Cost-related prescription nonadherence in the United States and Canada: a system-level comparison using the 2007 International Health Policy Survey in Seven Countries

Cost Barriers to Health Services in U.S. Adults Before and After the Implementation of the Affordable Care Act

Background: The Affordable Care Act (ACA) was passed in 2010 and implemented in 2014 in the United States (U.S.). It was partly intended to reduce the cost burden to health coverage and care.

Objective: To determine if ACA implementation reduced the odds of experiencing cost barriers to needed healthcare services for vulnerable groups.

Methodology: National Health Interview Survey Data from the Integrated Public Use Microdata Set (2011-2013; 2015-2017) were used to examine cost barriers to primary health, mental health, dental services, and prescription medications particularly for adults living in poverty, those of color, and unmarried individuals before and after implementation of the ACA. The study sample included 112,245 individuals, representing an annual average of 138 million adults (aged 26 to 64 years of age), including 59,367 survey respondents from 2011 to 2013 and 52,878 from 2015 to 2017.

Results: Pre/post-ACA, cost barriers to medical care decreased from 9.6% to 7.0% of adults, mental care from 3.0% to 2.4%, dental care 15.0 to 11.7%, and prescriptions from 9.9% to 7.0% (all comparisons p<.001). Survey design-adjusted regression results indicated significant decreases in the odds of experiencing cost barriers to physical, mental, dental health services and prescription medications after the implementation of the ACA for people living under 200% poverty, unmarried adults, and people of color. While the race was not a substantial barrier post-ACA, living in poverty and being unmarried remained the biggest predictors of cost barriers to services. Cost barriers for all services increased post ACA for adults with private coverage, and among older adults for prescription and dental services.

Conclusions: While the ACA was largely successful in reducing the number of uninsured adults in the U.S., remaining barriers suggest the need to strengthen the ACA and reduce cost barriers to healthcare services for everyone.

Access and Cost-Related Nonadherence to Prescription Medications Among Lupus Patients and Controls: The Michigan Lupus Epidemiology and Surveillance Program

OBJECTIVE

Medication access and adherence are important determinants of health outcomes. We investigated factors associated with access and cost-related nonadherence to prescriptions in a population-based cohort of systemic lupus erythematosus (SLE) patients and controls.

METHODS

Detailed sociodemographic and prescription data were collected by structured interview in 2014-2015 from participants in the Michigan Lupus Epidemiology and Surveillance (MILES) cohort. We compared access between cases and frequency-matched controls and examined associated factors in separate multivariable logistic regression models.

RESULTS

A total of 654 participants (462 SLE patients, 192 controls) completed the baseline visit; 584 (89%) were female, 285 (44%) were Black, and the mean age was 53 years. SLE patients and controls reported similar frequencies of being unable to access prescribed medications (12.1% versus 9.4%, respectively; P was not significant). SLE patients were twice as likely as controls to report cost-related prescription nonadherence in the preceding 12 months to save money (21.7% versus 10.4%; P = 0.001) but were also more likely to ask their doctor for lower cost alternatives (23.8% versus 15.6%; P = 0.02). Disparities were found in association with income, race, and health insurance status, but the main findings persisted after adjusting for these and other variables in multivariable models.

CONCLUSION

SLE patients were more likely than controls from the general population to report cost-related prescription nonadherence, including skipping doses, taking less medicine, and delaying filling prescriptions; yet, <1 in 4 patients asked providers for lower cost medications. Consideration of medication costs in patient decision-making could provide a meaningful avenue for improving access and adherence to medications.

Cost-related medication nonadherence in Canada: a systematic review of prevalence, predictors, and clinical impact

BACKGROUND

Cost-related nonadherence to medications (CRNA) is common in many countries and thought to be associated with adverse outcomes. The characteristics of CRNA in Canada, with its patchwork coverage of increasingly expensive medications, are unclear.

OBJECTIVES

Our objective in this systematic review was to summarize the literature evaluating CRNA in Canada in three domains: prevalence, predictors, and effect on clinical outcomes.

METHODS

We searched MEDLINE, Embase, Google Scholar, and the Cochrane Library from 1992 to December 2019 using search terms covering medication adherence, costs, and Canada. Eligible studies, without restriction on design, had to have original data on at least one of the three domains specifically for Canadian participants. Articles were identified and reviewed in duplicate. Risk of bias was assessed using design-specific tools.

RESULTS

Twenty-six studies of varying quality (n = 483,065 Canadians) were eligible for inclusion. Sixteen studies reported on the overall prevalence of CRNA, with population-based estimates ranging from 5.1 to 10.2%. Factors predicting CRNA included high out-of-pocket spending, low income or financial flexibility, lack of drug insurance, younger age, and poorer health. A single randomized trial of free essential medications with free delivery in Ontario improved adherence but did not find any change in clinical outcomes at 1 year.

CONCLUSION

CRNA affects many Canadians. The estimated percentage depends on the sampling frame, the main predictors tend to be financial, and its association with clinical outcomes in Canada remains unproven.

The Impact of Prescription Medication Cost Coverage on Oral Medication Use for Hypertension and Type 2 Diabetes Mellitus

BACKGROUND

No previous study, to the best of our knowledge, has examined both the time trend and impact of not having insurance or prescription medication cost coverage (PMCC) on the usage of type 2 diabetes and hypertension oral medications in Ontario and New Brunswick, Canada.

METHODS

We used data from the Canadian Community Health Survey (CCHS) from 2007 to 2014 to examine the time trend and impact of PMCC. A multivariable-adjusted logistic regression model was fitted.

RESULTS

The pseudo-cohort included 23,215 individuals representing a population of approximately 8.7 million people. Overall, 20.0% of respondents reported absence of PMCC. This proportion increased slightly from 19.6% (95% confidence interval [CI] 95% CI [17.5, 22.5]) to 20.7% (95% CI [16.9, 23.1]). Adjusted odds ratios (OR) showed that uninsured individuals were 23% less likely to use their medications (OR = 0.77, 95% CI [0.657, 0.911]).

CONCLUSION

There was a slight decline in PMCC over time and this decline was associated with reduced use of medications for type 2 diabetes and hypertension.

Cost-related medication nonadherence among over-indebted individuals enrolled in statutory health insurance in Germany: a cross-sectional population study

Background

Millions of citizens in high-income countries face over-indebtedness that implies being unable to cover payment obligations with available income and assets on an ongoing basis. Studies have shown an association between over-indebtedness and health outcomes, independent of standard socioeconomic status measures. Patterns of cost-related medication nonadherence (CRN) among over-indebted individuals are yet unclear. The aim of this study was to examine the frequency of nonadherence to prescribed medications due to cost, and to identify risk factors for CRN among over-indebted individuals in Germany.

Methods

In 2017, we conducted a cross-sectional survey among over-indebted individuals recruited in 70 debt advice agencies in North Rhine-Westphalia, Germany. Data on CRN in the last 12 months (i.e. not filling prescriptions, skipping or decreasing doses of prescribed medication due to financial problems) were collected by a survey using a self-administered written questionnaire that was returned by 699 individuals with a response rate of 50.2%. Prevalence of CRN was assessed using descriptive statistics. Multiple logistic regression analysis was performed to examine risk factors of CRN, including participants enrolled in statutory health insurance with complete data (n = 521).

Results

The prevalence of CRN was 33.6%. The chronically ill had significantly greater odds of cost-related medication nonadherence (aOR 1.96; 95% CI 1.27–3.03) than individuals without a chronic illness. CRN was more likely to occur in individuals who had discussed financial problems with their general practitioner (aOR 1.58; 95% CI 1.01–2.47). There was no association between CRN and other sociodemographic factors or socioeconomic status.

Conclusions

Medication nonadherence due to financial pressures is common among over-indebted citizens enrolled in statutory health insurance in Germany. Stakeholders in social policy, research and health care need to address over-indebtedness to develop strategies to safeguard access to relevant medications, especially among those with high morbidity.

Trial registration

Arzneimittelkonsum, insbesondere Selbstmedikation bei überschuldeten Bürgerinnen und Bürgern in Nordrhein-Westfalen (ArSemü), (engl. ‘Medication use, particularly self-medication among over-indebted citizens in North Rhine-Westphalia’), German Clinical Trials Register: DRKS00013100. Date of registration: 23.10.2017. Date of enrolment of the first participant: 18.07.2017, retrospectively registered.

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

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

Impact of cost on use of non-vitamin K antagonists in atrial fibrillation patients in Ontario, Canada

Canadian guidelines recommend non vitamin K antagonists (NOACs) in preference to vitamin K antagonists (VKAs) for stroke prevention in patients with atrial fibrillation (AF), but NOACs are more expensive than VKAs. Canada has a universal healthcare system that covers the cost of NOACs for select patient groups. Ability to pay for NOACs may influence their use. We reviewed medical charts of Hamilton General Hospital outpatients under the age of 65 with a new diagnosis of AF who were referred for initiation of OAC therapy. We contacted these patients by phone and asked them to complete a questionnaire regarding their OAC choice, economic factors that may have influenced this choice (income, insurance) and the financial burden of OAC therapy. We included 110 patients, mean age 56 years, and 26.4% females. NOAC users had a higher median neighborhood income than VKA users (p = 0.0144, n = 110). 73 patients responded to the questionnaire. NOAC users reported higher annual household income (p = 0.0038, n = 73). Patients with private insurance were more likely to use NOACs than those without insurance (p = 0.0496, n = 73). The cost of NOACs and ability to pay is a determinant of their use Ontario patients under the age of 65. This two tiered provision of care appears to contradict the values of Canada's universal healthcare system.

Cost-Related Insulin Underuse Among Patients With Diabetes

This survey study examines the association of higher insulin costs with nonadherence in patients with diabetes.

Prescription drug coverage in Canada: a review of the economic, policy and political considerations for universal pharmacare

BACKGROUND

Canadians have long been proud of their universal health insurance system, which publicly funds the cost of physician visits and hospitalizations at the point of care. Prescription drugs however, have been subject to a patchwork of public and private coverage which is frequently inefficient and creates access barriers to necessary medicine for many Canadians.

METHODS

A narrative review was undertaken to understand the important economic, policy and political considerations regarding implementation of universal prescription drug access in Canada (pan-Canadian pharmacare). PubMed, SCOPUS and google scholar were searched for relevant citations. Citation trails were followed for additional information sources. Published books, public reports, press releases, policy papers, government webpages and other forms of gray literature were collected from iterative internet searches to provide a complete view of the current state on this topic.

MAIN FINDINGS

Regarding health economics, all five of the reviewed pharmacare simulation models have shown reductions in annual prescription drug expenditure. However, differing policy and cost assumptions have resulted in a wide range of cost-saving estimates between models. In terms of policy, a single-payer, 'first-dollar' coverage model, using a minimum national formulary, is the model most frequently advocated by the academic community, healthcare professions and many public and patient groups. In contrast, a multi-payer, catastrophic 'last-dollar' coverage model, more similar to the current "patchwork" state of public and private coverage, is preferred by industry drug manufacturers and private health insurance companies. Primary concerns from the detractors of universal, single-payer, 'first-dollar' coverage are the financing required for its implementation and the access barriers that may be created for certain patient populations that are not majorly present in the current public-private payer mix.

CONCLUSION

Canada patiently awaits to see how the issue of prescription drug coverage will be resolved through the work of the Advisory Council on the Implementation of National Pharmacare. The overarching and ongoing discourse on policy and program implementation may be construed as a political debate informed by divergent public and private interests.

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

BACKGROUND

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

METHODS

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

RESULTS

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

INTERPRETATION

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

Is Canadian Healthcare Affordable? A Comparative Analysis of the Canadian Healthcare System from 2004 to 2014

Objective:

To compare cost-related non-adherence (CRNA), serious problems paying medical bills and average annual out-of-pocket cost over time in five countries.

Methods:

Repeated cross-sectional analysis of the Commonwealth Fund International Health Policy survey from 2004 to 2014. Responses were compared between Canada, the UK, Australia, New Zealand and the US.

Results:

Compared to the UK, respondents in Canada, Australia and New Zealand were two to three times and respondents in the US were eight times more likely to experience CRNA; these odds remained stable over time. From 2004 to 2014, Canadian respondents paid US $852–1,767 out-of-pocket for care. The US reported the largest risks of serious problems paying for care (13–18.5%), highest out-of-pocket costs (US $2,060–3,319) and greatest rise in expenditures.

Interpretation:

Over the 10-year period, financial barriers to care were identified in Canada and internationally. Such persistent challenges are of great concern to countries striving for equitable access to healthcare.

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

BACKGROUND

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

METHODS

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

RESULTS

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

INTERPRETATION

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

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.

Canadian Health Care System: Who Should Pay for All Medically Beneficial Treatments? A Burning Issue

The Canadian health care system can be characterized as a mix of public and private participation, although it is often described as a publicly funded system. In Canada, "medically necessary" services are covered with public funds; however, the Canada Health Act provides no formal definition of medical necessity. The provincial and territorial health care insurance plans decide which services are medically necessary. As a result, coverage of hospital and medical services differs among provinces. Outpatient prescription drugs are not covered by public plans. The coverage for diagnostics and medications for rare diseases is also limited. Private insurance plans, often provided by employers, are an expensive solution, although coverage is not sufficient. Those who are unemployed, self-employed, or informally employed and those with rare diseases that require expensive treatments and drugs frequently are not covered by any plan and face financial difficulty paying for their prescriptions and treatments. As a result, many Canadians are struggling and facing inequality in acquiring medical services for rare diseases and outpatient prescription drugs due to an unfair Canadian health care system. This paper proposes some recommendation to make medical services more accessible and affordable to every Canadian.

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

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

Does Increased Medication Use among Seniors Increase Risk of Hospitalization and Emergency Department Visits?

OBJECTIVE

To examine the extent of the health risks of consuming multiple medications among the older population.

DATA SOURCES/STUDY SETTING

Secondary data from the period 2004-2006. The study setting was the province of Ontario, Canada, and the sample consisted of individuals aged 65 years or older who responded to a national health survey.

STUDY DESIGN

We estimated a system of equations for inpatient and emergency department (ED) services to test the marginal effect of medication use on hospital services. We controlled for endogeneity in medication use with a two-stage residual inclusion approach appropriate for nonlinear models.

PRINCIPAL FINDINGS

Increased prescription drug use has the effect of increasing the likelihood of both being admitted into hospital and visiting a hospital ED. Each additional medication is associated with a 2-3 percent increase in the likelihood of hospitalization and a 3-4 percent increase in the likelihood of an ED visit, after controlling for past utilization, health status, the endogeneity of medication use, and the unobserved factors that may affect the use of both services.

CONCLUSIONS

Multiple medications appear to increase the risk of hospitalization among seniors covered by a universal prescription drug plan. These results raise questions about the appropriateness of medication use and the need for increased oversight of current prescribing practices.

Exploring the impact of financial barriers on secondary prevention of heart disease

BACKGROUND

Patients with coronary artery disease experience various barriers which impact their ability to optimally manage their condition. Financial barriers may result in cost related non-adherence to medical therapies and recommendations, impacting patient health outcomes. Patient experiences regarding financial barriers remain poorly understood. Therefore, we used qualitative methods to explore the experience of financial barriers to care among patients with heart disease.

METHODS

We conducted a qualitative descriptive study of participants in Alberta, Canada with heart disease (n = 13) who perceived financial barriers to care. We collected data using semi-structured face-to-face or telephone interviews inquiring about patients experience of financial barriers and the strategies used to cope with such barriers. Multiple analysts performed inductive thematic analysis and findings were bolstered by member checking.

RESULTS

The aspects of care to which participants perceived financial barriers included access to: medications, cardiac rehabilitation and exercise, psychological support, transportation and parking. Some participants demonstrated the ability to successfully self-advocate in order to effectively navigate within the healthcare and social service systems.

CONCLUSION

Financial barriers impacted patients' ability to self-manage their cardiovascular disease. Financial barriers contributed to non-adherence to essential medical therapies and health recommendations, which may lead to adverse patient outcomes. Given that it is such a key skill, enhancing patients' self-advocacy and navigation skills may assist in improving patient health outcomes.

Cost-related nonadherence to prescribed medicines among older Canadians in 2014: a cross-sectional analysis of a telephone survey

BACKGROUND

Canadians receive universal coverage for medically necessary hospital and physician services, but pharmaceutical coverage is incomplete. We sought to assess the effects of cost on access to medicines among older Canadians using data from a large survey conducted in 2014.

METHODS

This is a cross-sectional analysis of data from the Commonwealth Fund's 2014 International Health Policy Survey of Older Adults. Our primary outcome variable was self-reported cost-related nonadherence in the form of either not filling a prescription or skipping doses within the last 12 months because of out-of-pocket costs. We computed sample-weighted estimates of the population prevalence of cost-related nonadherence and conducted logistic regression analyses to determine associated factors.

RESULTS

We estimate that the prevalence of cost-related nonadherence in 2014 among Canadians aged 55 years and older was 8.3% (about 1 in 12). The population prevalence and adjusted odds of cost-related nonadherence was significantly higher among Canadians who were younger, in worse health, poorer or without private health insurance. Regional differences in population prevalence of cost-related nonadherence were not significant. The only provincial or regional difference in the adjusted odds of cost-related nonadherence was that residents of Quebec aged 55-64 years were about half as likely to report nonadherence as similarly aged residents of Ontario, our reference province (adjusted odds ratio 0.49, 95% confidence interval 0.29-0.82).

INTERPRETATION

The financial accessibility of prescription medicines still is a substantial public health issue in Canada that affects 1 in 12 Canadians older than 55 years of age. Older Canadians at greatest risk of cost-related nonadherence to prescribed treatments are those with low incomes and those without private insurance to cover costs not covered by public programs.

The international generalisability of evidence for health policy: A cross country comparison of medication adherence following policy change

Copayments for prescriptions may increase morbidity and mortality via reductions in adherence to medications. Relevant data can inform policy to minimise such unintended effects. We explored the generalisability of evidence for copayments by comparing two international copayment polices, one in Massachusetts and one in Ireland, to assess whether effects on medication adherence were comparable. We used national prescription data for public health insurance programmes in Ireland and Medicaid data in the U.S. New users of oral anti-hypertensive, anti-hyperlipidaemic and diabetic drugs were included (total n=14,259 in U.S. and n=43,843 in Ireland). We examined changes in adherence in intervention and comparator groups in each setting using segmented linear regression with generalised estimating equations. In Massachusetts, a gradual decrease in adherence to anti-hypertensive medications of -1% per month following the policy occurred. In contrast, the response in Ireland was confined to a -2.9% decrease in adherence immediately following the policy, with no further decrease over the 8 month follow-up. Reductions in adherence to oral diabetes drugs were larger in the U.S. group in comparison to the Irish group. No difference in adherence changes between the two settings for anti-hyperlipidaemic drugs occurred. Evidence on cost-sharing for prescription medicines is not 'one size fits all'. Time since policy implementation and structural differences between health systems may influence the differential impact of copayment policies in international settings.

Universal prescription drug coverage in Canada: Long-promised yet undelivered

Canada's universal public healthcare system is unique among developed countries insofar as it does not include universal coverage of prescription drugs. Universal, public coverage of prescription drugs has been recommended by major national commissions in Canada dating back to the 1960s. It has not, however, been implemented. In this article, we extend research on the failure of early proposals for universal drug coverage in Canada to explain failures of calls for reform over the past 20 years. We describe the confluence of barriers to reform stemming from Canadian policy institutions, ideas held by federal policy-makers, and electoral incentives for necessary reforms. Though universal "pharmacare" is once again on the policy agenda in Canada, arguably at higher levels of policy discourse than ever before, the frequently recommended option of universal, public coverage of prescription drugs remains unlikely to be implemented without political leadership necessary to overcome these policy barriers.

Medication Costs and Adherence of Treatment Before and After the Affordable Care Act: 1999-2015

To examine national changes in rates of cost-related prescription nonadherence (CRN) by age group, we used data from the 1999-2015 Sample Adult and Sample Child National Health Interview Surveys (n = 768 781). In a logistic regression analysis of 2015 data, we identified subgroups at risk for cost-related nonadherence. The proportion of all Americans who did not fill a prescription in the previous 12 months because they could not afford it grew from 1999 to 2009, peaking at 8.3% at the height of the Great Recession and dropping to 5.2% by 2015. CRN among seniors, however, peaked in 2004 at 5.4% and dropped to 3.6% after implementation of Medicare Part D in 2006. CRN is responsive to improved access related to implementation of Medicare Part D and the Affordable Care Act.

Persistence with medication and overactive bladder: an ongoing challenge

INTRODUCTION

For optimum results from pharmacological management of overactive bladder, adherence to prescribed medication is required. Overactive bladder treatment has been compromised by low adherence and persistence to medications, losing many people who might benefit from treatment and exposing them to unnecessary consequences of their disease.

AREAS COVERED

This narrative review examines what is known about adherence and persistence with treatment and, drawing evidence from other disease areas suggests factors which might be modifiable to improve the situation. A structured search of PubMed using the terms persistence, adherence, overactive bladder, urgency incontinence, and chronic conditions, was performed and added to as themes from exiting data emerged. Expert commentary: Adherence has traditionally been poor in this disease area with limited understanding of the modifiable factors underlying the observation. Increased understanding of the nature of the underlying disease should allow adoption of strategies tested in other disease areas.

Medication regimens of frail older adults after discharge from home healthcare

The purpose of this study was to examine the number and types of discrepancy errors present after discharge from home healthcare in older adults at risk for medication management problems following an episode of home healthcare. More than half of the 414 participants had at least one medication discrepancy error (53.2%, n = 219) with the participant's omission of a prescribed medication (n = 118, 30.17%) occurring most frequently. The results of this study support the need for home healthcare clinicians to perform frequent assessments of medication regimens to ensure that the older adults are aware of the regimen they are prescribed, and have systems in place to support them in managing their medications.

Reducing Medication Costs to Prevent Cardiovascular Disease: A Community Guide Systematic Review

INTRODUCTION

Hypertension and hyperlipidemia are major cardiovascular disease risk factors. To modify them, patients often need to adopt healthier lifestyles and adhere to prescribed medications. However, patients' adherence to recommended treatments has been suboptimal. Reducing out-of-pocket costs (ROPC) to patients may improve medication adherence and consequently improve health outcomes. This Community Guide systematic review examined the effectiveness of ROPC for medications prescribed for patients with hypertension and hyperlipidemia.

METHODS

We assessed effectiveness and economics of ROPC for medications to treat hypertension, hyperlipidemia, or both. Per Community Guide review methods, reviewers identified, evaluated, and summarized available evidence published from January 1980 through July 2015.

RESULTS

Eighteen studies were included in the analysis. ROPC interventions resulted in increased medication adherence for patients taking blood pressure and cholesterol medications by a median of 3.0 percentage points; proportion achieving 80% adherence to medication increased by 5.1 percentage points. Blood pressure and cholesterol outcomes also improved. Nine studies were included in the economic review, with a median intervention cost of $172 per person per year and a median change in health care cost of -$127 per person per year.

CONCLUSION

ROPC for medications to treat hypertension and hyperlipidemia is effective in increasing medication adherence, and, thus, improving blood pressure and cholesterol outcomes. Most ROPC interventions are implemented in combination with evidence-based health care interventions such as team-based care with medication counseling. An overall conclusion about the economics of the intervention could not be reached with the small body of inconsistent cost-benefit evidence.

Estimated cost of universal public coverage of prescription drugs in Canada

BACKGROUND

With the exception of Canada, all countries with universal health insurance systems provide universal coverage of prescription drugs. Progress toward universal public drug coverage in Canada has been slow, in part because of concerns about the potential costs. We sought to estimate the cost of implementing universal public coverage of prescription drugs in Canada.

METHODS

We used published data on prescribing patterns and costs by drug type, as well as source of funding (i.e., private drug plans, public drug plans and out-of-pocket expenses), in each province to estimate the cost of universal public coverage of prescription drugs from the perspectives of government, private payers and society as a whole. We estimated the cost of universal public drug coverage based on its anticipated effects on the volume of prescriptions filled, products selected and prices paid. We selected these parameters based on current policies and practices seen either in a Canadian province or in an international comparator.

RESULTS

Universal public drug coverage would reduce total spending on prescription drugs in Canada by $7.3 billion (worst-case scenario $4.2 billion, best-case scenario $9.4 billion). The private sector would save $8.2 billion (worst-case scenario $6.6 billion, best-case scenario $9.6 billion), whereas costs to government would increase by about $1.0 billion (worst-case scenario $5.4 billion net increase, best-case scenario $2.9 billion net savings). Most of the projected increase in government costs would arise from a small number of drug classes.

INTERPRETATION

The long-term barrier to the implementation of universal pharmacare owing to its perceived costs appears to be unjustified. Universal public drug coverage would likely yield substantial savings to the private sector with comparatively little increase in costs to government.

Determinants of Cost-Related Nonadherence to Medications among Chronically Ill Patients in Maccabi Healthcare Services, Israel

BACKGROUND

The effectiveness of value-based insurance design is based on nonadherence, which derives solely from patients' economic constraints.

OBJECTIVE

Our objective was to examine the extent of cost-related nonadherence to chronic medications and to analyze its potential determinants.

METHODS

We conducted a telephone survey among a representative sample of Maccabi Healthcare Services chronically ill patients aged 55 years or older (n = 522). We developed a 12-month recall questionnaire that included demographic and socioeconomic characteristics, out-of-pocket expenditure on prescribed medication, physician's provision of explanation regarding prescribed therapy, adherence, and reasons for nonadherence. Respondents were defined as nonadherent if they reported that they did not purchase prescribed medications in the previous year because of their cost. We applied the multivariable logistic regression model to examine predictors of nonadherence.

RESULTS

Median (interquartile range) age of the study sample was 69 (13) years (53% males). One hundred sixty-five patients (31.6%) reported not purchasing prescribed medications mainly because of medications' adverse effects and/or cost. Fifty respondents (9.6%) reported cost-related nonadherence. The multivariable logistic regression model revealed that cost-related nonadherence was associated with respondent's income lower than 4600 New Israeli shekel (odds ratio [OR] = 10.86; 95% confidence interval [CI] 1.45-81.12), unemployment (OR = 4.32; 95% CI 1.47-12.66), lack of physician explanation about the prescribed medication (OR = 2.38; 95% CI 1.18-4.78), and age (OR = 0.95; 95% CI 0.91-0.99).

CONCLUSIONS

Cost-related nonadherence to chronic pharmaceuticals is self-reported among nearly 10% of the chronically ill patients and is strongly affected by low socioeconomic status, even under universal health insurance coverage and with relatively low co-payments as applied in Israel. Lack of information provided by physicians regarding the therapy is associated with a higher likelihood of cost-related nonadherence.

How does complementary private prescription drug insurance coverage affect seniors' use of publicly funded medications?

BACKGROUND

Like in many other high-income jurisdictions, the public drug program in Ontario, Canada provides comprehensive coverage of prescription drugs to the 65 years and older population with some cost sharing. The objective of this study was to examine the marginal impact of holding private drug coverage on the use of publicly funded medicines among the senior population in Ontario.

METHODS

We drew on linked survey and administrative data sources to examine the impact of private drug coverage first on total spending and utilization of medications, and second, on clinically recommended medications for individuals with a diagnosis of diabetes.

RESULTS

Approximately 27% of Ontario seniors reported having private prescription drug insurance from a current or prior employer. The population-level analysis of all seniors found that individuals with private insurance coverage, on average, took about a quarter of an additional drug and incurred 16% more in costs to the public program in a year compared to those without additional coverage. The disease-specific analysis of seniors with a diagnosis of diabetes found that private coverage was associated with two-fold higher odds of taking an anti-hypertensive drug, but it had no association with the use of statins or anti-diabetic medications.

DISCUSSION

The results of this study provide some evidence that seniors in Ontario are sensitive to the price of drugs. These findings raise equity concerns relating to the cost sharing arrangements in the public system and our policy of allowing private plans to "top-up" the public plan.

Non-adherence to drug therapy and drug acquisition costs in a national population--a patient-based register study

Background

Patients' non-adherence to drug therapy is a major problem for society as it is associated with reduced health outcomes. Generally, approximately only 50% of patients with chronic disease in developed countries adhere to prescribed therapy, and the most common non-adherence refers to chronic under-use, i.e. patients use less medication than prescribed or prematurely stop the therapy. Patients' non-adherence leads to high additional costs for society in terms of poor health. Non-adherence is also related to the unnecessary sale of drugs. The aim of the present study was to estimate the drug acquisition cost related to non-adherence to drug therapy in a national population.

Methods

We constructed a model of the drug acquisition cost related to non-adherence to drug therapy based on patient register data of dispensed out-patient prescriptions in the entire Swedish population during a 12-month period. In the model, the total drug acquisition cost was successively adjusted for the assumed different rates of primary non-adherence (prescriptions not being filled by the patient), and secondary non-adherence (medication not being taken as prescribed) according to the patient's age, therapies, and the number of dispensed drugs per patient.

Results

With an assumption of a general primary non-adherence rate of 3%, and a general secondary non-adherence rate of 50%, for all types of drugs, the acquisition cost related to non-adherence totalled SEK 11.2 billion (€ 1.2 billion), or 48.5% of total drug acquisition costs in Sweden 2006.

With the assumption of varying primary non-adherence rates for different age groups and different secondary non-adherence rates for varying types of drug therapies, the acquisition cost related to non-adherence totalled SEK 9.3 billion (€ 1.0 billion), or 40.2% of the total drug acquisition costs.

When the assumption of varying primary and secondary non-adherence rates for a different number of dispensed drugs per patient was added to the model, the acquisition cost related to non-adherence totalled SEK 9.9 billion (€ 1.1 billion), or 42.6% of the total drug acquisition costs.

Conclusions

Our estimate indicates that drug acquisition costs related to non-adherence represent a substantial proportion of the economic resources in the health care sector. A low rate of primary non-adherence, combined with a high rate of secondary non-adherence, contributes to a large degree of unnecessary medical spending. Thus, efforts of different types of interventions are needed to improve secondary adherence.

Adherence, therapeutic intensity, and the number of dispensed drugs

PURPOSE

To estimate non-adherence in relation to the therapeutic intensity (TI) and the number of dispensed drugs per individual and study whether the TI can be used as an estimator of non-adherence with an increasing number of drugs.

METHODS

The study comprised an individual-based register of all dispensed outpatient prescriptions in Sweden in 2006, including 6.2 million individuals. The applied definition of drug was the chemical entity or substance comprising the fifth level in the World Health Organisation's Anatomic, Therapeutic, Chemical classification. The defined daily dosage per individual during 12 months was applied as an indicator of the TI.

RESULTS

We found a positive linear relation between the TI and the increasing number of dispensed drugs per individual, both for men and women. We found a slightly diminishing TI with an increasing number of drugs only for the age groups above 70 years, at a level above 13 drugs per individual.

CONCLUSIONS

The linear relationship between the TI and the increasing number of dispensed drugs per individual provides poor support for using decreasing TI as an estimator of non-adherence. The low rate of cost-related non-adherence in Sweden might contribute to explaining the linear relationship.

Determinants of patient-reported medication errors: a comparison among seven countries

OBJECTIVE

Medication errors are a frequent cause of adverse drug events and a major concern for patient safety. This study compared the predictors of error among seven countries (Australia, Canada, New Zealand, the United Kingdom, the United States, Germany and the Netherlands).

METHODS

We conducted a cross-sectional study using the 2007 Commonwealth Fund International Health Policy Survey data. The outcome was patient-reported error in the past 2 years. Possible predictors were studied using logistic regression.

RESULTS

Eleven thousand nine hundred and ten respondents were included in this analysis, of which 1291 respondents (11%) had experienced error. Poor coordination of care was a shared concern of all seven countries [adjusted odds ratios (ORs) ranged from 2.1 (95% CI: 1.3-3.5) to 3.0 (95% CI: 2.1-4.5)]. Cost-related barriers to medical services/medicines was also a predictor in six countries [ORs ranged from 1.9 (95% CI: 1.5-2.6) to 2.6 (95% CI: 1.5-4.6)]. Other common risk factors across countries included seeing multiple specialists, multiple chronic conditions, hospitalisation and multiple emergency room visits. Cross-country heterogeneity in contributing factors included age and specific chronic condition. Number of medications, number of doctor visits, household income and education level were not associated with error in most countries.

CONCLUSION

Poor coordination of care is a key risk factor in all seven countries. Cost-related barriers were also associated with an increased likelihood of error. The major challenge for all countries for error prevention is better communication among multiple healthcare providers and more structured organisation of care across healthcare settings.

Insurance status and demographic and clinical factors associated with pharmacologic treatment of depression: associations in a cohort in Buenos Aires

OBJECTIVE

There is a paucity of evidence about insurance status and the likelihood of receiving medical services in Latin America. The objective of this analysis was to examine the association between insurance status and pharmacologic treatment for depression.

METHODS

Patients referred to a memory clinic of a public hospital in Buenos Aires, Argentina, and identified with any of four types of depression (subsyndromal, dysthymia, major, and due to dementia) were included. Age, years of education, insurance status, Beck Depression Inventory score, and number of comorbidities were considered. Associations between these factors and not receiving pharmacologic treatment for depression were examined with logistic regression. Use of prescription neuroleptics, hypnotics, and anticholinesterase inhibitors was also explored.

RESULTS

Out of 100 patients, 92 with insurance status data were used. Sixty-one patients (66%) had formal insurance and 31 patients (34%) lacked insurance. Twenty-seven (44%) insured patients and 23 (74%) uninsured patients did not receive antidepressants (P = 0.001). Controlling for other factors, uninsured patients had 7.12 higher odds of not receiving treatment compared to insured patients (95% confidence interval 1.88-28.86). Older patients and those with more comorbidities had higher odds of not receiving treatment. More educated patients, those with higher Beck Depression Inventory score, and those without subsyndromal depression had lower odds of not receiving treatment. None of those associations were statistically significant.

CONCLUSIONS

These results suggest a potential negative effect of the lack of formal insurance regarding pharmacologic treatment for depression. These findings should be confirmed with larger samples, and for other diseases.

Sex, drugs and gender roles: mapping the use of sex and gender based analysis in pharmaceutical policy research

BACKGROUND

Sex and gender sensitive inquiry is critical in pharmaceutical policy due to the sector's historical connection with women's health issues and due to the confluence of biological, social, political, and economic factors that shape the development, promotion, use, and effects of medicinal treatments. A growing number of research bodies internationally have issued laws, guidance or encouragement to support conducting sex and gender based analysis (SGBA) in all health related research.

METHODS

In order to investigate the degree to which attempts to mainstream SGBA have translated into actual research practices in the field of pharmaceutical policy, we employed methods of literature scoping and mapping. A random sample of English-language pharmaceutical policy research articles published in 2008 and indexed in MEDLINE was analysed according to: 1) use of sex and gender related language, 2) application of sex and gender related concepts, and 3) level of SGBA employed.

RESULTS

Two thirds of the articles (67%) in our sample made no mention of sex or gender. Similarly, 69% did not contain any sex or gender related content whatsoever. Of those that did contain some sex or gender content, the majority focused on sex. Only 2 of the 85 pharmaceutical policy articles reviewed for this study were primarily focused on sex or gender issues; both of these were review articles. Eighty-one percent of the articles in our study contained no SGBA, functioning instead at a sex-blind or gender-neutral level, even though the majority of these (86%) were focused on topics with sex or gender aspects.

CONCLUSIONS

Despite pharmaceutical policy's long entwinement with issues of sex and gender, and the emergence of international guidelines for the inclusion of SGBA in health research, the community of pharmaceutical policy researchers has not internalized, or "mainstreamed," the practice. Increased application of SGBA is, in most cases, not only appropriate for the topics under investigation, but well within the reach of today's pharmaceutical policy researchers.

Medicine-taking practices in community-dwelling people aged > or =75 years in New Zealand

BACKGROUND

older people experience more chronic medical conditions than younger people, take more prescription medicines and are more likely to suffer from cognitive or memory problems. Older people are more susceptible to the adverse effects of medicines, which may reduce their quality of life or lead to hospitalisation or death.

OBJECTIVE

this study aims to identify medicine-taking practices amongst community-dwelling people aged > or =75 years in New Zealand.

METHODS

this study was carried out in an urban setting in Dunedin (population 120,000), New Zealand. Interviews of a random sample of people from the electoral roll using a structured questionnaire were conducted. Subjects were community-dwelling people aged > or =75 years taking one or more prescription medicines. From a random sample of 810 people extracted from the electoral roll intended to recruit 300 participants, 524 people met the study criteria and were invited to participate. People living in a rest home or hospital, not contactable by telephone, or now deceased, were excluded. Responses were analysed, medicines categorised by the Anatomical Therapeutic Chemical classification and adherence classed as high, medium and low using a modified four-item Morisky Medication Adherence Scale. Univariate and multivariate linear and logistic regression was applied to combinations of variables.

RESULTS

in total, 316 interviews were undertaken; a 61% response rate. Participants were 75-79 (35%), 80-84 (40%) and >85 years (25%); New Zealand European/European (84%), 'New Zealanders' (14%) or Maori (2%); and 141 (45%) lived alone. Almost half (49%) regularly saw a specialist and a third (34%) had been admitted to hospital in the past 12 months. Participants used a median of seven prescription medicines (range 1-19) and one non-prescription medicine (0-14). The majority (58%) believed medicines are effective and had systems/routines (92%) for remembering to take them. Doses tended to be missed following a change in routine, e.g. holiday. Men were more likely to report 'trouble remembering' than women (odds ratio = 1.86, 95% confidence interval 1.10-3.14; P = 0.020). Seventy-five percent of people had high or medium adherence scores and 25%, low scores. Common problems were reading and understanding labels (9 and 4%, respectively) and leaflets (12%, 6%), and difficulty swallowing solid dose forms (14%). Only 6% had problems paying for their medicines. Around 17% wanted to know more about their medicines, and some people were confused about their medicines following hospital discharge.

CONCLUSION

overall, community-dwelling people aged > or =75 years in this study appeared to manage their medicines well and found them affordable. Nevertheless, there is a need to improve labelling, leaflets and education on medicines, particularly at hospital discharge.

Medication issues in older individuals with CKD

Older US adults bear a substantial burden of chronic disease and take an average of five prescription and non-prescription medications per day. Recent data suggest that over 20% of older adults have chronic kidney disease (CKD) as defined by an impaired glomerular filtration rate. These individuals often have multiple comorbidities, including diabetes, hypertension, and cardiovascular disease. Although patients with CKD may receive substantial benefits from prescribed medications, they are also at high risk for adverse drug events and polypharmacy. In this review, we outline the risks and benefits of medication use in the CKD population as a specific case within geriatric pharmacoepidemiology as a framework.