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Yang HY, Song ZS, Collins JE, Losina E. Impact of depressive symptoms on direct medical cost among medicare recipients with knee osteoarthritis. Osteoarthritis Cartilage 2024; 32:922-930. [PMID: 38710438 DOI: 10.1016/j.joca.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 12/19/2023] [Accepted: 12/28/2023] [Indexed: 05/08/2024]
Abstract
OBJECTIVE Depressive symptoms are prevalent among knee osteoarthritis (KOA) patients and may lead to additional medical costs. We compared medical costs in Medicare Current Beneficiary Survey (MCBS) respondents with KOA with and without self-reported depressive symptoms. METHODS We identified a KOA cohort using ICD-9/10 diagnostic codes in both Part A and Part B claims among community-dwelling MCBS respondents from 2003 to 2019. We determined the presence of depressive symptoms using self-reported data on sadness or anhedonia. We considered three groups: 1) without depressive symptoms, 2) with depressive symptoms, no billable services, and 3) with depressive symptoms and billable services. We used a generalized linear model with log-transformed outcomes to compare annual total direct medical costs among the three groups, adjusting for age, gender, race, history of fall, Total Joint Replacement, comorbidities, and calendar year. RESULTS The analysis included 4118 MCBS respondents with KOA. Of them, 27% had self-reported depressive symptoms, and 6% reported depressive symptoms and received depression-related billable services. The adjusted mean direct medical costs were $8598/year for those without depressive symptoms, $9239/year for those who reported depressive symptoms and received no billable services, and $14,229/year for those who reported depressive symptoms and received billable services. CONCLUSION While over one quarter of Medicare beneficiaries with KOA self-reported depressive symptoms, only 6% received billable medical services. The presence of depressive symptoms led to higher direct medical costs, even among those who did not receive depression-related billable services.
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Affiliation(s)
- Heidi Y Yang
- Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA, United States
| | - Zoey S Song
- Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA, United States
| | - Jamie E Collins
- Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Elena Losina
- Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, United States; Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States.
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Mindlis I, Revenson TA, Erblich J, Fernández Sedano B. Multimorbidity and Depressive Symptoms in Older Adults: A Contextual Approach. THE GERONTOLOGIST 2023; 63:1365-1375. [PMID: 36516464 DOI: 10.1093/geront/gnac186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Among older adults, depressive symptoms increase with each chronic illness; however, specific disease-related stressors (e.g., pain) and contextual moderators (interpersonal, sociocultural, temporal) of this relationship remain understudied. We explored disease-related stressors associated with depressive symptoms and moderating effects of contextual factors on this relationship, guided by a social ecological framework. RESEARCH DESIGN AND METHODS Adults ≥62 years with multimorbidity (n = 366) completed validated scales assessing diagnoses, disease-related stressors (pain intensity, subjective cognitive function, physical function, somatic symptoms), and depressive symptoms. Moderators included age, expectations regarding aging, perceived social support, and difficulty affording medications. Data were analyzed using structural equation modeling. RESULTS Participants were 62-88 years old, with several comorbidities (M = 3.5; range: 2-9). As hypothesized, disease-related stressors were associated with depressive symptoms (b = 0.64, SE = 0.04, p < .001). The effect of disease-related stressors on depressive symptoms was greater among those reporting low social support (B = 0.70, SE = 0.06, p < .001) than for those reporting high social support (B = 0.46, SE = 0.06, p < .001). The negative effect of disease-related stressors on depressive symptoms was stronger for those with poorer expectations of aging (B = 0.68, SE = 0.07, p < .001), compared to those with more positive expectations (B = 0.47, SE = 0.06, p < .001). Age and difficulties affording medications were not significant moderators. DISCUSSION AND IMPLICATIONS Garnering social support and addressing low expectations for aging may prevent the detrimental effect of multimorbidity on mental health.
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Affiliation(s)
- Irina Mindlis
- Psychology Program, The Graduate Center, City University of New York, New York City, New York, USA
| | - Tracey A Revenson
- Psychology Program, The Graduate Center, City University of New York, New York City, New York, USA
- Psychology Department, Hunter College, City University of New York, New York City, New York, USA
| | - Joel Erblich
- Psychology Program, The Graduate Center, City University of New York, New York City, New York, USA
- Psychology Department, Hunter College, City University of New York, New York City, New York, USA
| | - Brandon Fernández Sedano
- Psychology Department, Hunter College, City University of New York, New York City, New York, USA
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Park C, Chang CCA, Ng BP, Young GJ. Cost-related medication nonadherence among Medicare beneficiaries with cardiovascular disease risk factors: The role of comprehension of the Medicare programme and its prescription drug benefits. J Eval Clin Pract 2023; 29:136-145. [PMID: 35982538 DOI: 10.1111/jep.13745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 06/14/2022] [Accepted: 07/01/2022] [Indexed: 01/18/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES This study aims to investigate how reported comprehension of the Medicare programme and its prescription drug benefits is associated with cost-related medication nonadherence (CRN) among Medicare beneficiaries with cardiovascular disease (CVD) risk factors. METHODS This cross-sectional study used the 2017 Medicare Current Beneficiary Survey Public Use File data and included Medicare beneficiaries aged ≥65 years who reported having at least one CVD risk factor (i.e., hypertension, hyperlipidemia, diabetes, smoking and obesity) (n = 2821). A survey-weighted logistic model was used to examine associations between perceived difficulty of understanding the Medicare programme and its prescription drug benefits and CRN, controlling for beneficiaries' demographic (e.g., age) and clinical characteristics (e.g, comorbidities). This study further analyzed five subgroups based on the type of CVD risk factors involved. RESULTS Among Medicare beneficiaries with CVD risk factors, 14.4% reported CRN. Medicare beneficiaries with CVD risk factors who reported difficulty understanding the overall Medicare programme and its prescription drug benefits were more likely to report CRN, compared to those who reported easy understanding of the overall Medicare programme (OR = 1.50; 95% CI = 1.11-2.04; p = 0.009) and its prescription drug benefits (OR = 2.01; 95% CI = 1.52-2.66; p < 0.001). Similar results were obtained for the subgroups with obesity, hypertension or hyperlipidemia. CONCLUSIONS Perceived difficulty of understanding the Medicare Programme and its prescription drug benefits is associated with CRN among Medicare beneficiaries with CVD risk factors, especially those with obesity, hypertension or hyperlipidemia. Monitoring and enhancing Medicare beneficiaries' overall understanding of the Medicare programme may reduce CRN.
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Affiliation(s)
- Chanhyun Park
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
| | - Chiu-Chi Angela Chang
- D'Amore-McKim School of Business, Northeastern University, Boston, Massachusetts, USA
| | - Boon Peng Ng
- College of Nursing, University of Central Florida, Orlando, Florida, USA.,Disability, Aging, and Technology Cluster, University of Central Florida, Orlando, Florida, USA
| | - Gary J Young
- D'Amore-McKim School of Business, Northeastern University, Boston, Massachusetts, USA.,Center for Health Policy and Healthcare Research, Northeastern University, Boston, Massachusetts, USA.,Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts, USA
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Green M, Resnicow K, Tariq M, Syed N, Alhawli A, Patel M. Risk and Protective Factors for Cost-Related Nonadherence Among Middle East and North African (MENA) Adults. Ethn Dis 2022; 32:11-20. [PMID: 35106040 PMCID: PMC8785864 DOI: 10.18865/ed.32.1.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
OBJECTIVE Cost-related nonadherence to health maintenance behaviors is common in the general population, yet we know little about these behaviors in Middle East and North African (MENA) Americans. We examined cost-related nonadherence (CRN) in the MENA community in SE Michigan to determine demographic predictors, and risk and protective factors. DESIGN SETTING AND PARTICIPANTS We used data from a cross-sectional convenience sample of MENA adults (N=398) conducted May-September 2019 to identify relevant demographic predictors, as well as the association between individual health, social, and clinical factors and the likelihood of reporting CRN. METHODS AND MEASURES CRN was defined by whether respondents reported any of the following: that they took less medicine, skipped doses, or delayed getting a prescription filled. Other factors included patient/provider communication and racial concordance, mental health distress, food insecurity and insurance status. We used multivariable logistic regression models to determine association of these health and social factors with CRN. RESULTS Those with highest incomes were least likely to report CRN. Participants with private insurance and with no coverage were more likely to report CRN compared with those with Medicaid coverage. Risk factors for CRN included food insecurity and mental health distress, though strong patient/provider communication was protective of CRN. DISCUSSION The risk factors for CRN in the MENA community align with risk factors in the general population. As provider communication is protective of CRN, interventions focused on improving patient/provider communication may serve as a way to protect against financially motivated medication nonadherence.
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Affiliation(s)
- Molly Green
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| | - Kenneth Resnicow
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, MI
- University of Michigan Rogel Cancer Center, Ann Arbor, MI
| | - Madiha Tariq
- Arab Community Center for Economic and Social Services, Dearborn, MI
| | - Nadia Syed
- Arab Community Center for Economic and Social Services, Dearborn, MI
| | - Asraa Alhawli
- Arab Community Center for Economic and Social Services, Dearborn, MI
| | - Minal Patel
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, MI
- University of Michigan Rogel Cancer Center, Ann Arbor, MI
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Alnijadi AA, Yuan J, Wu J, Li M, Lu ZK. Cost-Related Medication Nonadherence (CRN) on Healthcare Utilization and Patient-Reported Outcomes: Considerations in Managing Medicare Beneficiaries on Antidepressants. Front Pharmacol 2021; 12:764697. [PMID: 34950029 PMCID: PMC8688804 DOI: 10.3389/fphar.2021.764697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/05/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Many patients face a financial burden due to their medications, which may lead to poor health outcomes. The behaviors of non-adherence due to financial difficulties, known as cost-related medication non-adherence (CRN), include taking smaller doses of drugs, skipping doses to make prescriptions last longer, or delaying prescriptions. To date, the prevalence of CRN remains unknown, and there are few studies about the association of CRN on self-reported healthcare utilization (Emergency room (ER) visits and outpatient visits) and self-reported health outcomes (health status and disability status) among older adults taking antidepressants. Objectives: The objectives were to 1) examine the CRN prevalence, and 2) determine the association of CRN on self-reported healthcare utilization and self-reported health outcomes. Methods: This study was a cross-sectional study of a sample of older adults from the Medicare Current Beneficiary Survey (MCBS) who reported having used antidepressants in 2017. Four logistic regressions were implemented to evaluate the association of CRN, and self-reported healthcare utilization and self-reported health outcomes. Results: The study identified 602 participants who were Medicare beneficiaries on antidepressants. The prevalence of CRN among antidepressant users was (16.61%). After controlling for covariates, CRN was associated with poorer self-reported outcomes but not statistically significant: general health status [odds ratio (OR): 0.67; 95% confidence interval (CI): 0.39-1.16] and disability status (OR: 1.34; 95% CI: 0.83-2.14). In addition, CRN was associated with increased outpatient visits (OR: 1.89; 95% CI: 1.19-3.02), but not associated with ER visits (OR: 1.10; 95% CI: 0.69-1.76). Conclusion: For Medicare beneficiaries on antidepressants, CRN prevalence was high and contributed to more outpatient visits. The healthcare provider needs to define the reasoning for CRN and provide solutions to reduce the financial burden on the affected patient. Also, health care providers need to consider the factors that may enhance patient health status and healthcare efficiency.
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Affiliation(s)
- Abdulrahman A. Alnijadi
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, Columbia, SC, United States
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Jing Yuan
- Department of Clinical Pharmacy and Pharmacy Practice, School of Pharmacy, Fudan University, Shanghai, China
| | - Jun Wu
- Department of Pharmaceutical and Administrative Sciences, Presbyterian College, Clinton, SC, United States
| | - Minghui Li
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Z. Kevin Lu
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, Columbia, SC, United States
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Johnston KJ, Wen H, Joynt Maddox KE, Pollack HA. Ambulatory Care Access And Emergency Department Use For Medicare Beneficiaries With And Without Disabilities. Health Aff (Millwood) 2021; 40:910-919. [PMID: 34097512 DOI: 10.1377/hlthaff.2020.01891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Establishing care with primary care and specialist clinicians is critical for Medicare beneficiaries with complex care needs. However, beneficiaries with disabilities may struggle to access ambulatory care. This study uses the 2015-17 national Medicare Current Beneficiary Survey linked to claims and administrative data to explore these questions. Medicare beneficiaries (ages 21-64) with disabilities were 119 percent more likely to report difficulty accessing care and were 33 percent and 49 percent more likely to lack annual clinician evaluation and management visits for primary and specialty care, respectively, than those without disabilities. Beneficiaries (ages 21-64) with disabilities also had 42 percent, 67 percent, and 77 percent higher likelihood of having all-cause, nonemergent, and preventable emergency department (ED) visits. Furthermore, people with both a disability and a lack of specialist evaluation and management visits also had 21 percent, 48 percent, and 64 percent increased likelihood of all-cause, nonemergent, and preventable ED visits. Barriers to accessing ambulatory care may be a key contributor to the reliance of Americans with disabilities on ED services.
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Affiliation(s)
- Kenton J Johnston
- Kenton J. Johnston is an associate professor of health management and policy at Saint Louis University, in St. Louis, Missouri
| | - Hefei Wen
- Hefei Wen is an assistant professor in the Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and the Harvard Pilgrim Health Care Institute, in Boston, Massachusetts
| | - Karen E Joynt Maddox
- Karen E. Joynt Maddox is an assistant professor of medicine at the Washington University School of Medicine and codirector of the Center for Health Economics and Policy at the Institute for Public Health, Washington University in St. Louis, in St. Louis, Missouri
| | - Harold A Pollack
- Harold A. Pollack is the Helen Ross Professor in the School of Social Service Administration, University of Chicago, in Chicago, Illinois
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Nekui F, Galbraith AA, Briesacher BA, Zhang F, Soumerai SB, Ross-Degnan D, Gurwitz JH, Madden JM. Cost-related Medication Nonadherence and Its Risk Factors Among Medicare Beneficiaries. Med Care 2021; 59:13-21. [PMID: 33298705 PMCID: PMC7735208 DOI: 10.1097/mlr.0000000000001458] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Farrah Nekui
- School of Pharmacy, Northeastern University, 360 Huntington Ave R218X TF,Boston, MA 02115
| | - Alison A. Galbraith
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215
| | - Becky A. Briesacher
- School of Pharmacy, Northeastern University, 360 Huntington Ave R218X TF,Boston, MA 02115
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215
| | - Stephen B. Soumerai
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215
| | - Jerry H. Gurwitz
- Meyers Primary Care Institute, 630 Plantation Street, Worcester, MA 01655
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Jeanne M. Madden
- School of Pharmacy, Northeastern University, 360 Huntington Ave R218X TF,Boston, MA 02115
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215
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Kennedy J, Tuleu I, Mackay K. Unfilled Prescriptions of Medicare Beneficiaries: Prevalence, Reasons, and Types of Medicines Prescribed. J Manag Care Spec Pharm 2020; 26:935-942. [PMID: 32715958 PMCID: PMC10391240 DOI: 10.18553/jmcp.2020.26.8.935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Jae Kennedy
- An Associate Professor in the Department of Health Policy and Administration at Washington State University
| | - Iulia Tuleu
- An Internal Medicine Resident at Beaumont Hospital in Royal Oak, Michigan
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Gu D, Morgan RO, Li R, Weber ES, Shen C. Association between depression and healthcare expenditures among elderly cancer patients. BMC Psychiatry 2020; 20:131. [PMID: 32293366 PMCID: PMC7092441 DOI: 10.1186/s12888-020-02527-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 03/03/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Both depression and cancer are economically burdensome. However, how depression affects the healthcare expenditures of elderly cancer patients from payers' and patients' perspectives is largely unknown. This study investigated whether depression resulted in higher healthcare expenditures among these patients from both payers' and patients' perspectives and identified health service use categories associated with increased expenditures. METHODS From the Medicare Current Beneficiary Survey (MCBS)-Medicare database, we identified breast, lung and prostate cancer patients aged 65 years and over who were newly diagnosed between 2007 and 2012. Presence of depression was based on self-reports from the surveys. We used generalized linear models (GLM) and two-part models to examine the impact of depression on healthcare expenditures during the first two years of cancer diagnosis controlling for a vast array of covariates. We stratified the analyses of total healthcare expenditures by healthcare services and payers. RESULTS Out of the 710 elderly breast, lung and prostate cancer patients in our study cohort, 128 (17.7%) reported depression. Individuals with depression had $11,454 higher total healthcare expenditures, $8213 higher medical provider expenditures and $405 higher other services expenditures compared to their counterparts without depression. Also, they were significantly more likely to have inpatient services. For payers, they incurred $8280 and $1270 higher expenditures from Medicare's and patients' perspectives, respectively. CONCLUSIONS Elderly cancer patients with depression have significantly higher healthcare expenditures from both payers' and patients' perspectives and over different expenditure types. More research is needed in depression screening, diagnosis and treatment for this population.
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Affiliation(s)
- Dian Gu
- Department of Health Services Research, University of Texas M. D. Anderson Cancer Center, 1400 Pressler St, Unit 1444, Houston, TX, TX 77030, USA. .,Division of Management, Policy and Community Health, University of Texas School of Public Health, Houston, TX, USA.
| | - Robert O. Morgan
- grid.267308.80000 0000 9206 2401Division of Management, Policy and Community Health, University of Texas School of Public Health, Houston, TX USA
| | - Ruosha Li
- grid.267308.80000 0000 9206 2401Division of Biostatistics, University of Texas School of Public Health, Houston, TX USA
| | - Ellerie S. Weber
- grid.267308.80000 0000 9206 2401Division of Management, Policy and Community Health, University of Texas School of Public Health, Houston, TX USA
| | - Chan Shen
- grid.29857.310000 0001 2097 4281Division of Outcomes Research and Quality, Department of Surgery, College of Medicine, Pennsylvania State University, Hershey, PA USA
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Gu D, Shen C. Assessing the Importance of Factors Associated with Cost-Related Nonadherence to Medication for Older US Medicare Beneficiaries. Drugs Aging 2019; 36:1111-1121. [DOI: 10.1007/s40266-019-00715-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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11
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Gu D, Shen C. Cost-Related Medication Nonadherence and Cost-Reduction Strategies Among Elderly Cancer Survivors with Self-Reported Symptoms of Depression. Popul Health Manag 2019; 23:132-139. [PMID: 31287770 DOI: 10.1089/pop.2019.0035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Dian Gu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Division of Management, Policy and Community Health, University of Texas School of Public Health, Houston, Texas
| | - Chan Shen
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Kang H, Lobo JM, Kim S, Sohn MW. Cost-related medication non-adherence among U.S. adults with diabetes. Diabetes Res Clin Pract 2018; 143:24-33. [PMID: 29944967 PMCID: PMC6204232 DOI: 10.1016/j.diabres.2018.06.016] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 05/25/2018] [Accepted: 06/19/2018] [Indexed: 11/17/2022]
Abstract
AIMS To examine factors that affect cost-related medication non-adherence (CRN), defined as taking medication less than as prescribed because of cost, among adults with diabetes and to determine their relative contribution in explaining CRN. METHODS Behavioral Risk Factor Surveillance System data for 2013-2014 were used to identify individuals with diabetes and their CRN. We modeled CRN as a function of financial factors, regimen complexity, and other contextual factors including diabetes care, lifestyle, and health factors. Dominance analysis was performed to rank these factors by relative importance. RESULTS CRN among U.S. adults with diabetes was 16.5%. Respondents with annual income <$50,000 and without health insurance were more likely to report CRN, compared to those with income ≥$50,000 and those with insurance, respectively. Insulin users had 1.24 times higher risk of CRN compared to those not on insulin. Contextual factors that significantly affected CRN included diabetes care factors, lifestyle factors, and comorbid depression, arthritis, and COPD/asthma. Dominance analysis showed health insurance was the most important factor for respondents <65 and depression was the most important factor for respondents ≥65. CONCLUSIONS In addition to traditional risk factors of CRN, compliance with annual recommendations for diabetes and healthy lifestyle were associated with lower CRN. Policies and social supports that address these contextual factors may help improve CRN.
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Affiliation(s)
- Hyojung Kang
- Department of Systems and Information Engineering, School of Engineering, University of Virginia, Charlottesville, VA, United States.
| | - Jennifer Mason Lobo
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, United States.
| | - Soyoun Kim
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, United States.
| | - Min-Woong Sohn
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, United States.
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Lee MJ, Khan MM, Salloum RG. Recent Trends in Cost-Related Medication Nonadherence Among Cancer Survivors in the United States. J Manag Care Spec Pharm 2018; 24:56-64. [PMID: 29290172 PMCID: PMC10398090 DOI: 10.18553/jmcp.2018.24.1.56] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cancer survivors avoid necessary medications due to costs. OBJECTIVE To estimate the prevalence of cost-related medication non-adherence (CRN) by age and insurance status over a number of years in a national sample of U.S. cancer survivors. METHODS Using the 1999-2012 National Health Interview Survey, we examined the prevalence and correlates of self-reported CRN, that is, patient-reported inability to afford prescribed medications within the past 12 months, resulting in nonadherence among cancer survivors. Descriptive statistics and multivariate logistic regression models were used to identify time trends in CRN among cancer survivors. RESULTS In a nationally representative sample of 20,517 cancer survivors from 1999 to 2012, 1,788 (8.7%) survivors reported CRN, representing approximately 436,498 individuals nationally. CRN increased significantly from 11.8% (1999-2005) to 16.9% (2006-2012) among younger cancer survivors (P < 0.001). Among young cancer survivors (aged 45-64 years), the uninsurance rate was higher for those reporting CRN in the years 2006-2012 (48.5%) than in the earlier period (42.5%; P = 0.043). Among older cancer survivors, insurance coverage through Medicare only was lower for individuals reporting CRN in the years 2006-2012 (5.8%) than in the earlier period (7.8%; P = 0.0210). In adjusted models, younger cancer survivors without health insurance were more likely to report CRN than those with supplemental private insurance with Medicare, and older cancer survivors with Medicare only were more likely to report CRN than those with supplemental private insurance with Medicare. CONCLUSIONS Increasing trends in CRN were evident among younger cancer survivors. DISCLOSURES No external funding was received for this work. The authors have no conflicts of interest to report. Study concept and design were contributed by Lee, along with Khan and Salloum. Lee collected the data, and data interpretation was performed by Lee, Khan, and Salloum. The manuscript was written primarily by Lee, with assistance from Khan and Salloum, and revised by Lee, Khan, and Salloum.
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Affiliation(s)
- Min Jee Lee
- 1 Arnold School of Public Health, University of South Carolina, Columbia
| | - M Mahmud Khan
- 1 Arnold School of Public Health, University of South Carolina, Columbia
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Understanding the experience of care managers and relationship with patient outcomes: the COMPASS initiative. Gen Hosp Psychiatry 2017; 44:86-90. [PMID: 27558105 DOI: 10.1016/j.genhosppsych.2016.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 03/28/2016] [Accepted: 03/31/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To understand how care managers implemented COMPASS and if this was related to patient health outcomes. METHODS A total of 96 COMPASS care managers were approached to participate in the online survey and 93 (97%) provided responses. Correlations were generated between key survey responses and the average number of care management contacts, patient depression, blood pressure and glycosylated hemoglobin outcomes. RESULTS Patients of care managers who reported spending more time on COMPASS-related tasks had higher rates of depression improvement (r=0.34; P=.002) and remission (r=0.27; P=.02) as well as higher rates of blood pressure control (r=0.29; P=.03). CONCLUSIONS To improve the effectiveness of care management in collaborative care models, particularly for patients with comorbid conditions and complex nonmedical needs, care managers need the support of social work and administrative support staff. Care managers for this patient population would also benefit from more intensive training in nonpharmacological depression treatment, such as motivational interviewing and behavioral activation. Additionally, systems support is needed such as education for primary care teams and psychiatry on the value of collaborative care models and integration of population management tools into electronic medical records.
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Coleman KJ, Magnan S, Neely C, Solberg L, Beck A, Trevis J, Heim C, Williams M, Katzelnick D, Unützer J, Pollock B, Hafer E, Ferguson R, Williams S. The COMPASS initiative: description of a nationwide collaborative approach to the care of patients with depression and diabetes and/or cardiovascular disease. Gen Hosp Psychiatry 2017; 44:69-76. [PMID: 27558107 DOI: 10.1016/j.genhosppsych.2016.05.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 05/16/2016] [Accepted: 05/17/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To describe a national effort to disseminate and implement an evidence-based collaborative care management model for patients with both depression and poorly controlled diabetes and/or cardiovascular disease across multiple, real-world diverse clinical practice sites. METHODS Goals for the initiative were as follows: (1) to improve depression symptoms in 40% of patients, (2) to improve diabetes and hypertension control rates by 20%, (3) to increase provider satisfaction by 20%, (4) to improve patient satisfaction with their care by 20% and (5) to demonstrate cost savings. A Care Management Tracking System was used for collecting clinical care information to create performance measures for quality improvement while also assessing the overall accomplishment of these goals. RESULTS The Care of Mental, Physical and Substance-use Syndromes (COMPASS) initiative spread an evidence-based collaborative care model among 18 medical groups and 172 clinics in eight states. We describe the initiative's evidence-base and methods for others to replicate our work. CONCLUSIONS The COMPASS initiative demonstrated that a diverse set of health care systems and other organizations can work together to rapidly implement an evidence-based care model for complex, hard-to-reach patients. We present this model as an example of how the time gap between research and practice can be reduced on a large scale.
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Affiliation(s)
- Karen J Coleman
- Department of Research and Evaluation, Kaiser Permanente Southern California (KPSC), 100 S. Los Robles Ave., 2nd Floor, Pasadena, CA 91101-2453, USA.
| | - Sanne Magnan
- Institute for Clinical Systems Improvement (ICSI), 8009 34th Ave. S., Suite 1200, Bloomington, MN 55425-1624, USA
| | - Claire Neely
- Institute for Clinical Systems Improvement (ICSI), 8009 34th Ave. S., Suite 1200, Bloomington, MN 55425-1624, USA
| | - Leif Solberg
- HealthPartners Institute for Education and Research (HPIER), 8170 33rd Ave. S., MS23301A, P.O. Box 1524, Bloomington, MN 55440-1524, USA
| | - Arne Beck
- Institute for Health Research (KPCO), Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237-8066, USA
| | - Jim Trevis
- Institute for Clinical Systems Improvement (ICSI), 8009 34th Ave. S., Suite 1200, Bloomington, MN 55425-1624, USA
| | - Carla Heim
- Institute for Clinical Systems Improvement (ICSI), 8009 34th Ave. S., Suite 1200, Bloomington, MN 55425-1624, USA
| | - Mark Williams
- Mayo Clinic Health System, 200 First St. SW, Rochester, MN 55905, USA
| | - David Katzelnick
- Mayo Clinic Health System, 200 First St. SW, Rochester, MN 55905, USA
| | - Jürgen Unützer
- AIMS Center, Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St., Box 356650, Seattle, WA 98195-6560, USA
| | - Betsy Pollock
- AIMS Center, Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St., Box 356650, Seattle, WA 98195-6560, USA; Mount Auburn Cambridge IPA (MACIPA), 1380 Soldiers Field Rd., Floor 2, Brighton, MA 02135-1023, USA
| | - Erin Hafer
- Community Health Plan of Washington (CHPW), 720 Olive Way, Suite 300, Seattle, WA 98101-1830, USA
| | - Robert Ferguson
- Pittsburgh Regional Health Initiative (PRHI), 650 Smithfield St., Centre City Tower, Suite 2400, Pittsburgh, PA 15222-3900, USA
| | - Steve Williams
- Michigan Center for Clinical Systems Improvement (Mi-CCSI), 233 E. Fulton St., Suite 20, Grand Rapids, MI 49503-3261, USA
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Effects of economic recession on elderly patients' perceptions of access to health care and medicines in Portugal. Int J Clin Pharm 2016; 39:104-112. [PMID: 27933488 DOI: 10.1007/s11096-016-0405-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 11/22/2016] [Indexed: 01/09/2023]
Abstract
Background In view of the current financial and demographic situation in Portugal, accessibility to health care may be affected, including the ability to adhere to medication. Objective To evaluate the perceived effects of the crisis on elderly patient's access to medicines and medical care, and its implications on medicine-taking behaviour. Setting Community pharmacy. Method A cross-sectional study was undertaken during April 2013, where elderly patients answered a self-administered questionnaire based on their health-related experiences in the current and previous year. Binary logistic regression was used to ascertain the effects of potential predictors on the likelihood of adherence. Main outcome measures self-reported adherence. Results A total of 1231 questionnaires were collected. 27.3% of patients had stopped using treatments or health services in the previous year for financial motives; mostly private medical appointments, followed by dentist appointments. Almost 30% of patients stopped purchasing prescribed medicines. Over 20% of patients reduced their use of public services. Out-of-pocket expenses with medicines were considered higher in the current year by 40.1% of patients. The most common strategy developed to cope with increasing costs of medicines was generic substitution, but around 15% of patients also stopped taking their medication or started saving by increasing the interdose interval. Conclusion Reports of decreasing costs with medicines was associated with a decreased likelihood of adherence (OR 0.42; 95% CI 0.27-0.65). Lower perceived health status and having 3 or more co-morbidities were associated with lower odds of adhering, whilst less frequent medical appointments was associated with a higher likelihood of exhibiting adherence.
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Naci H, Soumerai SB, Ross-Degnan D, Zhang F, Briesacher BA, Gurwitz JH, Madden JM. Medication affordability gains following Medicare Part D are eroding among elderly with multiple chronic conditions. Health Aff (Millwood) 2016; 33:1435-43. [PMID: 25092846 DOI: 10.1377/hlthaff.2013.1067] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Elderly Americans, especially those with multiple chronic conditions, face difficulties paying for prescriptions, which results in worse adherence to and discontinuation of therapy, called cost-related medication nonadherence. Medicare Part D, implemented in January 2006, was supposed to address issues of affordability for prescriptions. We investigated whether the gains in medication affordability attributable to Part D persisted during the six years that followed its implementation. Overall, we found continued incremental improvements in medication affordability in the period 2007-09 that eroded during the period 2009-11. Among elderly beneficiaries with four or more chronic conditions, we observed an increase in the prevalence of cost-related nonadherence from 14.4 percent in 2009 to 17.0 percent in 2011, reversing previous downward trends. Similarly, the prevalence among the sickest elderly of forgoing basic needs to purchase medicines decreased from 8.7 percent in 2007 to 6.8 percent in 2009 but rose to 10.2 percent in 2011. Our findings highlight the need for targeted policy efforts to alleviate the persistent burden of drug treatment costs on this vulnerable population.
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Affiliation(s)
- Huseyin Naci
- Huseyin Naci is a fellow in pharmaceutical policy research, Department of Population Medicine, Harvard Medical School, in Boston, Massachusetts, and a research fellow at the London School of Economics and Political Science, in the United Kingdom
| | - Stephen B Soumerai
- Stephen B. Soumerai is a professor in the Department of Population Medicine and director of the Drug Policy Research Group, Harvard Medical School and Harvard Pilgrim Health Care Institute, both in Boston
| | - Dennis Ross-Degnan
- Dennis Ross-Degnan is an associate professor in the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute
| | - Fang Zhang
- Fang Zhang is an assistant professor in the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute
| | - Becky A Briesacher
- Becky A. Briesacher is an associate professor at the University of Massachusetts Medical School, in Worcester
| | - Jerry H Gurwitz
- Jerry H. Gurwitz is a professor at the University of Massachusetts Medical School and executive director of the Meyers Primary Care Institute, in Worcester
| | - Jeanne M Madden
- Jeanne M. Madden is an instructor in the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute
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Lee M, Salloum RG. Racial and ethnic disparities in cost-related medication non-adherence among cancer survivors. J Cancer Surviv 2015; 10:534-44. [PMID: 26620816 DOI: 10.1007/s11764-015-0499-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 11/17/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Cancer survivors are delaying or avoiding necessary care due to costs, and medication non-adherence is an important aspect of deferred treatment. This study estimates the prevalence of cost-related medication non-adherence (CRN) by race and ethnicity and examines factors associated with CRN among cancer survivors. METHODS Using the 2006-2013 National Health Interview Survey, we examine self-reported CRN among cancer survivors compared with cancer-free controls. Descriptive statistics and multiple logistic regression models were used to identify factors associated with CRN among cancer survivors. RESULTS In a nationally representative sample of 472,542 adults, 10,998 participants reported a history of cancer and 461,544 did not. Among 10,998 cancer survivors, 1397 (12.70 %) reported CRN. Among older cancer survivors, African-Americans were 2.64 times more likely (95 % confidence interval (CI), 1.73 to 4.01) and Hispanics 2.07 times more likely (95 % CI, 1.32 to 3.24) than whites to report CRN. Among younger cancer survivors, Hispanics were 1.61 times more likely (95 % CI, 1.23 to 2.10) than whites to report CRN. CONCLUSIONS Significant racial and ethnic disparities in CRN were evident among cancer survivors. Older African-American and Hispanic overall survivors were more likely to report CRN in the past year compared with non-Hispanic whites. IMPLICATIONS FOR CANCER SURVIVORS Given increasing prescription drug expenditure, it is important to closely monitor CRN in high-risk subgroups. Racial and ethnic minority groups at high risk for CRN should be counseled on the importance of medication adherence and offered support services to promote medication adherence. Further studies are warranted to establish effective policies and interventions in vulnerable populations.
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Affiliation(s)
- Minjee Lee
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
| | - Ramzi G Salloum
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, FL, USA
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19
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Lee M, Khan MM. Gender differences in cost-related medication non-adherence among cancer survivors. J Cancer Surviv 2015; 10:384-93. [PMID: 26350680 DOI: 10.1007/s11764-015-0484-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 08/27/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE It has been reported that cancer survivors are delaying or avoiding necessary care due to costs. Medication non-adherence is one of the important aspects of deferred treatment. This study estimates the prevalence of cost-related medication non-adherence (CRN) by gender and factors associated with CRN among cancer survivors. METHODS Using 2006-2013 National Health Interview Survey (NHIS), we examined self-reported CRN among cancer survivors by gender. Descriptive statistics and multiple logistic regression models were used to examine gender differences in CRN. RESULTS In a nationally representative sample of 15,159 cancer survivors, 7.4% of male and 12.5% of female reported CRN. Overall, the prevalence of CRN was found to be the highest for uninsured group and the lowest for Medicare, but gender differences persist for all insurance types, including Medicare. After controlling for relevant covariates, female cancer survivors were 27% more likely (odds ratio (OR) = 1.27, confidence intervals (CI), 1.06-1.53) than male to report CRN. With higher number of comorbidities and activity limitations, CRN rates tend to increase for both male and female cancer survivors. CONCLUSIONS Significant gender differences in CRN were found among cancer survivors after controlling for differences in sociodemographic, health status, and insurance coverage. IMPLICATIONS FOR CANCER SURVIVORS Given the rapid increase in prescription drug costs, it is important to monitor closely the CRN in high-risk subgroups.
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Affiliation(s)
- Minjee Lee
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene St, Suite 357, Columbia, SC, 29208, USA
| | - M Mahmud Khan
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene St, Suite 357, Columbia, SC, 29208, USA.
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20
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Bakk L. Medicare Part D coverage gap: race, gender, and cost-related medication nonadherence. SOCIAL WORK IN PUBLIC HEALTH 2015; 30:473-485. [PMID: 26247585 DOI: 10.1080/19371918.2015.1052607] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This study examined whether the Medicare Part D coverage gap directly and indirectly affects the relationship between race, gender, and cost-related nonadherence (CRN). Using a nationally representative sample (N = 1,157), this study found that racial disparities in CRN existed under Medicare Part D. However, reaching the coverage gap mediated differences in CRN between older Blacks and Whites. The coverage gap was associated with CRN and poorer health and lower income were associated with CRN after accounting for coverage gap status. Findings highlight the need to help vulnerable populations avoid CRN and for greater consideration of racial inequities in future policy decisions.
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Affiliation(s)
- Louanne Bakk
- a School of Social Work, University at Buffalo, The State University of New York , Buffalo , New York , USA
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21
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August KJ, Billimek J. A theoretical model of how neighborhood factors contribute to medication nonadherence among disadvantaged chronically ill adults. J Health Psychol 2015; 21:2923-2933. [PMID: 26089191 DOI: 10.1177/1359105315589391] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In addition to individual-level socioeconomic and psychological factors, the neighborhood environment has been found to be related to medication nonadherence, particularly among low-income, minority populations managing a chronic disease. In this article, we synthesize the relevant literature on how neighborhood factors contribute to engagement in health behaviors and reasons for medication nonadherence among this population. We propose a theoretical framework for understanding the mediating and moderating mechanisms whereby the neighborhood environment may impact medication nonadherence among individuals most at risk for adverse disease outcomes. Guided by this model, we provide recommendations for future research, practice, and policy.
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22
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Ayyagari P, Shane DM. Does prescription drug coverage improve mental health? Evidence from Medicare Part D. JOURNAL OF HEALTH ECONOMICS 2015; 41:46-58. [PMID: 25666229 DOI: 10.1016/j.jhealeco.2015.01.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 01/09/2015] [Accepted: 01/17/2015] [Indexed: 06/04/2023]
Abstract
The introduction of the Medicare Prescription Drug program (Part D) in 2006 resulted in a significant increase in access to coverage for older adults in the U.S. Several studies have documented the impact of this program on prescription drug utilization, expenditures and medication adherence among older adults. However, few studies have evaluated the extent to which these changes have affected the health of seniors. In this study we use data from the Health and Retirement Study to identify the impact of the Medicare Part D program on mental health. Using a difference-in-difference approach, we find that the program significantly reduced depressive symptoms among older adults. We explore the mechanisms through which this effect operates and evaluate heterogeneity in impact.
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Affiliation(s)
- Padmaja Ayyagari
- Department of Health Management and Policy, University of Iowa, 145 North Riverside Drive, Iowa City, IA 52242, United States.
| | - Dan M Shane
- Department of Health Management and Policy, University of Iowa, 145 North Riverside Drive, Iowa City, IA 52242, United States.
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Construct Validity and Factor Structure of Survey-based Assessment of Cost-related Medication Burden. Med Care 2015; 53:199-206. [DOI: 10.1097/mlr.0000000000000286] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Persistent medication affordability problems among disabled Medicare beneficiaries after Part D, 2006-2011. Med Care 2014; 52:951-6. [PMID: 25122530 DOI: 10.1097/mlr.0000000000000205] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Disabled Americans who qualify for Medicare coverage typically have multiple chronic conditions, are highly dependent on effective drug therapy, and have limited financial resources, putting them at risk for cost-related medication nonadherence (CRN). Since 2006, the Part D benefit has helped Medicare beneficiaries afford medications. OBJECTIVE To investigate recent national trends in medication affordability among this vulnerable population, stratified by morbidity burden. DESIGN AND SUBJECTS We estimated annual rates of medication affordability among nonelderly disabled participants in a nationally representative survey (2006-2011, n=14,091 person-years) using multivariate logistic regression analyses. MEASURE Survey-reported CRN and spending less on other basic needs to afford medicines. RESULTS In the 6 years following Part D implementation, the proportion of disabled Medicare beneficiaries reporting CRN ranged from 31.6% to 35.6%, while the reported prevalence of spending less on other basic needs to afford medicines ranged from 17.7% to 21.8%. Across study years, those with multiple chronic conditions had consistently worse affordability problems. In 2011, the prevalence of CRN was 37.3% among disabled beneficiaries with ≥ 3 morbidities as compared with 28.1% among those with fewer morbidities; for spending less on basic needs, the prevalence was 25.4% versus 15.7%, respectively. There were no statistically detectable changes in either measure when comparing 2011 with 2007. CONCLUSIONS Disabled Medicare beneficiaries continue to struggle to afford prescription medications. There is an urgent need for focused policy attention on this vulnerable population, which has inadequate financial access to drug treatments, despite having drug coverage under Medicare Part D.
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Bakk L, Woodward AT, Dunkle RE. The Medicare Part D coverage gap: implications for non-dually eligible older adults with a mental illness. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2013; 57:37-51. [PMID: 24377835 DOI: 10.1080/01634372.2013.854857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
This study examines how the Medicare Part D coverage gap impacts non-dually eligible older adults with a mental illness. Qualitative, semistructured interviews were conducted with 11 case managers from community-based agencies serving persons, age 55 and over, with a mental disorder. Five themes illustrating the central difficulties associated with the Part D gap emerged: medication affordability, beneficiary understanding, administrative barriers, Low-Income Subsidy income and asset guidelines, and medication compliance. Although the Patient Protection and Affordable Care Act gradually reduces cost sharing within the gap, findings suggest that medication access and adherence may continue to be impacted by the benefit's structure.
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Affiliation(s)
- Louanne Bakk
- a School of Social Work , University at Buffalo, The State University of New York , Buffalo , New York , USA
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Blanchard J, Madden JM, Ross-Degnan D, Gresenz CR, Soumerai SB. The relationship between emergency department use and cost-related medication nonadherence among Medicare beneficiaries. Ann Emerg Med 2013; 62:475-485. [PMID: 23726522 DOI: 10.1016/j.annemergmed.2013.04.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 04/02/2013] [Accepted: 04/12/2013] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE The objective of this study was to evaluate the relationship between self-reported cost-related nonadherence to prescription medications and emergency department (ED) utilization among Medicare beneficiaries. We hypothesized that persons who report cost-related medication nonadherence would have subsequent higher ED use. METHODS We conducted a retrospective cohort study of continuously enrolled Medicare beneficiaries in 2006 and 2007. We used multivariate logistic regression to evaluate the relationship between ED use and cost-related medication nonadherence. Our principal dependent variable was any ED visit within a 364-day period after an interview assessing cost-related medication nonadherence. Our principal independent variables both denoted cost-related medication nonadherence: mild cost-related medication nonadherence, defined as a reduction in dose or a delay in filling medications because of cost; and severe cost-related medication nonadherence, defined as not filling a medication at all because of cost. RESULTS Our sample consisted of 7,177 Medicare Current Beneficiary Survey respondents. Approximately 7.5% of respondents reported mild cost-related medication nonadherence only (n=541) and another 8.2% reported severe cost-related medication nonadherence (n=581). Disabled Medicare beneficiaries with severe cost-related medication nonadherence were more likely to have at least 1 ED visit (1.53; 95% confidence interval 1.03 to 2.26) compared with both disabled Medicare beneficiaries without cost-related medication nonadherence and elderly Medicare beneficiaries in all cost-related medication nonadherence categories. CONCLUSION Our results show an association between severe cost-related medication nonadherence and ED use. Disabled beneficiaries younger than 65 years who report severe cost-related medication nonadherence were more likely to have at least 1 ED visit, even when adjusting for other factors that affect utilization.
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Affiliation(s)
- Janice Blanchard
- Department of Emergency Medicine, George Washington University, Washington, DC.
| | - Jeanne M Madden
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Carol Roan Gresenz
- Department of Health Systems Administration, Georgetown University, Washington, DC
| | - Stephen B Soumerai
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
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Williams J, Steers WN, Ettner SL, Mangione CM, Duru OK. Cost-related nonadherence by medication type among Medicare Part D beneficiaries with diabetes. Med Care 2013; 51:193-8. [PMID: 23032359 PMCID: PMC3780603 DOI: 10.1097/mlr.0b013e318270dc52] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Despite the rollout of Medicare Part D, cost-related nonadherence (CRN) among older adults remains a problem. OBJECTIVES To examine the rate and correlates of self-reported CRN among a population of older persons with diabetes. RESEARCH DESIGN Cross-sectional. SUBJECTS A total of 1264 Part D patients with diabetes, who entered the coverage gap in 2006. MEASURES Initial administrative medication lists were verified in computer-assisted telephone interviews, in which participants brought their medication bottles to the phone. Medications were classified into cardiometabolic (diabetes, hypertension, cholesterol-lowering), symptom relief, and "other." Participants were asked if they had any CRN during 2006, and if so to which medication/s. We used the person-medication dyad as the unit of analysis, and tested a multivariate random effects logistic regression model to analyze the correlates of CRN. RESULTS Approximately 16% of participants reported CRN. CRN was more frequent for cholesterol-lowering medications (relative risk, 1.54; 95% confidence interval, 1.01-2.32) compared with medications taken for symptom relief. CRN was reported less frequently with increasing age above 75 years, compared with patients between 65 and 69. In addition, compared with those with incomes of ≥$40,000, CRN risk for those with incomes of <$25,000 was markedly higher (relative risk, 3.05; 95% confidence interval, 1.99-4.65). CONCLUSIONS In summary, we found high rates of CRN among Medicare beneficiaries with diabetes, particularly those with lower incomes. We observed more frequent CRN for cholesterol-lowering medications as compared with medications for symptom relief. Efforts to ensure medication affordability for this population will be important in boosting adherence to key medications.
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Affiliation(s)
- Jessica Williams
- Department of Health Services, School of Public Health, University of California, Los Angeles, CA 90024, USA
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Harrold LR, Briesacher BA, Peterson D, Beard A, Madden J, Zhang F, Gurwitz JH, Soumerai SB. Cost-related medication nonadherence in older patients with rheumatoid arthritis. J Rheumatol 2013; 40:137-43. [PMID: 23322458 DOI: 10.3899/jrheum.120441] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Economic access to costly medications including biologic agents can be challenging. Our objective was to examine whether patients with rheumatoid arthritis (RA) are at particular risk for cost-related medication nonadherence (CRN) and spending less on basic needs. METHODS We identified a nationally representative sample of older adults with RA (n = 1100) in the Medicare Current Beneficiary Survey (2004-2008) and compared them to older adults with other morbidities categorized by chronic disease count: 0 (n = 5898), 1-2 (n = 30,538), and ≥ 3 (n = 34,837). We compared annual rates of self-reported CRN (skipping or reducing medication doses or not obtaining prescriptions because of cost) as well as spending less on basic needs to afford medications and tested for differences using survey-weighted logistic regression analyses adjusted for demographic characteristics, health status, and prescription drug coverage. RESULTS In the RA sample, the unadjusted weighted prevalence of CRN ranged from 20.7% in 2004 to 18.4% in 2008 as compared to 18.5% and 11.9%, respectively, in patients with 3 or more non-RA conditions. In adjusted analyses, having RA was associated with a 3.5-fold increase in the risk of CRN (OR 3.52, 95% CI 2.63-4.71) and almost a 2.5-fold risk of spending less on basic needs (OR 2.41, 95% CI 1.78-3.25) as compared to those without a chronic condition. CONCLUSION Patients with RA experience a high prevalence of CRN and forgoing of basic needs, more than do older adults with multiple other chronic conditions. The situation did not improve during a period of policy change aimed at alleviating high drug costs.
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Affiliation(s)
- Leslie R Harrold
- Meyers Primary Care Institute, and the University of Massachusetts Medical School, Department of Medicine, Worcester, MA 01605, USA.
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Predictors of Treatments Acceptable to Patients for Late-Life Depression. ScientificWorldJournal 2013; 2013:207493. [PMID: 24250257 PMCID: PMC3821957 DOI: 10.1155/2013/207493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 09/02/2013] [Indexed: 11/17/2022] Open
Abstract
Objectives. Describe older patients' perceptions about depression and characteristics associated with acceptance of treatments. Design. Cross-sectional study. Setting. Three primary care clinics in Iowa. Participants. Consecutive sample of 529 primary care patients. Measurements. Depression screening tool (a 9-item patient health questionnaire [PHQ-9]) and questionnaire including sociodemographic data, patient attitudes about depression, and acceptability of different treatments. Results. Mean age was 71.9 years (range 60–93 years), 314 (59%) female. Among the 529 participants, 93 (17.5%) had history of depression and 60 (11.3%) had PHQ-9 scores of 10 or greater. Participants believed depression is a disease for which they would use medication and counseling. Accepting medications from primary physicians was strongly associated with a past history of depression (P < 0.01) and with agreeing that depression needs treatment (P < 0.01). Counseling was not acceptable for those believing that they can control depression on their own (P < 0.01). Older patients (P < 0.001) and those with higher education levels (P < 0.01) were less likely to accept herbs or supplements as treatment options. Willingness to discuss treatments with family was associated with not using alcohol as a treatment and acceptance of all other treatment options (P < 0.001). Conclusions. Attitude that depression is a disease and the willingness to discuss depression with family may enhance treatment acceptance.
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Frankenfield DL, Howell BL, Wei II, Anderson KK. Cost-related nonadherence to prescribed medication therapy among Medicare Part D beneficiaries with end-stage renal disease. Am J Health Syst Pharm 2012; 68:1339-48. [PMID: 21719594 DOI: 10.2146/ajhp100400] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Medication nonadherence due to cost issues among community-dwelling patients with end-stage renal disease (ESRD) enrolled in Medicare prescription drug plans was evaluated. METHODS Demographic and health status data were collected on 1329 patients with ESRD enrolled in Medicare Part D prescription drug plans who responded to a Centers for Medicare and Medicaid Services consumer survey in early 2007. The survey data were assessed for self-reported cost-related nonadherence (CRN), defined as delaying or not filling a prescription due to cost concerns. Multivariate logistic regression analysis was performed to evaluate CRN risk relative to patient demographic characteristics, socioeconomic status, other chronic conditions, health behaviors, and access to health care services. RESULTS Overall, survey respondents with ESRD were significantly more likely than those without ESRD to report CRN in the prior six months (unadjusted odds ratio [OR], 2.34; 95% confidence interval [CI], 2.00-2.75). After controlling for potential confounding factors such as other chronic conditions, the data analysis continued to show a significant association between ESRD and an increased risk of CRN (adjusted OR, 1.23; 95% CI, 1.07-1.41). Black race and receipt of Medicare Part D Low-Income Subsidy assistance were significant independent predictors of CRN for respondents with ESRD. CONCLUSION In early 2007, 31% of survey respondents with ESRD enrolled in Medicare Part D drug plans reported CRN in the preceding six months. After adjusting for potential confounders, respondents with ESRD remained 23% more likely than respondents without ESRD to report CRN in the preceding six months.
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Affiliation(s)
- Diane L Frankenfield
- The Innovation Center, Centers for Medicare and Medicaid Services, Baltimore, MD, USA.
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Impact of Medicare Part D on antidepressant treatment, medication choice, and adherence among older adults with depression. Am J Geriatr Psychiatry 2011; 19:989-97. [PMID: 22123272 PMCID: PMC3233981 DOI: 10.1097/jgp.0b013e3182051a9b] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Depression in older adults is often undertreated due, in part, to medication costs. We examined the impact of improved prescription drug coverage under Medicare Part D on use of antidepressants, medication choice, and adherence. DESIGN, SETTING AND PARTICIPANTS Observational claims-based study of older adults with depression (ICD-9: 296.2, 296.3, 311, 300.4) continuously enrolled in a Medicare managed care plan between 2004 and 2007. Three groups with limited ($150 or $350 quarterly caps) or no drug coverage in 2004-2005 obtained Part D benefits in 2006. A comparison group had stable employer-sponsored coverage throughout. MEASUREMENTS Any antidepressant prescription fill, antidepressant choice (tricyclics or monoamine oxidase inhibitors versus newer antidepressants), and adherence (80% of days covered) in the first 6 months of treatment. RESULTS : Part D was associated with increased odds of any antidepressant use among those who previously lacked coverage (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.41-1.85) but odds of use did not change among those with limited prior coverage. Use of older antidepressant agents did not change with Part D. All three groups whose coverage improved with Part D had significantly higher odds of 80% of days covered with an antidepressant (OR = 1.86 [95% CI: 1.44-2.39] for no coverage, 1.74 [95% CI: 1.25%3.42] for $150 cap; and 1.19 [95% CI: 1.06-1.34] for the $350 cap groups). CONCLUSIONS Medicare Part D was associated with improvements in antidepressant use and adherence in depressed older adults who previously had no or limited drug coverage but not with changes in use of older agents. use and adherence in depressed older adults who previously had no or limited drug coverage but not with changes in use of older agents.
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Nekhlyudov L, Madden J, Graves AJ, Zhang F, Soumerai SB, Ross-Degnan D. Cost-related medication nonadherence and cost-saving strategies used by elderly Medicare cancer survivors. J Cancer Surviv 2011; 5:395-404. [PMID: 21800053 DOI: 10.1007/s11764-011-0188-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 06/02/2011] [Indexed: 12/01/2022]
Abstract
OBJECTIVES This study was conducted to compare cost-related medication nonadherence among elderly Medicare enrollees with and without cancer and to describe the strategies cancer survivors used to offset the costs of medications. METHODS Using the 2005 Medicare Current Beneficiary Survey and Medicare claims, we compared self-reported cost-related medication nonadherence (CRN), spending less on basic needs to afford medicines, and cost reduction strategies among elderly beneficiaries with and without cancer. Descriptive statistics and logistic regression models were used to characterize and compare these populations. RESULTS In a nationally representative sample of 9,818 non-institutionalized elderly Medicare enrollees, 1,392 (14%) were classified as cancer survivors based on Medicare claims. Cancer survivors were older, more highly educated, more likely to be male and non-Hispanic, and more likely to have multiple comorbidities, poorer health status, and employer-paid medication coverage. While 10% of cancer survivors and 11% without cancer reported CRN, about 6% and 9% (p = 0.004) of those with and without cancer, respectively, reported spending less on basic needs to offset the costs of medications. Cancer survivors who reported CRN (n = 143) had lower income (62.2% versus 48.6%, p = 0.11) and were more likely to be African-American (13.0% versus 6.4%, p = 0.033) and have non-employer-based medication insurance (p = 0.002) compared to those who did not report CRN. In adjusted analyses, CRN among the two groups was similar, but with some subgroup differences noted by gender and cancer type. Use of cost reduction strategies was mostly similar among cancer survivors and those without cancer. CONCLUSION Cost-related medication nonadherence medication is common among elderly Medicare beneficiaries, but appears to be similar among those with and without cancer.
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Affiliation(s)
- Larissa Nekhlyudov
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, USA.
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The effect of cognitive impairment on mental healthcare costs for individuals with severe psychiatric illness. Am J Geriatr Psychiatry 2011; 19:176-84. [PMID: 20808129 PMCID: PMC3239219 DOI: 10.1097/jgp.0b013e3181e56cfa] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study was conducted to determine the effect of cognitive impairment (CI) on mental healthcare costs for older low-income adults with severe psychiatric illness. METHODS Data were collected from 62 ethnically diverse low-income older adults with severe psychiatric illness who were participating in day programming at a large community mental health center. CI was diagnosed by a neuropsychologist utilizing the Mattis Dementia Rating Scale-Second Edition and structured ratings of functional impairment (Clinical Dementia Rating Scale). Mental healthcare costs for 6, 12, and 24-month intervals before cognitive assessments were obtained for each participant. Substance abuse history was evaluated utilizing a structured questionnaire, depression symptom severity was assessed utilizing the Hamilton Depression Rating Scale, and psychiatric diagnoses were obtained through medical chart abstraction. RESULTS CI was exhibited by 61% of participants and was associated with significantly increased mental healthcare costs during 6, 12, and 24-month intervals. Results of a regression analysis indicated that ethnicity and CI were both significant predictors of log transformed mental healthcare costs over 24 months with CI accounting for 13% of the variance in cost data. CONCLUSIONS CI is a significant factor associated with increased mental healthcare costs in patients with severe psychiatric illness. Identifying targeted interventions to accommodate CI may lead to improving treatment outcomes and reducing the burden of mental healthcare costs for individuals with severe psychiatric illness.
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Milea D, Guelfucci F, Bent-Ennakhil N, Toumi M, Auray JP. Antidepressant monotherapy: A claims database analysis of treatment changes and treatment duration. Clin Ther 2010; 32:2057-72. [DOI: 10.1016/j.clinthera.2010.11.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2010] [Indexed: 10/18/2022]
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Bengle R, Sinnett S, Johnson T, Johnson MA, Brown A, Lee JS. Food insecurity is associated with cost-related medication non-adherence in community-dwelling, low-income older adults in Georgia. ACTA ACUST UNITED AC 2010; 29:170-91. [PMID: 20473811 DOI: 10.1080/01639361003772400] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Low-income older adults are at increased risk of cutting back on basic needs, including food and medication. This study examined the relationship between food insecurity and cost-related medication non-adherence (CRN) in low-income Georgian older adults. The study sample includes new Older Americans Act Nutrition Program participants and waitlisted people assessed by a self-administered mail survey (N = 1000, mean age 75.0 + so - 9.1 years, 68.4% women, 25.8% African American). About 49.7% of participants were food insecure, while 44.4% reported practicing CRN. Those who were food insecure and/or who practiced CRN were more likely to be African American, low-income, younger, less educated, and to report poorer self-reported health status. Food insecure participants were 2.9 (95% CI 2.2, 4.0) times more likely to practice CRN behaviors than their counterparts after controlling for potential confounders. Improving food security is important inorder to promote adherence to recommended prescription regimens.
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Affiliation(s)
- Rebecca Bengle
- Department of Foods and Nutrition, University of Georgia, 280 Dawson Hall, Athens, GA 30602, USA
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Zivin K, Ratliff S, Heisler MM, Langa KM, Piette JD. Factors influencing cost-related nonadherence to medication in older adults: a conceptually based approach. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2010; 13:338-45. [PMID: 20070641 PMCID: PMC3013351 DOI: 10.1111/j.1524-4733.2009.00679.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Although multiple noncost factors likely influence a patient's propensity to forego treatment in the face of cost pressures, little is known about how patients' sociodemographic characteristics, physical and behavioral health comorbidities, and prescription regimens influence cost-related nonadherence (CRN) to medications. We sought to determine both financial and nonfinancial factors associated with CRN in a nationally representative sample of older adults. METHODS We used a conceptual model developed by Piette and colleagues that describes financial and nonfinancial factors that could increase someone's risk of CRN, including income, comorbidities, and medication regimen complexity. We used data from the 2004 wave of the Health and Retirement Study and the 2005 HRS Prescription Drug Study to examine the influence of factors within each of these domains on measures of CRN (including not filling, stopping, or skipping doses) in a nationally representative sample of Americans age 65+ in 2005. RESULTS Of the 3071 respondents who met study criteria, 20% reported some form of CRN in 2005. As in prior studies, indicators of financial stress such as higher out-of-pocket payments for medications and lower net worth were significantly associated with CRN in multivariable analyses. Controlling for these economic pressures, relatively younger respondents (ages 65-74) and depressive symptoms were consistent independent risk factors for CRN. CONCLUSIONS Noncost factors influenced patients' propensity to forego treatment even in the context of cost concerns. Future research encompassing clinician and health system factors should identify additional determinants of CRN beyond patients' cost pressures.
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Affiliation(s)
- Kara Zivin
- Department of Veterans Affairs, Health Services Research and Development (HSR&D) Center of Excellence, Serious Mental Illness Treatment Research and Evaluation Center (SMITREC), Ann Arbor, MI, USA.
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Early Depressive Symptoms after Ischemic Stroke Are Associated with a Left Lenticulocapsular Area Lesion. J Stroke Cerebrovasc Dis 2010; 19:184-189. [DOI: 10.1016/j.jstrokecerebrovasdis.2009.04.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Bieler GS, Brown GG, Williams RL, Brogan DJ. Estimating model-adjusted risks, risk differences, and risk ratios from complex survey data. Am J Epidemiol 2010; 171:618-23. [PMID: 20133516 DOI: 10.1093/aje/kwp440] [Citation(s) in RCA: 372] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is increasing interest in estimating and drawing inferences about risk or prevalence ratios and differences instead of odds ratios in the regression setting. Recent publications have shown how the GENMOD procedure in SAS (SAS Institute Inc., Cary, North Carolina) can be used to estimate these parameters in non-population-based studies. In this paper, the authors show how model-adjusted risks, risk differences, and risk ratio estimates can be obtained directly from logistic regression models in the complex sample survey setting to yield population-based inferences. Complex sample survey designs typically involve some combination of weighting, stratification, multistage sampling, clustering, and perhaps finite population adjustments. Point estimates of model-adjusted risks, risk differences, and risk ratios are obtained from average marginal predictions in the fitted logistic regression model. The model can contain both continuous and categorical covariates, as well as interaction terms. The authors use the SUDAAN software package (Research Triangle Institute, Research Triangle Park, North Carolina) to obtain point estimates, standard errors (via linearization or a replication method), confidence intervals, and P values for the parameters and contrasts of interest. Data from the 2006 National Health Interview Survey are used to illustrate these concepts.
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Affiliation(s)
- Gayle S Bieler
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, North Carolina 27709-2194, USA.
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Abstract
BACKGROUND The literature on nonfulfillment of prescription medications spans over three decades of work. There is a wide variation in reported nonfulfillment rates, but no previous study has systematically reviewed this literature to explore the reasons behind this variation. OBJECTIVE The objective of this study was to review estimates of medication nonfulfillment rates and published reasons for nonfulfillment and explore whether nonfulfillment rates vary by study variables. METHODS Articles were identified through searches conducted on MEDLINE, CINAHL, Psych Info, and EMBASE, and review of relevant reference citations. Methodological variables, nonfulfillment rate, and unit of analysis (i.e., patient or prescription) were abstracted from each article selected for review. Mean and median nonfulfillment rates for groups categorized by unit of analysis and selected methodological variables (method for assessing nonfulfillment, sample characteristics, disease subgroup, sample size, country of data collection, recall period or time allowed before classifying as nonfulfillment, and year of study) were calculated. Reasons for nonfulfillment were abstracted from all articles that included a relevant discussion. FINDINGS A total of 79 studies reporting pure nonfulfillment rates (59 at the patient level and 20 at the prescription level) and six studies reporting nonfulfillment rates in combination with nonpersistence rates were included. There was a wide variation in nonfulfillment rates reported by the studies - from 0.5% to 57.1%. The three primary reasons for nonfulfillment identified from this review were perceived concerns about medications, lack of perceived need for medications, and medication affordability issues. CONCLUSION To the best of the authors' knowledge, this study is the first narrative systematic review on nonfulfillment of prescription medications. Despite the wide variation in individual study rates, the mean and median rates across different modes of data collection and sources of data were in a relatively narrow range (11% to 19%) and surprisingly close to the overall mean (16.4%) and median (15%.0) rates for all studies. The reasons for nonfulfillment identified through this review address barriers to nonfulfillment at the patient, physician, and health system level and thus bear important implications for policy makers.
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Cost-related medication nonadherence among beneficiaries with depression following Medicare Part D. Am J Geriatr Psychiatry 2009; 17:1068-76. [PMID: 20104063 PMCID: PMC3773722 DOI: 10.1097/jgp.0b013e3181b972d1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
CONTEXT Cost-related medication nonadherence (CRN) was problematic for Medicare beneficiaries with depressive symptoms before Medicare Part D. OBJECTIVE To estimate changes in CRN and forgoing basic needs to pay for drugs among Medicare beneficiaries with and without depressive symptoms following Part D implementation. DESIGN AND SETTING The authors compared changes in outcomes between 2005 and 2006 before and after Part D with changes between 2004 and 2005 using logistic regression to control for demographic characteristics, health status, and historical trends. PARTICIPANTS The community-dwelling sample of the Medicare Current Beneficiary Survey (N = 24,234). MAIN OUTCOME MEASURES Self-reports of CRN (skipping or reducing doses and not obtaining prescriptions) and spending less on basic needs to afford medicines. RESULTS The unadjusted annual prevalence of CRN among beneficiaries with depressive symptoms was 27% (2004), 27% (2005), and 24% (2006), compared with 13%, 12%, and 9% among beneficiaries without depressive symptoms. The annual prevalence of spending less on basic needs was 22% (2004), 23% (2005), and 19% (2006), compared with 8%, 9%, and 5% among beneficiaries without depressive symptoms. Controlling for historical changes and demographic characteristics, CRN did not decline among beneficiaries with depressive symptoms compared with beneficiaries without depressive symptoms (ratio of Part D changes 0.98; 95% confidence interval [CI], 0.73-1.32). Respondents with depressive symptoms seemed less likely to spend less on basic needs compared with individuals without depressive symptoms (0.70; 95% CI, 0.49-1.01); however, this difference was not statistically significant. CONCLUSIONS Despite a Medicare Part D goal to improve medication adherence among mentally ill beneficiaries, the disparity in economic access to medications between beneficiaries with and without depressive symptoms did not improve after the start of Part D.
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Litwin H, Sapir EV. Forgone health care due to cost among older adults in European countries and in Israel. Eur J Ageing 2009; 6:167-176. [PMID: 23293574 DOI: 10.1007/s10433-009-0126-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This study sought to identify the principal factors that predict forgone health care due to cost among European and Israeli older adults. The analysis applied the Andersen-Newman model of health service utilization to data from the first wave of the Survey of Health, Ageing and Retirement in Europe (n = 28,849). Relinquished health care was regressed on the predisposing characteristics, need factors and economic access attributes of the respondents, in general, and in each of 12 countries, in particular. The results showed that forgone health care due to cost occurs among a substantial minority of older adults. Moreover, relinquished care is associated with younger old age, greater health needs and perceived economic inadequacy. Although statistically significant in certain cases, country of residence does not constitute a robust predictor of health care relinquishment. Social policy should address the antecedents of forgone health care in order to more effectively meet the health needs of the older population.
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Affiliation(s)
- Howard Litwin
- Israel Gerontological Data Center, Hebrew University, Jerusalem, Israel
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Zivin K, Kabeto MU, Kales HC, Langa KM. The effect of depression and cognitive impairment on enrollment in Medicare Part D. J Am Geriatr Soc 2009; 57:1433-40. [PMID: 19515100 DOI: 10.1111/j.1532-5415.2009.02348.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine concerns that vulnerable populations, such as depressed or cognitively impaired beneficiaries would have challenges accessing Part D coverage. DESIGN Logistic regression analysis was used to assess whether elderly Medicare beneficiaries with depression or cognitive impairment differentially planned to and actually signed up for Part D. SETTING 2004 and 2006 data from the Health and Retirement Study (HRS) were used, including a subsample that completed the Prescription Drug Study (PDS) in 2005. PARTICIPANTS Nine thousand five hundred ninety-three HRS respondents and 3,567 PDS respondents. MEASUREMENTS The outcome variables of interest were planned and actual enrollment in Part D. The independent variables were depression and cognitive impairment status. The analyses were adjusted using clinical and demographic predictors including age, sex, race or ethnicity, educational attainment, net worth, marital status, health status, number of health conditions being treated with prescription medications, and presence of a caregiver. RESULTS Although having depression or cognitive impairment was associated with a higher likelihood of planning to and actually signing up for Part D in unadjusted analyses, in adjusted analyses, having depression or cognitive impairment was not significantly associated with whether Medicare beneficiaries planned to enroll in or actually enrolled in Part D. CONCLUSION Vulnerable Medicare beneficiaries with depression or cognitive impairment were able to access Part D benefits to the same extent as nonvulnerable beneficiaries. More research is needed to determine how well Part D meets the needs of these populations.
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Affiliation(s)
- Kara Zivin
- Serious Mental Illness Treatment Research and Evaluation Center, Department of Veterans Affairs, Ann Arbor, Michigan, USA.
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Haeusler JMC. Change in formulation and its potential clinical and pharmacoeconomic value: example of extended release venlafaxine. Curr Med Res Opin 2009; 25:1089-94. [PMID: 19301988 DOI: 10.1185/03007990902858303] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The 505(b)(2) route of a New Drug Application (NDA) allows published literature or previous FDA findings of safety and effectiveness to be used for approval. Such drugs are not therapeutic equivalents (i.e., generics); instead, the FDA calls them pharmaceutical alternatives. A recent example is the approval of venlafaxine extended-release (ER) tablets, developed as an alternative to the widely used ER venlafaxine capsules. The smaller size of the tablets makes them available in a 225-mg strength, which is the approved maximum dose in major depressive disorder after up-titration but currently unavailable in the capsule formulation, requiring patients on this dose to take two or three capsules; in addition, the tablets are priced at a discount compared to the capsules. METHODS The objective of this review was to investigate how the change in formulation of ER venlafaxine from capsules to tablets, as an example of such a change in formulation, can potentially offer value to patients and society, with a specific focus on pill burden, drug cost, and adherence. Based on a MEDLINE literature search, the pertinent literature was reviewed in a qualitative manner. REVIEW OF THE LITERATURE Simplifying treatment regimens, reducing pill burden, and reducing drug costs are recognized strategies for improving adherence. This can be of particular benefit in psychiatric illness because of high rates of nonadherence to treatment. Lack of adherence may negatively impact treatment outcomes and increase disease cost. As such, the ER venlafaxine tablets have the potential to reduce pill burden, improve adherence and outcomes, and reduce cost to patients and society. These preliminary findings need to be corroborated with more primary research and a systematic review of formulation changes. CONCLUSION A change in formulation of established therapies such as ER venlafaxine has the potential to offer clinical and pharmacoeconomic benefits to patients and society.
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Abstract
Postpartum depression is common in women with infants in the neonatal ICU. Maternal depression can affect infant health and development adversely. A screening program for depression in the neonatal ICU could identify women who have depressive symptoms and facilitate their referral for follow-up services.
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Affiliation(s)
- Kyle O Mounts
- Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road Milwaukee, WI 53226, USA.
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Das-Douglas M, Riley ED, Ragland K, Guzman D, Clark R, Kushel MB, Bangsberg DR. Implementation of the Medicare Part D prescription drug benefit is associated with antiretroviral therapy interruptions. AIDS Behav 2009; 13:1-9. [PMID: 18483850 DOI: 10.1007/s10461-008-9401-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 04/28/2008] [Indexed: 11/25/2022]
Abstract
Antiretroviral (ARV) treatment interruptions are associated with virologic rebound, drug resistance, and increased morbidity and mortality. The Medicare Part D prescription drug benefit, implemented on January 1st, 2006, increased consumer cost-sharing. Consumer cost-sharing is associated with decreased access to medications and adverse clinical outcomes. We assessed the association of Part D implementation with treatment interruptions by studying 125 HIV-infected homeless and marginally housed individuals with drug coverage receiving ARV therapy. Thirty-five percent of respondents reported Medicare coverage and 11% reported ARV interruptions. The odds of ARV interruptions were six times higher among those with Part D coverage and remained significant after adjustment. The majority of Part D-covered respondents reporting ARV interruptions cited increased cost as their primary barrier. Directed interventions to monitor the long-term effects of increased cost burden on interruptions and clinical outcomes and to reduce cost burden are necessary to avoid preventable increases in morbidity and mortality.
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Affiliation(s)
- Moupali Das-Douglas
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA, 94143, USA.
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McHorney CA. The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease. Curr Med Res Opin 2009; 25:215-38. [PMID: 19210154 DOI: 10.1185/03007990802619425] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To conceptualize, develop, and provide preliminary psychometric evidence for the Adherence Estimator--a brief, three-item proximal screener for the likelihood of non-adherence to prescription medications (medication non-fulfillment and non-persistence) for chronic disease. RESEARCH DESIGN AND METHODS Qualitative focus groups with 140 healthcare consumers and two internet-based surveys of adults with chronic disease, comprising a total of 1772 respondents, who were self-reported medication adherers, non-persisters, and non-fulfillers. Psychometric tests were performed on over 150 items assessing 14 patient beliefs and skills hypothesized to be related to medication non-adherence along a proximal-distal continuum. Psychometric tests included, but were not limited to, known-groups discriminant validity at the scale and item level. The psychometric analyses sought to identify: (1) the specific multi-item scales that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters) and, (2) the single best item within each prioritized multi-item scale that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters). RESULTS The two rounds of psychometric testing identified and cross-validated three proximal drivers of self-reported adherence: perceived concerns about medications, perceived need for medications, and perceived affordability of medications. One item from each domain was selected to include in the Adherence Estimator using a synthesis of psychometric results gleaned from classical and modern psychometric test theory. By simple summation of the weights assigned to the category responses of the three items, a total score is obtained that is immediately interpretable and completely transparent. Patients can be placed into one of three segments based on the total score--low, medium, and high risk for non-adherence. Sensitivity was 88%--of the non-adherers, 88% would be accurately classified as medium or high risk by the Adherence Estimator. The three risk groups differed on theoretically-relevant variables external to the Adherence Estimator in ways consistent with the hypothesized proximal-distal continuum of adherence drivers. CONCLUSIONS The three-item Adherence Estimator measures three proximal beliefs related to intentional non-adherence (medication non-fulfillment and non-persistence). Preliminary evidence of the validity of the Adherence Evidence supports its intended use to segment patients on their propensity to adhere to a newly-prescribed prescription medication. The Adherence Estimator is readily scored and is easily interpretable. Due to its brevity and transparency, it should prove to be practical for use in everyday clinical practice and in disease management for adherence quality improvement. Study limitations related to sample representation and self reports of chronic disease and adherence behaviors were discussed.
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Affiliation(s)
- Colleen A McHorney
- US Outcomes Research, Merck & Co., Inc., West Point, PA 19486-0004, USA.
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Abstract
OBJECTIVE Older patients may regard some medications, particularly psychotropic medications, as discretionary compared with what they perceive as more "essential " nonpsychiatric medications. Patients' concerns about psychotropic medication costs under Medicare Part D may reinforce these impressions. DESIGN The authors examined which Medicare prescription drug plans (PDPs) would be least expensive for beneficiaries considering the costs of 1) all medications; and 2) only nonpsychiatric medications. SETTING The authors collected data from the PDP online comparison tool provided by the Centers for Medicare and Medicaid Services (CMS). PARTICIPANTS Hypothetical Medicare beneficiaries. MEASUREMENTS The authors examined four clinical scenarios from older outpatients with both chronic medical and psychiatric conditions (including psychosis, bipolar disorder, depression, and dementia with behavioral disturbances). RESULTS The authors examined data from all 160 plans available in CMS PDP regions in May 2007. There were frequent discrepancies in the least expensive PDPs within region, depending on considering the costs of all medications, or just nonpsychiatric medications. In the clinical scenarios, patients selecting a PDP based on nonpsychiatric medications alone would pick an unnecessarily more expensive plan 74%-100% of the time (when they took any brand name medication), suggesting that excluding psychiatric medications from PDP choices may be excessively costly. However, brand name psychotropic medications significantly increased the costs of the least expensive plans. The latter finding might persuade patients to avoid taking needed psychiatric medication due to cost. CONCLUSION This research highlights the complexity that patients with psychiatric and cognitive disorders face when choosing a Medicare PDP. Policymakers and clinicians should be aware of the tradeoffs that beneficiaries with psychiatric disorders face when making PDP plan choices.
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Abstract
Many argue that high costs of pharmaceutical research and development leads to high drug-prices and that existing prices are necessary to fund future expenditures on research and development. However, high pharmaceutical-prices can limit patient access to life-saving therapeutics. This paper examines the impact of high prices on patients and the relation between prices and innovation, and finally, considers policies that may balance patients' access to medications and financial rewards to industry.
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Affiliation(s)
- Salomeh Keyhani
- Mount Sinai School of Medicine, Department of Health Policy, Box 1077, One Gustave L. Levy Place, NY 10029, New York, USA
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