTS

The findings from this study suggest that overall out-of-pocket spending significantly decreased after closing the coverage gap, mainly because of a significant reduction in out-of-pocket spending on brand-name drugs. Conversely, the results show that generic drug utilization increased after closing the coverage gap. As expected, the effects were considerably larger for people who fell into the doughnut hole.

CONCLUSIONS

The ACA doughnut hole provisions likely contributed to a reduction in out-of-pocket spending for prescription drugs for part D beneficiaries, especially for people who fell into the doughnut hole.