The effect of drug co-payment policy on the purchase of prescription drugs for children with infections in the community

Using early childhood infections to predict late childhood antibiotic consumption: a prospective cohort study

Background

In the Swedish welfare system, the prescription and price of antibiotics is regulated. Even so, socioeconomic circumstances might affect the consumption of antibiotics for children.

Aim

This study aimed to investigate if socioeconomic differences in antibiotic prescriptions could be found for children aged 2–14 years, and to find predictors of antibiotic consumption in children, especially if morbidity or socioeconomic status in childhood may function as predictors.

Design & setting

Participants were from All Babies In Southeast Sweden (ABIS), a prospectively followed birth cohort (N = 17 055), born 1997-1999. Pharmaceutical data for a 10-year period, from 2005–2014 were used (the cohort were aged from 5–7, up to 14–16 years). Participation at the 5-year follow-up was 7443 children. All prescriptions from inpatient, outpatient, and primary care were included. National registries and parent reports were used to define socioeconomic data for all participants. Most children’s infections were treated in primary healthcare centres.

Method

Parents of included children completed questionnaires about child morbidity at birth and at intervals up to 12 years. Their answers, combined with public records and national registries, were entered into the ABIS database and analysed. The primary outcome measure was the number of antibiotic prescriptions for each participant during a follow-up period between 2005–2014.

Results

The most important predictor for antibiotic prescription in later childhood was parent-reported number of antibiotic-treated infections at age 2–5 years (odds ratio (OR) range 1.21 to 2.23, depending on income quintile; P<0.001). In the multivariate analysis, lower income and lower paternal education level were also significantly related to higher antibiotic prescription.

Conclusion

Parent-reported antibiotic-treated infection at age 2–5 years predicted antibiotic consumption in later childhood. Swedish doctors are supposed to treat all patients individually and to follow official guidelines regarding antibiotics, to avoid antibiotics resistance. As socioeconomic factors are found to play a role, awareness is important to get unbiased treatment of all children.

The impact of prescription drug co-payments for publicly insured families

Co-payments for prescription drugs are a common feature of many healthcare systems, although often with exemptions for vulnerable population groups. International evidence demonstrates that cost-sharing for medicines may delay necessary care, increase use of other forms of healthcare and result in poorer health outcomes. Existing studies concentrate on adults and older people, particularly in the US, with relatively less attention afforded to paediatric and European populations. In Ireland, prescription drug co-payments were introduced for the first time for medical cardholders (i.e. those with public health insurance) in October 2010, initially at a cost of €0.50 per item, rising to €1.50 in January 2013, and further increasing to €2.50 in December 2013. Using data from the Growing Up in Ireland longitudinal study of children, and a difference-in-difference research design, we estimate the impact of the introduction (and increase) of these co-payments on health, healthcare utilisation and household financial wellbeing. The introduction of modest co-payments on prescription items was not estimated to impinge on the health of children and parents from low-income families. For the younger Infant Cohort, difference-in-difference estimates indicated that the introduction (and increase) in co-payments was associated with a decrease in GP visits and hospital nights, and a decrease in the proportion of households reporting 'difficulties with making ends meet'. In contrast, for the older cohort of children (the Child Cohort), co-payments were associated with an increase in GP visiting, and an increase in household deprivation. While the parallel trends assumption for difference-in-difference analysis appeared to be satisfied, further investigation revealed that there were other time-varying observable factors (such as exposure to the economic recession over the period) that affected the treatment and control groups, as well as the two cohorts of children differentially, that may partly explain these divergent results. For example, while the analysis suggests that the introduction of the €0.50 co-payment in 2010 was associated with an increase in the probability of treated families in the Child Cohort being deprived by 9.4 percentage points, the proportion of treated families experiencing unemployment and reductions in household income also increased significantly around the time of the co-payment introduction. This highlights the difficulty in identifying the effect of the co-payment policy in an environment in which assignment to the treatment (i.e. medical cardholder status) was not randomly assigned.

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.

Socioeconomic factors and epinephrine prescription in children with peanut allergy

BACKGROUND

Epinephrine autoinjectors provide life-saving therapy for individuals with peanut allergies. OJECTIVE: To evaluate the association between socioeconomic status (SES) and epinephrine prescription among urban Canadian children with peanut allergy.

METHODS

Population-based survey data from school children in grades 1 and 2 participating in the Toronto Child Health Evaluation Questionnaire were used. Children with peanut allergy, their epinephrine autoinjector prescription status and their SES were identified by parental report.

RESULTS

Between January and April 2006, 5619 completed questionnaires from 231 Toronto, Ontario, schools were returned. A total of 153 (2.83%) children were identified as having a peanut allergy, 68.6% of whom reported being prescribed an epinephrine autoinjector. Children from upper-middle and high-income homes (OR 8.35 [95% CI 2.72 to 25.61]) and with asthma (OR 4.74 [95% CI 1.56 to 14.47]) were more likely to report having an epinephrine prescription.

CONCLUSION

A significant health disparity exists in the prescribing pattern of epinephrine autoinjectors for peanut-allergic children from families of differing SES.

Financial incentive increases CPAP acceptance in patients from low socioeconomic background

Objective

We explored whether financial incentives have a role in patients′ decisions to accept (purchase) a continuous positive airway pressure (CPAP) device in a healthcare system that requires cost sharing.

Design

Longitudinal interventional study.

Patients

The group receiving financial incentive (n = 137, 50.8±10.6 years, apnea/hypopnea index (AHI) 38.7±19.9 events/hr) and the control group (n = 121, 50.9±10.3 years, AHI 39.9±22) underwent attendant titration and a two-week adaptation to CPAP. Patients in the control group had a co-payment of $330–660; the financial incentive group paid a subsidized price of $55.

Results

CPAP acceptance was 43% greater (p = 0.02) in the financial incentive group. CPAP acceptance among the low socioeconomic strata (n = 113) (adjusting for age, gender, BMI, tobacco smoking) was enhanced by financial incentive (OR, 95% CI) (3.43, 1.09–10.85), age (1.1, 1.03–1.17), AHI (>30 vs. <30) (4.87, 1.56–15.2), and by family/friends who had positive experience with CPAP (4.29, 1.05–17.51). Among average/high-income patients (n = 145) CPAP acceptance was affected by AHI (>30 vs. <30) (3.16, 1.14–8.75), living with a partner (8.82, 1.03–75.8) but not by the financial incentive. At one-year follow-up CPAP adherence was similar in the financial incentive and control groups, 35% and 39%, respectively (p = 0.82). Adherence rate was sensitive to education (+yr) (1.28, 1.06–1.55) and AHI (>30 vs. <30) (5.25, 1.34–18.5).

Conclusions

Minimizing cost sharing reduces a barrier for CPAP acceptance among low socioeconomic status patients. Thus, financial incentive should be applied as a policy to encourage CPAP treatment, especially among low socioeconomic strata patients.

Low socioeconomic status is a risk factor for CPAP acceptance among adult OSAS patients requiring treatment

STUDY OBJECTIVE

To evaluate whether socioeconomic status (SES) has a role in obstructive sleep apnea syndrome (OSAS) patients' decision to accept continuous positive airway pressure (CPAP) treatment.

DESIGN

Cross-sectional study; patients were recruited between March 2007 and December 2007.

SETTING

University-affiliated sleep laboratory.

PATIENTS

162 consecutive newly diagnosed (polysomnographically) adult OSAS patients who required CPAP underwent attendant titration and a 2-week adaptation period.

RESULTS

40% (n = 65) of patients who required CPAP therapy accepted this treatment. Patients accepting CPAP were older, had higher apnea-hypopnea index (AHI) and higher income level, and were more likely to sleep in a separate room than patients declining CPAP treatment. More patients who accepted treatment also reported receiving positive information about CPAP treatment from family or friends. Multiple logistic regression (after adjusting for age, body mass index, Epworth Sleepiness Scale, and AHI) revealed that CPAP purchase is determined by: each increased income level category (OR, 95% CI) (2.4; 1.2-4.6), age + 1 year (1.07; 1.01-1.1), AHI ( > or = 35 vs. < 35 events/hr) (4.2, 1.4-12.0), family and/or friends with positive experience of CPAP (2.9, 1.1-7.5), and partner sleeps separately (4.3, 1.4-13.3).

CONCLUSIONS

In addition to the already known determinants of CPAP acceptance, patients with low SES are less receptive to CPAP treatment than groups with higher SES. CPAP support and patient education programs should be better tailored for low SES people in order to increase patient treatment initiation and adherence.

What impact do prescription drug charges have on efficiency and equity? Evidence from high-income countries

As pharmaceutical expenditure continues to rise, third-party payers in most high-income countries have increasingly shifted the burden of payment for prescription drugs to patients. A large body of literature has examined the relationship between prescription charges and outcomes such as expenditure, use, and health, but few reviews explicitly link cost sharing for prescription drugs to efficiency and equity. This article reviews 173 studies from 15 high-income countries and discusses their implications for important issues sometimes ignored in the literature; in particular, the extent to which prescription charges contain health care costs and enhance efficiency without lowering equity of access to care.

A co-payment for consultant services: primary care physicians' referral actualization

Prospective evaluation of the effect of a new copayment for specialists consultations on actualization of referrals (2,432 patient), was examined. Actualization of the appointment, reasons for not actualizing, and sociodemographic characteristics were recorded. Actualization was 85.1% in community consultation clinics and 91.7% in hospital outpatient clinics. The main reasons for non actualization were: inability to reach the clinic (53.4%), the problem had resolved (15%), and co-payment (2%). In addition, 19.1% stated that they did not actualize a past consultant visit due to co-payment. Referring physicians noted that co-payment had some effect on their decision, especially with the elderly or lower income patients. A relatively small compulsory co-payment was not found to have a long term effect on utilization of specialists' services.

Dispensing pattern of generic and brand-name drugs in children

OBJECTIVE

To describe the dispensing patterns of generic and brand-name drugs in children and to identify patient sociodemographic characteristics associated with generic drug use.

METHODS

We analyzed data from the 2002 Medical Expenditures Panel Survey. This survey is conducted by the Agency for Healthcare Research and Quality and consists of a nationally representative sample of civilian noninstitutionalized population of the United States. The 2002 survey included 14 828 families and 37 418 individuals, 11 099 of whom were children 0 to 17 years of age. Our unit of analysis was individual prescription drugs dispensed to children 0 to 17 years of age. The main dependent variable for the logistic model was the use of generic drugs. Independent variables included age, gender, race, insurance type, family income, Metropolitan Statistical Area status, and health status.

RESULTS

Generic drugs were filled in 40.6% of the 24 465 prescriptions analyzed. Average expenditure for generic drugs was $20.92 (SD 24.53) per prescription versus $71.65 (SD $170.22) for brand-name drugs. Use of generic versus brand-name drugs varied by conditions and medication class. Uninsured patients were more likely than privately insured patients to have a generic drug dispensed than brand-name drugs (odds ratio [OR] 1.42; 95% confidence interval [CI], 1.10-1.84). Asian children were more likely than white children to receive generic drugs (OR, 1.66; 95% CI, 1.07-2.57). Girls were also more likely than boys to receive generic drugs over brand-name drugs (OR, 1.36; 95% CI, 1.08-1.73).

CONCLUSIONS

Generic drugs were dispensed more often to uninsured children, Asian children, and girls.

Barriers to rehabilitation following surgery for primary breast cancer

Surgery is a mainstay of primary breast cancer therapy. Alterations in surgical technique have reduced normal tissue injury, yet pain and functional compromise continue to occur following treatment. A tenuous evidence base bolstered by considerable expert opinion suggests that early intervention with conventional rehabilitative modalities can reduce surgery-associated pain and dysfunction. Barriers to the timely rehabilitation of functionally morbid sequelae are discussed at length in this article. Barriers arise from a wide range of academic, human, logistic, and financial sources. Despite obstacles, expeditious and effective post-surgical rehabilitation is being regularly delivered to breast cancer patients at many institutions. This experience has given rise to anecdotal information on the management of common sequelae that may undermine function. The epidemiology, pathophysiology, and management of these sequelae are outlined in this article with an emphasis on the caliber of supporting evidence. Myofascial dysfunction, axillary web syndrome, frozen shoulder, lymphostasis, post-mastectomy syndrome, and donor site morbidity following breast reconstruction are addressed. A critical need for more definitive evidence to guide patient management characterizes the current treatment algorithms for surgical sequelae.

Antibiotic treatment of wheezing in children with asthma: what is the practice?

OBJECTIVE

Antibiotics are not recommended for the treatment of wheezing in children with asthma, but little is known about their use. This study was undertaken to evaluate trends and determinants of antibiotic use in children with wheezing during the fiscal years 1995 through 2001.

METHODS

Using the population-based health care and prescription databases in Manitoba, Canada, this descriptive study examined time trends in antibiotic prescription use for wheezing episodes in a population of children with asthma. The likelihood of receiving an antibiotic prescription according to child and physician characteristics also was determined. Annual population-based rates of antibiotic prescriptions for wheezing episodes were modeled by age and antibiotic class, using general estimating equations. The odds ratio for receiving an antibiotic prescription according to child demographics and physician factors was determined from hierarchical linear modeling.

RESULTS

The antibiotic prescription rate for wheezing decreased by 28% from 708 prescriptions per 1000 children with asthma in 1995 to 511 prescriptions in 2001. Fifteen-fold increases in use were observed for broader spectrum macrolides in preschool children. Twenty-three percent of physician visits for wheezing resulted in an immediate antibiotic prescription, but this percentage increased to 64% for antibiotics that were received within 7 days of the episode. General practitioners prescribed antibiotics more often than did pediatricians. Physicians who were not trained in Canada or the United States were 40% more likely to prescribe antibiotics than their counterparts.

CONCLUSIONS

Antibiotic use for wheezing in children declined in the 1990s, but the increased use of broader spectrum macrolides has implications for antibiotic resistance. A link between antibiotic prescribing and physician specialty and location of training identifies opportunities for intervention.

Breast-feeding, day-care attendance and the frequency of antibiotic treatments from 1.5 to 5 years: a population-based longitudinal study in Canada

This paper aims to study, at the population level, the protective role of breast-feeding on child health and its relation to day-care attendance during the first 5 years of life. The analysis, done on a national sample of children, uses antibiotic treatments as a general measure of health. It takes into account mother's education level, family poverty level, mother's smoking status during pregnancy and after birth, mother's age, sex, gestation duration, and birth rank. The analyses were performed using data from the Longitudinal Study of Child Development in Quebec (LSCDQ), conducted by Santé Québec, a division of the Institut de la Statistique du Québec (ISQ). The study was based on face-to-face interviews and included a set of questionnaires addressed to the children's mothers and fathers. A total of 1841 were included in the sample analyzed. Detailed information on breast-feeding and complementary feeding was collected at 5 and 17 months through face-to-face interviews with the most knowledgeable person, generally the mother. From this information, it has been possible to estimate breast-feeding duration and exclusivity. Our results indicate that the positive effects of breast-feeding on health persist up to the second year of life, even in the presence of day-care attendance. The analyses indicate that breast-feeding reduced the number of antibiotic treatments given to children entering day care before 2.5 years of age. The study also indicates that the more-at-risk children could be protected by breast-feeding and by being taken care of in a familial setting, especially before 2.5 years of age. Mother's education, family poverty level, and other social inequality indicators did not play a role in the frequency of antibiotic treatments. Over the long term, it will be important to continue to monitor the health of children and to implement public health interventions aimed at reducing health problems among children of preschool age.

Decrease in antibiotic use among children in the 1990s: not all antibiotics, not all children

BACKGROUND

Decreases in antibiotic use were widely reported in the 1990s. This study was undertaken to determine trends in the use of antibiotics from fiscal year (FY) 1995 (April 1995 to March 1996) to FY 2001 in a complete population of Manitoba children.

METHODS

Using Manitoba's health care databases, we determined annual population-based rates of antibiotic prescription among children by antibiotic class (narrow-spectrum and broader-spectrum antibiotics), age group, physician diagnosis (e.g., otitis media or bronchitis) and neighbourhood income in urban areas (derived from the 1996 census). Antibiotic prescription rates were generated within a generalized linear model framework with general estimating equations, and differences between FY 2001 and FY 1995 were tested. Differences in antibiotic use over time were compared across antibiotic classes, age groups, diagnoses and income neighbourhoods.

RESULTS

The overall antibiotic prescription rate decreased by almost one-third, from 1.2 prescriptions per child in FY 1995 to 0.9 prescriptions in FY 2001. Total antibiotic use declined for all respiratory tract infections; decreases were greatest for the sulfonamides (decrease to less than one-third the FY 1995 rate) and narrow-spectrum macrolides (decrease to less than half the FY 1995 rate). In contrast, the FY 2001 rate for broader-spectrum macrolides was as much as 12.5 times the FY 1995 rate. Otitis media accounted for one-quarter of the use of the latter agents. Preschool children and low-income children received the greatest number of antibiotic prescriptions. Declines in antibiotic prescriptions were of a lesser magnitude for low-income children (for whom rates in FY 2001 were four-fifths the rates in FY 1995) than for higher-income children (for whom rates in FY 2001 were about two-thirds the rates in FY 1995).

INTERPRETATION

Overall, antibiotic use declined over the late 1990s in this population of Canadian children, but the increasing use of broader-spectrum macrolides and higher rates of antibiotic use among preschool and low-income children may have implications for antibiotic resistance.

Evidence-based prescribing of antibiotics for children: role of socioeconomic status and physician characteristics

BACKGROUND

Evidence-based guidelines for antibiotic use are well established, but nonadherence to these guidelines continues. This study was undertaken to determine child, household and physician factors predictive of nonadherence to evidence-based antibiotic prescribing in children.

METHODS

The prescription and health care records of 20 000 Manitoba children were assessed for 2 criteria of nonadherence to evidence-based antibiotic prescribing during the period from fiscal year 1996 (April 1996 to March 1997) to fiscal year 2000: receipt of an antibiotic for a viral respiratory tract infection (VRTI) and initial use of a second-line agent for acute otitis media, pharyngitis, pneumonia, urinary tract infection or cellulitis. The likelihood of nonadherence to evidence-based prescribing, according to child demographic characteristics, physician factors (specialty and place of training) and household income, was determined from hierarchical linear modelling. Child visits were nested within physicians, and the most parsimonious model was selected at p < 0.05.

RESULTS

During the study period, 45% of physician visits for VRTI resulted in an antibiotic prescription, and 20% of antibiotic prescriptions were for second-line antibiotics. Relative to general practitioners, the odds ratio for antibiotic prescription for a VRTI was 0.51 (95% confidence interval [CI] 0.42-0.62) for pediatricians and 1.58 (95% CI 1.03-2.42) for other specialists. The likelihood that an antibiotic would be prescribed for a VRTI was 0.99 for each successive 10,000 Canadian dollars increase in household income. Pediatricians and other specialists were more likely than general practitioners to prescribe second-line antibiotics for initial therapy. Both criteria for nonadherence to evidence-based prescribing were 40% less likely among physicians trained in Canada or the United States than among physicians trained elsewhere.

INTERPRETATION

The links that we identified between nonadherence to evidence-based antibiotic prescribing in children and physician specialty and location of training suggest opportunities for intervention. The independent effect of household income indicates that parents also have an important role.

Adenotonsillectomy in children with obstructive sleep apnea syndrome reduces health care utilization

OBJECTIVE

To investigate health care utilization of children with obstructive sleep apnea syndrome (OSAS) 1 year after adenotonsillectomy (T&A).

METHODS

A longitudinal, case-controlled, prospective study was conducted at Clalit Health Care Services (CHS), a health maintenance organization in the southern region of Israel. We defined 3 groups of children: 1) children who had OSAS and were treated with T&A (n = 130); 2) children who had OSAS and did not undergo surgery (n = 90); and 3) control subjects who were matched by age, sex, and area of residency (n = 520) and randomly selected from the CHS database. OSAS was verified with polysomnography studies in all patients. Indices of health care utilization were analyzed 1 year before and 1 year after T&A. Medical records in the emergency department and during hospitalization were reviewed for diagnosis before the polysomnography diagnosis.

RESULTS

Mean age of all children with OSAS was 5.6 +/- 3.6 years. Total annual health care costs were reduced by one third in children who underwent T&A, whereas there was no change in the control and untreated OSAS groups. T&A was associated with a 60% reduction in the number of new admissions, 39% reduction in emergency department visits, 47% reduction in the number of consultations, and 22% reduction in costs for prescribed drugs. In group 2, the total costs were similar in years 1 and 2.

CONCLUSIONS

T&A significantly reduces health care utilization in children with OSAS. Untreated children with moderate and severe OSAS will continue to consume high levels of health care resources. Increased morbidity among children with OSAS is mainly related to upper respiratory tract infections.