Impact of drug plans on adherence to and the cost of antihypertensive medications among patients covered by a universal drug insurance program

The impact of prescription drug insurance on cost related non-adherence to medications in Canada: A Heckman sample selection approach

Unlike some other high-income counties, Canada does not provide universal prescription drug coverage. The various extent of coverage may left some Canadians vulnerable to cost-related non-adherence (CRNA) to medications. Using data from the 2015 national cycle of the Canadian Community Health Survey, we examine the impact of having private and public drug coverage on mitigating the risk of CRNA with a logit model and a Heckman selection model. CRNA was only observed in respondents who had prescriptions to fill, and respondents did not randomly make decisions on whether to get a prescription. This results in a classic sample selection problem. We found a higher estimated probability of reporting CRNA for uninsured respondents from the Heckman selection model than from the logit model. Respondents with government coverage only had a slightly higher probability of reporting CRNA relative to respondents with private coverage. These findings suggest that, without accounting for sample selection, the risk of not having drug insurance coverage is likely to be underestimated. Moreover, despite covering a less healthy cohort of respondents, the government insurance plans reduce risk of CRNA to a comparable level with private insurance.

Individual-related factors associated with treatment adherence among hypertensive patients

Background

Currently, some of the most prevalent illnesses are attributable to external sources, such as chronic disorders that threaten people's health. The goal of the study was to investigate the differences in individual characteristics associated with treatment adherence among hypertension patients.

Materials and Methods

In this descriptive cross-sectional study, 176 hypertensive patients who reviewed primary healthcare facilities in Babylon Province were included. Experts were used to ensure the study questionnaire's validity, and a pilot study was used to ensure its reliability. Using a standardized questionnaire and interviewing methods, data were collected and analyzed.

Results

According to the study's findings, participants' average ages were 59 (10.86), 67% of them were over 60, 55.1% and 65.3% of them were men and married respectively, nearly half of them had moderate monthly income, the unemployed percentage was 61.9%, and 36.4% had completed their secondary education. Two-thirds, or 70.5%, of hypertension patients, reported poor treatment adherence. Ages 30-59, male patients, married, highincome, and college-educated patients showed significantly better treatment compliance (P<0.05).

Conclusions

Every individual characteristic of patients with high blood pressure is regarded as a predictor of therapy adherence. The current study is one of the few in Iraq to evaluate treatment adherence and look into the various elements that may influence it using the survey approach. Future research on the subject of antihypertensive treatment adherence in the hypertensive population in Iraq employing a representative sample, a qualitative methodology, and more factor exploration may offer additional insights.

Pharmaceutical policies: effects of regulating drug insurance schemes

BACKGROUND

Drug insurance schemes are systems that provide access to medicines on a prepaid basis and could potentially improve access to essential medicines and reduce out-of-pocket payments for vulnerable populations.

OBJECTIVES

To assess the effects on drug use, drug expenditure, healthcare utilisation and healthcare outcomes of alternative policies for regulating drug insurance schemes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers between November 2014 and September 2020, including a citation search for included studies on 15 September 2021 using Web of Science. We screened reference lists of all the relevant reports that we retrieved and reports from the Background section. Authors of relevant papers, relevant organisations, and discussion lists were contacted to identify additional studies, including unpublished and ongoing studies.

SELECTION CRITERIA

We planned to include randomised trials, non-randomised trials, interrupted time-series studies (including controlled ITS [CITS] and repeated measures [RM] studies), and controlled before-after (CBA) studies. Two review authors independently assessed the search results and reference lists of relevant reports, retrieved the full text of potentially relevant references and independently applied the inclusion criteria to those studies. We resolved disagreements by discussion, and when necessary by including a third review author. We excluded studies of the following pharmaceutical policies covered in other Cochrane Reviews: those that determined how decisions were made about which conditions or drugs were covered; those that placed restrictions on reimbursement for drugs that were covered; and those that regulated out-of-pocket payments for drugs.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies and assessed risk of bias for each study, with disagreements being resolved by consensus. We used the criteria suggested by  Cochrane Effective Practice and Organisation of Care (EPOC)  to assess the risk of bias of included studies. For randomised trials, non-randomised trials and controlled before-after studies, we planned to report relative effects. For dichotomous outcomes, we reported the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For interrupted time series and controlled interrupted time-series studies, we computed changes along two dimensions: change in level; and change in slope. We undertook a structured synthesis following the EPOC guidance on this topic, describing the range of effects found in the studies for each category of outcomes.

MAIN RESULTS

We identified 58 studies that met the inclusion criteria (25 interrupted time-series studies and 33 controlled before-after studies). Most of the studies (54) assessed a single policy implemented in the United States (US) healthcare system: Medicare Part D. The other four assessed other drug insurance schemes from Canada and the US, but only one of them provided analysable data for inclusion in the quantitative synthesis. The introduction of drug insurance schemes may increase prescription drug use (low-certainty evidence). On the other hand, Medicare Part D may decrease drug expenditure measured as both out-of-pocket spending and total drug spending (low-certainty evidence). Regarding healthcare utilisation, drug insurance policies (such as Medicare Part D) may lead to a small increase in visits to the emergency department. However, it is uncertain whether this type of policy increases or decreases hospital admissions or outpatient visits by beneficiaries of the scheme because the certainty of the evidence was very low. Likewise, it is uncertain if the policy increases or reduces health outcomes such as mortality because the certainty of the evidence was very low.

AUTHORS' CONCLUSIONS

The introduction of drug insurance schemes such as Medicare Part D in the US health system may increase prescription drug use and may decrease out-of-pocket payments by the beneficiaries of the scheme and total drug expenditures. It may also lead to a small increase in visits to the emergency department by the beneficiaries of the policy. Its effects on other healthcare utilisation outcomes and on health outcomes are uncertain because of the very low certainty of the evidence. The applicability of this evidence to settings outside US healthcare is limited.

Difference in drug cost between private and public drug plans in Quebec, Canada

Background

We expect a difference in drug cost between private drug plans and the Public Drug Plan (PDP) because the dispensing fee is fixed and regulated by the PDP for publicly insured patients, whereas it is determined freely by the pharmacy owner for privately insured patients. This study compared the drug cost of Quebec residents covered by private drug plans with those covered by PDP.

Methods

We used a sample of prescriptions filled between 1 January 2015 and 23 May 2019 selected from reMed, a database of Quebecers’ drug claims. We created strata of prescriptions filled by privately insured patients and matched them with strata of prescriptions filled by publicly insured patients based on the Drug Identification Number, quantity dispensed, number of days of supply, pharmacy identifier, and a date corresponding to the publication of List of Medications of Régie de l’Assurance Maladie du Québec. The differences in drug cost between private plans and the PDP were analyzed with linear regression models using prescription strata as the unit of analysis.

Results

Based on 38 896 prescription strata, we observed that privately insured patients payed $9·35 (95% confidence interval [CI]: 5·58; 13·01) more on average per drug prescription than publicly insured patients, representing a difference of 17·6%.

Conclusions

This study showed that, on average, drug cost is substantially higher for privately insured Quebecers. Knowing that adherence to treatment is affected by drug cost, these results will help public health authorities to make informed decisions about drug policies.

Patterns of cost-related medication underuse among Canadian adults with cancer: a cross-sectional study using survey data

BACKGROUND

Cost-related medication underuse (CRMU) has been reported within the general population in Canada. In this study, we assessed patterns of CRMU among Canadian adults with cancer.

METHODS

This is a cross-sectional study using survey data. We accessed data sets from the 2015/16 Canadian Community Health Survey (CCHS) and reviewed the records of adults (≥ 18 yr) with a history of cancer who were prescribed medication in the previous 12 months. We collected information about sociodemographic features, health behaviours and CRMU, and conducted a multivariable logistic regression analysis for factors associated with CRMU.

RESULTS

A total of 8581 participants were eligible for the current study. In the weighted multivariable logistic regression analysis, the following factors were associated with CRMU: younger age (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.79-3.63), female sex (male sex v. female sex OR 0.62, 95% CI 0.44-0.88), Indigenous racial background (Indigenous v. White OR 2.37, 95% CI 1.49- 3.77), unmarried status (OR 1.59, 95% CI 1.09-2.30), poor self-perceived health (excellent v. poor self-perceived health OR 0.36, 95% CI 0.17-0.77), lower annual income (< $20 000 v. income ≥ $80 000 OR 3.08, 95% CI 1.75-5.41) and lack of insurance for prescription medications (OR 2.49, 95% CI 1.77-3.50).

INTERPRETATION

The toll of CRMU among adults seems to be unequally carried by women, racial minorities, and younger (< 65 yr) and uninsured patients with cancer. Discussion about a national pharmacare program for people without private insurance is needed.

Adherence to Antihypertensive Therapy: A Systematic Review of Russian Prospective Studies from 2000 to 2019

Russia belongs to countries with a high prevalence of arterial hypertension (AH), which is the main cause of premature death in the Russian population. The level of blood pressure (BP) is controlled in less than a third of patients, which may be due to poor adherence to medical recommendations and irregular medication. The manuscript provides a review of studies evaluating the effectiveness of measures to improve adherence to antihypertensive therapy (AHT).

Aim. To prepare a systematic review of Russian studies to assess the effectiveness of measures to increase adherence to AHT, to determine/describe the main directions of the intervention and the methodological level.

Material and methods. The search for full-text articles on adherence to AHT published in Russian in the period from 2000 to 2019 was carried out in the main Russian and international electronic databases eLIBRARY.ru, Embase, Russian Medicine, MEDLINE. Of the 563 publications found, 20 were included in the review.

Results. In 14 studies, adherence was assessed using the 4-item Morisky Medication Adherence Scale (MMAS-4), other studies used bespoke questionnaires or pill counts. Two studies examined factors associated with adherence. The observation period was up 6 weeks to 12 months, the number of participants is 30-2435 people. A higher adherence was noted in women, people over 50 years old, with higher education, working, with concomitant diabetes mellitus and a history of myocardial infarction. Patient education was effective interventions to improve adherence (in particular, in studies, improvement on the MMAS-4 from 1.8 to 3.9 points, p=0.0002 or from 2.80 to 3.79 points, p<0.0001), telephone reminders (p<0.0001), training in self-measurement of blood pressure (p<0.05) and fixed combinations of drugs (p<0.05).

Conclusion. The most effective ways to improve adherence are patient education and the use of drugs fixed combinations. In most studies, subjective methods of adherence assessing were used.

Adherence to antihypertensive medication in Russia: a scoping review of studies on levels, determinants and intervention strategies published between 2000 and 2017

Background

Arterial hypertension (HT) is common in the Russian adult population, with half of affected individuals inadequately controlled. Low adherence to medication seems likely to be a factor. We report a scoping review of studies on adherence to antihypertensive therapy (AHT) in Russia to determine the extent of research undertaken, the frequency of adherence among adults diagnosed with HT, methodologies used in the studies, and their ability to describe determinants of adherence.

Methods

A scoping review of published studies that have assessed adherence to AHT in Russian HT patients searched the main Russian and international electronic databases eLIBRARY.ru, Russian Medicine, Embase, MEDLINE for full-text reports published in the Russian language between 2000 and 2017. The last search was on November 28, 2017. Among 520 reports identified, 31 were included in the review.

Results

Eighteen studies assessed adherence using the 4-item Morisky Medication Adherence Scale (MMAS-4); others used bespoke questionnaires or pill counts. 25 studies assessed levels of adherence, 11 examined its determinants, and 18 examined intervention strategies. The proportion of “adherent” patients varied from 11 to 44% using the MMAS-4, from 23 to 74% when using bespoke questionnaires, and from 5 to 43% when using pill counts. Adherence was associated with sociodemographic factors, access to free drugs provided through the Medicine Assistance Scheme (MAS), use of home blood pressure (BP) monitoring, anxiety, and comorbidity. There was no evidence that adherence was associated with income or physical activity. Evidence of an association between MAS, grade of HT, or experience of hypertensive crisis was inconclusive. Various methods to improve adherence were studied including patient education (improved from 1.8 to 3.9 points, p = 0.0002 or 2.80 to 3.79 points, p < 0.0001 measured by the MMAS-4), telephone reminders (p < 0.0001), training in home BP monitoring (p < 0.05), and use of fixed-dose combinations (p < 0.05).

Conclusions

The main determinants of adherence to AHT are sociodemographic characteristics, the severity of HT, and presence of comorbidity. Patient education and use of fixed-dose combinations of drugs were identified as most important for improving adherence. Most studies assessing adherence use self-reported methods so there is a need for greater use of objective methods.

Trial registration

This scoping review has not been registered.

Electronic supplementary material

The online version of this article (10.1186/s13690-019-0366-9) contains supplementary material, which is available to authorized users.

Cost-related nonadherence to prescription medications in Canada: a scoping review

PURPOSE

The evidence is emerging that prescription medications are the topmost drivers of increasing health care costs in Canada. The financial burden of medications may lead individuals to adopt various rationing or restrictive behaviors, such as cost-related nonadherence (CRNA) to medications. Therefore, the purpose of this study is to provide an overview of the type, extent, and quantity of research available on CRNA to prescription drugs in Canada, and evaluate existing gaps in the literature.

METHODS

The study was conducted using a scoping review methodology. Six databases were searched from inception till June 2017. Articles were considered for inclusion if they focused on extent, determinants, and consequences of CRNA to prescription medication use in the Canadian context. Variables extracted for data charting included author(s), year of publication, study design, the focus of the article, sample size, population characteristics, and key outcomes or results.

RESULTS

This review found 37 studies that offered evidence on the extent, determinants, and consequences of CRNA to prescription medications in Canada. Depending on the population characteristics and province, the prevalence of CRNA varies between 4% and 36% in Canada. Canadians who are young (between 18 and 64 years), without drug insurance, have lower income or precarious or irregular employment, and high out-of-pocket expenditure on drugs are most likely to face CRNA to their prescriptions. The evidence that CRNA has negative health and social outcomes for patients is insufficient. Literature regarding the influence of prescribing health care professionals on patients' decisions to stop taking medications is limited. There is also a dearth of literature that explores patients' decisions and strategies to manage their prescription cost burden.

CONCLUSION

More evidence is required to make a strong case for national Pharmacare which can ensure universal, timely, and burden-free access to prescription medications for all Canadians.

Impact of Patient Reimbursement Timing and Patient Out-of-Pocket Expenses on Medication Adherence in Patients Covered by Private Drug Insurance Plans

BACKGROUND

Adherence to prescribed medications used in the treatment of chronic diseases is suboptimal, and drug insurance plans can have an impact on adherence. There is little evidence on the impact of patient reimbursement timing on medication adherence.

OBJECTIVE

To compare adherence to prescribed medications in privately insured patients from Quebec, Canada, with different patient reimbursement timing and levels of patient out-of-pocket expenses.

METHODS

A retrospective cohort was constructed by selecting privately insured patients aged 18-64 years from the reMed database (2008-2012) who filled at least 1 prescription for a medication belonging to 1 of the 10 most prescribed drug classes for chronic diseases. Patient reimbursement timing was classified as immediate (immediate patient reimbursement at the point of service of the portion of the medication cost covered by the insurer) or deferred (patient reimbursement at a later time). Patient outof-pocket expenses related to the medication under study at cohort entry (available only for the immediate patient reimbursement group), which included the deductible and the coinsurance, were categorized into 5 levels (null category and quartiles): $0, $0.01-$3.59, $3.60-$8.11, $8.12-$14.40, and $14.41-$89.99. Adherence was measured with the proportion of days covered (PDC) over 1 year among new users of the medication under study. Linear regression models were used to estimate the adjusted mean difference of PDC between groups.

RESULTS

There was no difference in medication adherence between the immediate (n = 1,345) and deferred patient reimbursement (n = 437; difference, 0.0%; 95% CI, -3.0 to 3.0). Patients with the highest patient out-of-pocket expenses were less adherent than those with the lowest patient out-of-pocket expenses (difference, -19.0%; 95% CI, -24.0 to -13.0); however, patients with no patient out-of-pocket expenses were less adherent than those with low patient out-of-pocket expenses (difference, -9.0%; 95% CI, -15.0 to -2.0).

CONCLUSIONS

Medication adherence appeared to be unaffected by patient reimbursement timing but was affected by the level of patient out-of-pocket expenses. The absence of a correlation between medication adherence and timing of patient reimbursement might be explained by the relatively rapid reimbursement of expenses by insurance companies in Canada. Subjects with no patient out-of-pocket expenses at the point of service might be less adherent because they place less value on their medications than do patients who must pay even a small amount.

DISCLOSURES

This study was funded by Pfizer Canada, Montréal, Québec, Canada. Blais received research grants or honorarium from AstraZeneca, Pfizer Canada, Sanofi, Novartis, Almirall, GlaxoSmithKline, and Merck for research projects and co-chairs the AstraZeneca Endowment Pharmaceutical Chair in Respiratory Health. Després, Kettani, and Forget have no competing interests to declare. All authors contributed to the concept and design of the study. Data were collected by Blais and Forget. Data analysis was conducted by Després. The manuscript was written by Després and revised by all authors.