Inadequate prescription-drug coverage for Medicare enrollees--a call to action

Health Outcomes, Income and Income Inequality: Revisiting the Empirical Relationship

In this paper we revisit the relationship between health outcomes, income, and income inequality by applying alternative panel methodologies to a dataset of high-income countries spanning the time period 1980-2017. In this direction, we adopt alternative methodological frameworks in order to provide a) meaningful results by taking into account standard errors that alleviate problems of cross-sectional (spatial) and temporal dependence, and b) insights into the underlying relationships at several points of the conditional distribution of the health outcomes dependent variables. The evidence strongly supports the significant role that income plays in determining health outcomes. The findings relating to income inequality and nonlinear terms are more fragmented in that their significance and sign-direction depend on the functional form and the respective quantiles of the distribution the relationships are evaluated.

Minority Women

Perceptions of illness, pain, and death are not static. They vary among populations according to their cultural and biological characteristics. Older black and Hispanic/Latinx women are unique in their approach to health care with respect to mentation, mobility, medication adherence, and what matters to them. It is the complexity of these components, which affect the ability of these women to age gracefully.

Strengthening value-based medication management in a free clinic for the uninsured: Quality interventions aimed at reducing costs and enhancing adherence

Skyrocketing costs of prescription medications in the USA pose a significant threat to the financial viability of safety net clinics that opt to supply medications at low to no out-of-pocket costs to patients. At the East Harlem Health Outreach Partnership clinic of the Icahn School of Medicine at Mount Sinai, a physician-directed student-run comprehensive primary care clinic for uninsured adults of East Harlem, expenditures on pharmaceuticals represent nearly two-thirds of annual costs. The practice of minimising costs while maintaining quality, referred to as high-value care, represents a critical cost-saving opportunity for safety net clinics as well as for more economical healthcare in general. In this paper, we discuss a series of quality improvement initiatives aimed at reducing pharmacy-related expenditures through two distinct yet related mechanisms: (A) promoting value-conscious prescribing by providers and (B) improving patient adherence to medication regimens. Interventions aimed at promoting value-conscious prescribing behaviour included blacklisting a costly medication on our clinic’s formulary and adding a decision tree in our mobile clinician reference application to promote value-conscious prescribing. Interventions targeted to improving patient adherence involved an automated text messaging system with English and Spanish refill reminders to encourage timely pick-up of medication refills. As a result of these processes, the free clinic experienced a 7.3%, or $3768, reduction in annual pharmacy costs. Additionally, medication adherence in patients with diabetes on oral antihyperglycaemic medications increased from 55% to 67%. Simultaneous patient-based and provider-based interventions may be broadly applicable to addressing rising pharmacy costs in healthcare across the USA.

Prescription Assistance for Older Adults with Limited Incomes: Client and Program Characteristics

Objective:

To describe the sociodemographic, medication-related, health services utilization and health characteristics of the community-dwelling senior citizens (≥65 y) with limited incomes who enrolled in Senior PHARM Assist, a community-based prescription assistance program.

Patients:

Senior citizens (n = 387) enrolled in the program between June 1994 and May 1996. All eligible participants were 65 years of age or older, had incomes below 140% of the federal poverty level, but were not enrolled in Medicaid. All the patients were living in Durham County and were taking prescription medications.

Measurements:

Self- or caregiver-reported. In addition to demographic characteristics, polypharmacy (taking ≥5 prescription medications in the last month), medication adherence (adherence to directions on the medication container), medication knowledge (client or caregiver stated appropriate purpose for taking the medication), adverse effects from medications, and activities of daily living and instrumental activities of daily living limitations were measured.

Results:

Eighty percent of the senior citizens lived below the federal poverty level, 82% were women, 53% were African-American, 53% lived alone, and the mean monthly income for a single person was $595 and for a couple was $939. They were taking, on average, 8.9 medications, were adherent with 71% of their medications, knew the purpose of 69% of their medications, and reported adverse effects from 10% of their prescription medications.

Conclusions:

This population of community-dwelling seniors takes, on average, a higher number of prescription medications than previously reported, posing a higher risk for the hazards associated with polypharmacy and uncoordinated prescribing, such as nonadherence, drug interactions, and adverse effects. There may be a greater need for future intervention programs to include a comprehensive educational component, such as a coordinated medication review, in addition to financial assistance.

Evaluating availability and price of essential medicines in Boston area (Massachusetts, USA) using WHO/HAI methodology

BACKGROUND

Many patients even those with health insurance pay out-of-pocket for medicines. We investigated the availability and prices of essential medicines in the Boston area.

METHODS

Using the WHO/HAI methodology, availability and undiscounted price data for both originator brand (OB) and lowest price generic (LPG) equivalent versions of 25 essential medicines (14 prescription; 11 over-the-counter (OTC)) were obtained from 17 private pharmacies. The inclusion and prices of 26 essential medicines in seven pharmacy discount programs were also studied. The medicine prices were compared with international reference prices (IRPs).

RESULTS

In surveyed pharmacies, the OB medicines were less available as compared to the generics. The OB and LPG versions of OTC medicines were 21.33 and 11.53 times the IRP, respectively. The median prices of prescription medicines were higher, with OB and LPG versions at 158.14 and 38.03 times the IRP, respectively. In studied pharmacy discount programs, the price ratios of surveyed medicines varied from 4.4-13.9.

CONCLUSIONS

While noting the WHO target that consumers should pay no more than four times the IRPs, medicine prices were considerably higher in the Boston area. The prices for medicines included in the pharmacy discount programs were closest to WHO's target. Consumers should shop around, as medicine inclusion and prices vary across discount programs. In order for consumers to identify meaningful potential savings through comparison shopping, price transparency is needed.

Near equality in quality for medication utilization among older adults with diabetes with universal medication insurance in Ontario, Canada

RATIONALE, AIMS AND OBJECTIVES

To determine whether demographic, community or health status disparities in cardioprotective medication utilization by diabetes patients exist under a universal drug insurance programme, and whether they narrow or widen during periods of increasing drug utilization.

METHODS

We examined all prescriptions filled by all people with diabetes aged ≥65 years in Ontario, Canada in annual cohorts from 1996 (n = 175 345) to 2010 (n = 504 093). We ascertained whether any disparities in use of three classes of cardioprotective medication (statins, all antihypertensives and renin-angiotensin-aldosterone system inhibitors) existed, and whether disparities changed over time.

RESULTS

Utilization of all three cardioprotective medication classes increased substantially over time, particularly statins (rate ratio per year: 1.13, 95% confidence interval 1.11-1.15). We found no disparities associated with many of the demographic or community characteristics examined (including sex, income or rural residence). Use of statins was lower in those aged ≥80 compared with younger age groups, although this disparity narrowed during the study. Persistently lower use of antihypertensives by minorities and by recent immigrants may be due to lower quality of care, barriers to access, or other patient or provider factors, which highlights the need for ongoing monitoring for disparities even in populations with universal drug insurance. Differences in medication utilization based on health status characteristics such as previous cardiovascular disease were medically indicated.

CONCLUSIONS

Although a universal drug insurance programme was reasonably successful in ensuring few disparities in cardioprotective medication use by older patients with diabetes, disparities persisted for some subpopulations, so additional interventions continue to be needed to ensure equitable care.

Food insecurity and low self-efficacy are associated with health care access barriers among Puerto-Ricans with type 2 diabetes

Racial/ethnic minorities are disproportionately affected by barriers to health care access and utilization. The primary objective was to test for an independent association between household food insecurity and health care access/utilization. In this cross-sectional survey, 211 Latinos (predominantly, Puerto-Ricans) with type 2 diabetes (T2D) were interviewed at their homes. Factor analyses identified four barriers for health care access/utilization: enabling factor, doctor access, medication access and forgetfulness. Multivariate logistic regression models examined the association between each of the barrier factors and food insecurity controlling for sociodemographic, cultural, psychosocial, and diabetes self-care variables. Higher food insecurity score was a risk factor for experiencing enabling factor (OR = 1.46; 95% CI = 1.17-1.82), medication access (OR = 1.26; 95 CI% = 1.06-1.50), and forgetfulness (OR = 1.22; 95 CI% = 1.04-1.43) barriers. Higher diabetes management self-efficacy was protective against all four barriers. Other variables associated with one or more barriers were health insurance, perceived health, depression, blood glucose, age and education. Findings suggest that addressing barriers such as food insecurity, low self-efficacy, lack of health insurance, and depression could potentially result in better health care access and utilization among low income Puerto-Ricans with T2D.

Work-related asthma, financial barriers to asthma care, and adverse asthma outcomes: asthma call-back survey, 37 states and District of Columbia, 2006 to 2008

BACKGROUND

Proper asthma management and control depend on patients having affordable access to healthcare yet financial barriers to asthma care are common.

OBJECTIVE

To examine associations of work-related asthma (WRA) with financial barriers to asthma care and adverse asthma outcomes.

RESEARCH DESIGN

Cross-sectional, random-digit-dial survey conducted in 37 states and District of Columbia.

SUBJECTS

A total of 27,927 ever-employed adults aged ≥18 years with current asthma.

MEASURES

Prevalence ratios (PR) for the associations of WRA with financial barriers to asthma care and of WRA with adverse asthma outcomes stratified by financial barriers.

RESULTS

Persons with WRA were significantly more likely than those with non-WRA to have at least 1 financial barrier to asthma care [PR, 1.66; 95% confidence interval (CI), 1.43-1.92]. Individuals with WRA were more likely to experience adverse asthma outcomes such as asthma attack (PR, 1.31; 95% CI, 1.22-1.40), urgent treatment for worsening asthma (PR, 1.57; 95% CI, 1.39-1.78), asthma-related emergency room visit (PR, 1.69; 95% CI, 1.41-2.03), and very poorly controlled asthma (PR, 1.54; 95% CI: 1.36-1.75). After stratifying for financial barriers to asthma care, the associations did not change.

CONCLUSIONS

Financial barriers to asthma care should be considered in asthma management, and individuals with WRA are more likely to experience financial barriers. However, individuals with WRA are more likely to experience adverse asthma outcomes than individuals with non-WRA, regardless of financial barriers. Additional studies are needed to identify medical, behavioral, occupational, or environmental factors associated with adverse asthma outcomes among individuals with WRA.

Prescription Drug Use and Seniors

L'augmentation des dépenses de médicaments a placé les aîné(e)s sous les feux de la réforme de santé puisqu'ils en sont les plus grands consommateurs. On pourrait apporter des modifications substantielles à la consommation de médicaments presents, ce qui rehausserait les bienfaits des traitements et en minimiserait les effets négatifs, surtout chez les aîné(e)s. On documente ici un bon nombre de problèmes, notamment la surconsommation et la sous-consommation des médicaments, les erreurs d'ordonnances, la conformité au traitement et les médicaments inutilement coûteux. On a démontré l'efficacité de certaines éléments à l'égard de certains aspects du problème; qu'on cite simplement les politiques reliées au système de soins de santé, les interventions de certains médecins et de pharmaciens d'hôpitaux, les aides à la prise de dècisions et à la conformité aux traitements. Il faut mettre en place l'intégration des principales politiques et des interventions en une solution globale visant une meilleure utilisation des médicaments. Elle pourrait se composer des éléments suivants: (1) la révision des politiques de relations entre l'industrie pharmacologique et le secteur de la santé; (2) l'établissement de règlements d'expérimentation des médicaments chez les aînés avant leur approbation; (3) un institut du consommateur servant de ressource centrale objective aux demandes de renseignements des patients et de système d'appui aux décisions; (4) des systèmes intégrés d'information clinique à l'appui des systèmes de gestion des ordonnances et de la fourniture des médicaments et de la gestion des médicaments et des maladies à l'intention des pharmaciens et des médecins de premier recours; (5) une réforme de la formation médicale et de l'octroi des permis.

Food insecurity is associated with cost-related medication non-adherence in community-dwelling, low-income older adults in Georgia

Low-income older adults are at increased risk of cutting back on basic needs, including food and medication. This study examined the relationship between food insecurity and cost-related medication non-adherence (CRN) in low-income Georgian older adults. The study sample includes new Older Americans Act Nutrition Program participants and waitlisted people assessed by a self-administered mail survey (N = 1000, mean age 75.0 + so - 9.1 years, 68.4% women, 25.8% African American). About 49.7% of participants were food insecure, while 44.4% reported practicing CRN. Those who were food insecure and/or who practiced CRN were more likely to be African American, low-income, younger, less educated, and to report poorer self-reported health status. Food insecure participants were 2.9 (95% CI 2.2, 4.0) times more likely to practice CRN behaviors than their counterparts after controlling for potential confounders. Improving food security is important inorder to promote adherence to recommended prescription regimens.

Lessons learned: who didn't enroll in Medicare drug coverage in 2006, and why?

The law that created Medicare's prescription drug benefit, Medicare Part D, also established extra help for low-income seniors in the form of a subsidy. This study, the first in-depth analysis of Part D enrollment among Medicare beneficiaries without prior drug coverage, finds that 63 percent of all eligible seniors and 69 percent of low-income beneficiaries were enrolled in Part D in 2006. However, only 29 percent of low-income beneficiaries were enrolled in the subsidy program, leaving millions without coverage. Many reported that premiums were too costly, enrollment too difficult, and information too hard to obtain for enrollment. Additionally, provisions of the recently enacted Patient Protection and Affordable Care Act may have the perverse impact of reducing enrollment in Part D for certain beneficiaries. Our findings emphasize the need to expand eligibility and improve policies to foster enrollment.

Effect of Medicare Part D on potentially inappropriate medication use by older adults

OBJECTIVES

To empirically estimate changes of potentially inappropriate medication (PIM) use attributable to the Medicare Part D prescription drug benefit.

DESIGN

Difference-in-difference strategy in the quasi-experimental design with a control group.

SETTING

U.S. nationally representative community-dwelling sample of older adults.

PARTICIPANTS

One thousand seven hundred seventy-four adults aged 65 and older in the 2005 and 2006 Medical Expenditure Panel Surveys were followed up for 2 years with five rounds of interviews.

MEASUREMENTS

PIM use was identified based on the 2002 Beers criteria. Analyses were conducted for likelihood of PIM use and number of PIM prescriptions using logit models and negative binomial models, respectively.

RESULTS

There was a trend of less likelihood of PIM use for all older adults from 2005 to 2006 (odds ratio=0.67, 95% confidence interval (CI)=0.52-0.86). After accounting for this secular trend and potential confounders, no significant difference of the likelihood of PIM use was found between Part D enrollees and nonenrollees, although enrollees were found to use significantly more PIM prescriptions in round 5 (in 2006) than nonenrollees (incidence rate ratio=1.56, 95% CI=1.08-2.25).

CONCLUSION

This initial evidence suggests that Medicare Part D could result in more PIM use in older enrollees than in nonenrollees, although the overall likelihood of PIM use has decreased in all older community-dwelling adults. Future research is needed to examine the effect over the longer term and focusing on particular categories of PIMs.

Challenges and struggles: lived experiences of individuals with co-occurring disorders

Approximately 20 million people have substance abuse disorder in a given year, and approximately 7-10 million of them will have co-occurring disorders (CODs) of both mental illness and substance abuse. Individuals with COD have higher rates of other chronic health problems (i.e., diabetes) and multiple rehospitalizations and overutilize emergent services. Despite their elevated risk for physical morbidities, there is a dearth of literature that focuses on the impact for those with COD of having multiple physical health disorders. The purpose of this interpretive study was to understand, describe, and illustrate the social and structural barriers that individuals with COD of mental illness, substance abuse, and general medical conditions encounter in regard to their health care. A purposive sampling of 20 individuals with COD (11 men and 9 women; 65% African American) were recruited from community treatment centers and supportive housing sites. Social and structural barriers to managing medical health conditions while living with COD were identified in three realms: (a) in having interpersonal relationships with health care providers, (b) in negotiating an arduous health care "system," and (c) in trying to manage health conditions while living in unstable shelter.

A Review of the Comprehensiveness of Provincial Drug Coverage for Canadian Seniors

Provincial government drug plans are the primary source of insurance for drugs taken by seniors in outpatient settings. The adequacy of this coverage has been called into question, given the increased clinical importance of pharma-ceuticals, shifts in the provision of health care from inpatient to outpatient settings, increased use of restrictive formularies, and reductions in provincial drug subsidies. To assess the adequacy of provincial coverage, we estimated what a typical single senior beneficiary of a provincial drug plan paid out-of-pocket in 1998 on prescription drugs covered by the public program, depending on his/her province of residence, level of drug consumption, and income. We compared provincial coverage for seniors with large drug costs. We also assessed provincial coverage of drugs that were introduced into the Canadian market between 1991 and 1998. The cost of drugs consumed by a senior in a given province and year was estimated by multiplying the average number of prescription drugs consumed by senior drug users by the average per-prescription costs. High drug consumption was defined as twice the average. We used the provincial drug cost sharing rules to estimate the senior's share of the total cost of drugs consumed. Mean out-of-pocket costs range from $42 to $1,302 per year, are lower for lower-income seniors, and increase with drug use, although the charge per drug decreases with the number used. There was up to a 12-fold variation among the provinces in the charges faced by seniors with similar incomes and drug use. All but one province limits costs to seniors with catastrophic drug costs, but there was 21-fold variation in the expenditure limits. The substantial variation in seniors' out-of-pocket drug costs raises questions about the distributive equity of drug subsidies in Canada. Recent evidence on the deleterious health effects of drug charges faced by seniors in Quebec and the fact that seniors in some other provinces face direct charges similar to those faced in Quebec raise the possibility of adverse consequences of drug charges in other provinces.

Potentially inappropriate medication utilization in the emergency department visits by older adults: analysis from a nationally representative sample

OBJECTIVES

The objectives were to determine the frequency of administration of potentially inappropriate medications (PIMs) to older emergency department (ED) patients and to examine recent trends in the rates of PIM usage.

METHODS

The data examined during the study were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS). This study utilized the nationally representative ED data from 2000-2006 NHAMCS surveys. Our sample included older adults (age 65 years and greater) who were treated in the ED and discharged home. Estimated frequencies of PIM-associated ED visits were calculated. A multivariable logistic regression model was created to assess demographic, clinical, and hospital factors associated with PIM administration and to assess temporal trends.

RESULTS

Approximately 19.5 million patients, or 16.8% (95% confidence interval [CI]=16.1% to 17.4%) of eligible ED visits, were associated with one or more PIMs. The five most common PIMs were promethazine, ketorolac, propoxyphene, meperidine, and diphenhydramine. The total number of medications prescribed or administered during the ED visit was most strongly associated with PIM use. Other covariates associated with PIM use included rural location outside of the Northeast, being seen by a staff physician only (and not by a resident or intern), presenting with an injury, and the combination of female sex and age 65-74 years. There was a small but significant decrease in the proportion of visits associated with a PIM over the study period.

CONCLUSIONS

Potentially inappropriate medication administration in the ED remains common. Given rising concerns about preventable complications of medical care, this area may be of high priority for intervention. Substantial regional and hospital type (teaching versus nonteaching) variability appears to exist.

Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis

CONTEXT

It is well-documented that the financial burden of out-of-pocket expenditures for prescription drugs often leads people with medication-sensitive chronic illnesses to restrict their use of these medications. Less is known about the extent to which such cost-related medication underuse is associated with increases in subsequent hospitalizations and deaths.

OBJECTIVE

We compared the risk of hospitalizations among 5401 and of death among 6135 middle-aged and elderly adults with one or more cardiovascular diseases (diabetes, coronary artery disease, heart failure, and history of stroke) according to whether participants did or did not report restricting prescription medications because of cost.

DESIGN AND SETTING

A retrospective biannual cohort study across 4 cross-sectional waves of the Health and Retirement Study, a nationally representative survey of adults older than age 50. Using multivariate logistic regression to adjust for baseline differences in sociodemographic and health characteristics, we assessed subsequent hospitalizations and deaths between 1998 and 2006 for respondents who reported that they had or had not taken less medicine than prescribed because of cost.

RESULTS

Respondents with cardiovascular disease who reported underusing medications due to cost were significantly more likely to be hospitalized in the next 2 years, even after adjusting for other patient characteristics (adjusted predicted probability of 47% compared with 38%, P < 0.001). The more survey waves respondents reported cost-related medication underuse during 1998 to 2004, the higher the probability of being hospitalized in 2006 (adjusted predicted probability of 54% among respondents reporting cost-related medication underuse in all 4 survey waves compared with 42% among respondents reporting no underuse, P < 0.001). There was no independent association of cost-related medication underuse with death.

CONCLUSIONS

In this nationally representative cohort, middle-aged and elderly adults with cardiovascular disease who reported cutting back on medication use because of cost were more likely to report being hospitalized over a subsequent 2-year period after they had reported medication underuse. The more extensively respondents reported cost-related underuse over time, the higher their adjusted predicted probability of subsequent hospitalization.

Prescription coverage, use and spending before and after Part D implementation: a national longitudinal panel study

BACKGROUND

In January 2006, 43 million Medicare beneficiaries became eligible for subsidized prescription coverage (Part D) through Medicare. To date, no longitudinal study has afforded information on beneficiaries' prescription coverage transitions and corresponding changes in prescription use and spending.

OBJECTIVE

To evaluate changes in Medicare beneficiaries' prescription coverage, use and spending before and after Part D implementation, including comparison of those who enrolled in Part D with those who did not.

DESIGN, SETTING AND PARTICIPANTS

Longitudinal observational study of non-institutionalized Medicare beneficiaries aged 65 and older (n = 9,573) employing administrative data from the Centers for Medicare and Medicaid Services (CMS) and survey-based data from beneficiaries (2003, 2006). Sampling drew from a 1% national probability sample (2003), oversampling low-income beneficiaries including those dually-enrolled in Medicare and Medicaid. MEASUREMENTS & MAIN RESULTS: Number and type of prescriptions, monthly out-of-pocket prescription spending, and cost-related non-adherence to prescription regimens. Most respondents who lacked prescription coverage in 2003 had acquired it by 2006 (82.6%)-primarily through Part D (63.1%). Part D enrollees who previously lacked coverage or had Medigap coverage appear particularly advantaged by Part D, as evidenced by significantly increased prescription use, lower out-of-pocket spending and lower non-adherence. Those with employer-based coverage experienced significantly increased spending. Among those still lacking coverage in 2006, high rates of cost-related non-adherence (31.8%) were reported by the low-income, chronically ill subgroup.

CONCLUSIONS

In its first year, Part D coverage appears to have moderated prescription spending and cost-related burden for those who previously had meager benefits or none. Increased spending among those with employer-based coverage may reflect a narrowing of those benefits over this period. Evidence of foregone care among low-income, chronically ill seniors who still lack prescription coverage highlights the importance of targeted outreach to this group for Part D's low-income subsidy program.

The effect of depression and cognitive impairment on enrollment in Medicare Part D

OBJECTIVES

To examine concerns that vulnerable populations, such as depressed or cognitively impaired beneficiaries would have challenges accessing Part D coverage.

DESIGN

Logistic regression analysis was used to assess whether elderly Medicare beneficiaries with depression or cognitive impairment differentially planned to and actually signed up for Part D.

SETTING

2004 and 2006 data from the Health and Retirement Study (HRS) were used, including a subsample that completed the Prescription Drug Study (PDS) in 2005.

PARTICIPANTS

Nine thousand five hundred ninety-three HRS respondents and 3,567 PDS respondents.

MEASUREMENTS

The outcome variables of interest were planned and actual enrollment in Part D. The independent variables were depression and cognitive impairment status. The analyses were adjusted using clinical and demographic predictors including age, sex, race or ethnicity, educational attainment, net worth, marital status, health status, number of health conditions being treated with prescription medications, and presence of a caregiver.

RESULTS

Although having depression or cognitive impairment was associated with a higher likelihood of planning to and actually signing up for Part D in unadjusted analyses, in adjusted analyses, having depression or cognitive impairment was not significantly associated with whether Medicare beneficiaries planned to enroll in or actually enrolled in Part D.

CONCLUSION

Vulnerable Medicare beneficiaries with depression or cognitive impairment were able to access Part D benefits to the same extent as nonvulnerable beneficiaries. More research is needed to determine how well Part D meets the needs of these populations.

Impact of Drug Plan Management Policies in Canada: A Systematic Review

Background/objective:

In Canada, pharmaceutical expenditures require an increasing proportion of total health care dollars. Drug plan managers use various policies to manage medication use and control costs, but these policies can have unintended consequences. The objective of this systematic review is to evaluate the impact of drug policies on economic, clinical and humanistic (quality of life or satisfaction) outcomes.

Methods:

Articles in which the primary objective was to evaluate the impact of a drug policy tool or technique in Canada and that measured one or more economic, clinical or humanistic outcomes were considered for inclusion. Studies were excluded if they were based in institutions or not published in peer-reviewed journals. The search process included searching 9 electronic databases, searching the reference lists of identified articles and working papers and contacting drug policy researchers. Studies were assessed for quality and suitability for meta-analysis. We performed a qualitative synthesis of the study design, study sample and outcomes.

Results:

Thirty-five articles satisfied the inclusion criteria. Most ( n= 25, 71%) determined that drug policies reduced the costs, utilization or both of the studied drug therapy. Only 13 studies (37%) measured the impact of the drug policy on the cost or utilization of medical care, and the impact of the policy was favourable in only 4 of these cases. Six studies (17%) evaluated the impact of the policy on clinical outcomes; none reported a favourable impact. No studies evaluated the impact of the drug policy on humanistic outcomes.

Discussion:

Although the drug policies in most of the studies included in this systematic review did achieve the desired goal of reducing drug costs, utilization or both, the impact on other outcomes was seldom examined. In the 6 studies in which clinical outcomes were included in the evaluation framework, the impact was inconclusive. Humanistic outcomes have been completely excluded from evaluations to date.

Cost-related medication nonadherence and spending on basic needs following implementation of Medicare Part D

CONTEXT

Cost-related medication nonadherence (CRN) has been a persistent problem for individuals who are elderly and disabled in the United States. The impact of Medicare prescription drug coverage (Part D) on CRN is unknown.

OBJECTIVE

To estimate changes in CRN and forgoing basic needs to pay for drugs following Part D implementation.

DESIGN, SETTING, AND PARTICIPANTS

In a population-level study design, changes in study outcomes between 2005 and 2006 before and after Medicare Part D implementation were compared with historical changes between 2004 and 2005. The community-dwelling sample of the nationally representative Medicare Current Beneficiary Survey (unweighted unique n = 24,234; response rate, 72.3%) was used, and logistic regression analyses were controlled for demographic characteristics, health status, and historical trends.

MAIN OUTCOME MEASURES

Self-reports of CRN (skipping or reducing doses, not obtaining prescriptions) and spending less on basic needs to afford medicines.

RESULTS

The unadjusted, weighted prevalence of CRN was 15.2% in 2004, 14.1% in 2005, and 11.5% after Part D implementation in 2006. The prevalence of spending less on basic needs was 10.6% in 2004, 11.1% in 2005, and 7.6% in 2006. Adjusted analyses comparing 2006 with 2005 and controlling for historical changes (2005 vs 2004) demonstrated significant decreases in the odds of CRN (ratio of odds ratios [ORs], 0.85; 95% confidence interval [CI], 0.74-0.98; P = .03) and spending less on basic needs (ratio of ORs, 0.59; 95% CI, 0.48-0.72; P < .001). No significant changes in CRN were observed among beneficiaries with fair to poor health (ratio of ORs, 1.00; 95% CI, 0.82-1.21; P = .97), despite high baseline CRN prevalence for this group (22.2% in 2005) and significant decreases among beneficiaries with good to excellent health (ratio of ORs, 0.77; 95% CI, 0.63-0.95; P = .02). However, significant reductions in spending less on basic needs were observed in both groups (fair to poor health: ratio of ORs, 0.60; 95% CI, 0.47-0.75; P < .001; and good to excellent health: ratio of ORs, 0.57; 95% CI, 0.44-0.75; P < .001).

CONCLUSIONS

In this survey population, there was evidence for a small but significant overall decrease in CRN and forgoing basic needs following Part D implementation. However, no net decrease in CRN after Part D was observed among the sickest beneficiaries, who continued to experience higher rates of CRN.

Potentially inappropriate medication use in hospitalized elders

BACKGROUND

Prescribing of potentially harmful medications has not been well documented in hospitals.

OBJECTIVE

The objective of the study was to determine the rate of and factors associated with potentially inappropriate medication (PIM) prescribing in a large inpatient sample.

DESIGN

The study was a retrospective cohort of the period between September 1, 2002, and June 30, 2005. We used multivariable logistic regression to identify patient, physician, and hospital characteristics associated with PIM prescribing.

SETTING

The study collected data from 384 US hospitals.

PATIENTS

The sample was composed of patients aged >or=65 years admitted with 1 or more of 7 common medical diagnoses.

MEASUREMENTS

The percentage of patients prescribed PIMs as defined using a modified Beers list was measured. Multivariable-adjusted odds ratios for PIM use were computed.

RESULTS

Of the 493,971 patients, 49% received at least 1 PIM, and 6% received 3 or more, most commonly promethazine, diphenhydramine, and propoxyphene. Patient, physician, and hospital characteristics were all associated with PIM use. Patients with myocardial infarction or heart failure were most likely (61% and 52% vs. 46% for pneumonia), men (47% vs. 49% for women) and those in managed care plans (44% vs. 49% for other plans) were less likely, and patients >or=85 years were least likely (42% vs. 53% for patients aged 65-74 years) to receive PIMs (P < .0001 for all comparisons). For high-severity PIMs, internists and hospitalists had similar prescribing rates (33%), cardiologists had a higher rate (48%), and geriatricians had the lowest rate (24%). The proportion of elders receiving PIMs ranged from 34% in the Northeast to 55% in the South, and variation at the individual hospital level was extreme. At 7 hospitals, PIMs were never prescribed.

CONCLUSIONS

Wide variation in the use of PIMs is associated with hospital and physician characteristics. Care may be improved by minimizing this non-patient-centered variation.

Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly

BACKGROUND

Potentially inappropriate medication (PIM) use is a major source of drug-related problems in the elderly. Few studies have quantified the effect of PIM use on total healthcare expenditures in the United States.

OBJECTIVES

: We sought to determine the relationship between PIM use and healthcare expenditure and to estimate the annual incremental healthcare expenditures related to PIM use in the community-dwelling elderly population in the United States in 2001.

METHODS

This was a retrospective cohort study. Participants were age 65 years or older who had no PIM use in rounds 1 and 2 of the 2000-2001 Medical Expenditure Panel Survey, a nationally representative survey of the US noninstitutionalized population. On the basis of the 2002 Beers criteria, PIM users were identified as those who had been prescribed at least one PIM during specified time periods in the study. Propensity scores were used to match PIM users and nonusers in the analysis examining differences in total healthcare expenditures.

RESULTS

PIM utilization is a significant predictor for higher healthcare expenditures (P < 0.05). A conservative estimate of the incremental healthcare expenditures related to PIM use in the community-dwelling elderly population would be $7.2 billion (95% confidence interval, $3.4 billion-$15.7 billion) in the United States in 2001.

CONCLUSIONS

PIM use is a major patient safety concern that results in increased healthcare expenditures. This study emphasizes the need for continued provider education to inform prescribers of the potential risks of using certain medications in the elderly and to improve prescribing practices.

The demise of Oregon's Medically Needy program: effects of losing prescription drug coverage

BACKGROUND

In January 2003, people covered by Oregon's Medically Needy program lost benefits owing to state budget shortfalls. The Medically Needy program is a federally matched optional Medicaid program. In Oregon, this program mainly provided prescription drug benefits.

OBJECTIVE

To describe the Medically Needy population and determine how benefit loss affected this population's health and prescription use.

DESIGN

A 49-question telephone survey instrument created by the research team and administered by a research contractor.

PARTICIPANTS

A random sample of 1,269 eligible enrollees in Oregon's Medically Needy Program. Response rate was 35% with 439 individuals, ages 21-91 and 64% women, completing the survey.

MEASUREMENTS

Demographics, health information, and medication use at the time of the survey obtained from the interview. Medication use during the program obtained from administrative data.

RESULTS

In the 6 months after the Medically Needy program ended, 75% had skipped or stopped medications. Sixty percent of the respondents had cut back on their food budget, 47% had borrowed money, and 49% had skipped paying other bills to pay for medications. By self-report, there was no significant difference in emergency department visits, but a significant decrease in hospitalizations comparing 6 months before and after losing the program. Two-thirds of respondents rated their current health as poor or fair.

CONCLUSIONS

The Medically Needy program provided coverage for a low-income, chronically ill population. Since its termination, enrollees have decreased prescription drug use and increased financial burden. As states make program changes and Medicare Part D evolves, effects on vulnerable populations must be considered.

Medication utilization in an urban homebound population

BACKGROUND

The number of medically homebound adults has grown with the aging of the U.S. population, yet little is known about their health care utilization. We sought to characterize the health status and medication utilization of an urban cohort of homebound adults and to identify factors associated with medication use in this population.

METHODS

We performed a retrospective cross-sectional analysis of 415 patients enrolled in a primary care program for homebound adults in New York City during October 2002. Numbers of medications were obtained from formularies corroborated by home visits. For patients without prescription insurance, medication out-of-pocket costs were estimated according to average wholesale pricing. Sociodemographic and disease characteristics were obtained by chart abstraction.

RESULTS

The median age was 83 years (range 25-106 years). Seventy-seven percent of patients were female, 63% were non-white, and 28% spoke Spanish. Sixty-four percent of patients had Medicaid. The cohort had a mean of 8.2 (range 1-27, standard deviation 4.5) medications prescribed per month. Multivariate analysis showed that increasing age was associated with fewer medications (p <.001). Charlson comorbidity score was positively associated with number of medications (p <.001), whereas Activities of Daily Living score, a measure of functional dependence, was not. Twenty-seven percent of the cohort lacked prescription drug coverage. The total number of medications per month among the uninsured patients was 7.4 (standard deviation 4.4). Estimated median monthly out-of-pocket cost for the uninsured patients was dollar 223 (range dollar 1-dollar 1512).

CONCLUSIONS

For homebound patients without prescription drug coverage, medication use may represent substantial financial burden. Additional research is needed to determine whether out-of-pocket medication costs represent a barrier to care in this population.

Unintended consequences of caps on Medicare drug benefits

BACKGROUND

Little information exists about the consequences of limits on prescription-drug benefits for Medicare beneficiaries.

METHODS

We compared the clinical and economic outcomes in 2003 among 157,275 Medicare+Choice beneficiaries whose annual drug benefits were capped at 1,000 dollars and 41,904 beneficiaries whose drug benefits were unlimited because of employer supplements.

RESULTS

After adjusting for individual characteristics, we found that subjects whose benefits were capped had pharmacy costs for drugs applicable to the cap that were lower by 31 percent than subjects whose benefits were not capped (95 percent confidence interval, 29 to 33 percent) but had total medical costs that were only 1 percent lower (95 percent confidence interval, -4 to 6 percent). Subjects whose benefits were capped had higher relative rates of visits to the emergency department (relative rate, 1.09 [95 percent confidence interval, 1.04 to 1.14]), nonelective hospitalizations (relative rate, 1.13 [1.05 to 1.21]), and death (relative rate, 1.22 [1.07 to 1.38]; difference, 0.68 per 100 person-years [0.30 to 1.07]). Among subjects who used drugs for hypertension, hyperlipidemia, or diabetes in 2002, those whose benefits were capped were more likely to be nonadherent to long-term drug therapy in 2003; the respective odds ratios were 1.30 (95 percent confidence interval, 1.23 to 1.38), 1.27 (1.19 to 1.34), and 1.33 (1.18 to 1.48) for subjects using drugs for hypertension, hyperlipidemia, and diabetes. In each subgroup, the physiological outcomes were worse for subjects whose drug benefits were capped than for those whose benefits were not capped; the odds ratios were 1.05 (95 percent confidence interval, 1.00 to 1.09), 1.13 (1.03 to 1.25), and 1.23 (1.03 to 1.46), respectively, for subjects with a systolic blood pressure of 140 mm Hg or more, a serum low-density-lipoprotein cholesterol level of 130 mg per deciliter or more, and a glycated hemoglobin level of 8 percent or more.

CONCLUSIONS

A cap on drug benefits was associated with lower drug consumption and unfavorable clinical outcomes. In patients with chronic disease, the cap was associated with poorer adherence to drug therapy and poorer control of blood pressure, lipid levels, and glucose levels. The savings in drug costs from the cap were offset by increases in the costs of hospitalization and emergency department care.

Will the Medicare Prescription Drug Benefit Eliminate Cost Barriers for Older Adults with Diabetes Mellitus?

OBJECTIVES

To determine the proportion of older people with diabetes mellitus (DM) eligible to enroll in the standard Medicare Part D drug benefit who will exceed the initial $2,250 coverage limit and to determine the effect of hypoglycemic choice on risk of exceeding the coverage limit.

DESIGN

Cross-sectional survey.

SETTING

Nationally representative sample of adults living in United States households participating in the 2001 Medical Expenditure Panel Survey (MEPS).

PARTICIPANTS

Individuals aged 65 and older with a diagnosis of DM eligible to enroll in the standard Medicare Part D drug benefit.

MEASUREMENTS

Prescription medication use and expenditures adjusted to 2006 U.S. dollars as reported in the MEPS prescribed medicine file. Survey-weighted logistic regression models were used to estimate the odds of annual medication expenditures exceeding $2,250, controlling for hypoglycemic type, sociodemographic characteristics, chronic conditions, and health status.

RESULTS

Of the estimated 3.2 million elderly people with DM eligible for the standard drug benefit filling a prescription in 2001, approximately 64% had medication expenditures in excess of $2,250 in 2006 adjusted dollars. The proportion exceeding the initial coverage limit varied by type of hypoglycemic drug used from 60% of those using traditional hypoglycemics to more than 75% of those using novel hypoglycemics. Patients with more comorbidities and poorer health status were at greater risk of exceeding the initial coverage limit.

CONCLUSION

A large proportion of older adults with DM may exceed the initial coverage limit under the standard Medicare Part D drug benefit and incur significant out-of-pocket spending.

Factors associated with potentially inappropriate drug utilization in a sample of rural community-dwelling older adults

BACKGROUND

Many medications present special risks when used by older adults (ie, those aged > or = 65 years) and are considered potentially inappropriate for this population. The Beers criteria are often used to identify such medications. Past research has documented that use of Beers drugs is common among older adults.

OBJECTIVE

The aim of this work was to examine factors associated with potentially inappropriate drug use among rural community-dwelling older adults using a conceptual framework adapted from the Andersen-Newman behavioral model of health service use.

METHODS

This was a population-based, cross-sectional survey. Data were collected via face-to-face home interviews between 2002 and 2004. Rural community-dwelling older adults residing in a single county in North Carolina were eligible. Potentially inappropriate drug use was operationalized using the Beers criteria. Data concerning predisposing (ie, age, sex, race, education, and marital status), enabling (ie, social support and insurance status), need (ie, disability and history of major depression, hypertension, osteoarthritis, back problems, or other comorbidities), and utilization factors (ie, number of medications used) were collected.

RESULTS

Data were gathered from 892 people, with information on medication use available for 800. Two hundred thirteen of these 800 participants (26.6%) used > or = 1 Beers drug. Compared with individuals who used no Beers drugs, those who used > or = 1 Beers drug reported lower levels of social support (odds ratio [OR], 0.94; 95% CI, 0.90-0.99) and higher levels of disability (OR, 1.48; 95% CI, 1.11-1.97), used more medications (OR, 1.07; 95% CI, 1.01-1.13), and were more likely to have a history of major depression (OR, 1.67; 95% CI, 1.05-2.66), hypertension (OR, 1.58; 95% CI, 1.07-2.33), osteoarthritis (OR, 1.58; 95% CI, 1.09-2.29), and back problems (OR, 1.72; 95% CI, 1.19-2.47).

CONCLUSION

As suggested by the Andersen-Newman model, the risk of potentially inappropriate drug use is highest among those with the greatest medication needs, as evidenced by poorer health status in this sample of rural community-dwelling older patients.

Perceived barriers to health care access among rural older adults: a qualitative study

CONTEXT

Many rural elders experience limited access to health care. The majority of what we know about this issue has been based upon quantitative studies, yet qualitative studies might offer additional insight into individual perceptions of health care access.

PURPOSE

To examine what barriers rural elders report when accessing needed health care, including how they cope with the high cost of prescription medication.

METHODS

During Spring 2001, thirteen 90-minute focus groups were conducted in 6 rural West Virginia communities. A total of 101 participants, aged 60 years and older, were asked several culminating questions about their perceptions of health care access.

FINDINGS

Five categories of barriers to health care emerged from the discussions: transportation difficulties, limited health care supply, lack of quality health care, social isolation, and financial constraints. In addition, 6 diverse coping strategies for dealing with the cost of prescription medication were discussed. They included: reducing dosage or doing without, limiting other expenses, relying on family assistance, supplementing with alternative medicine, shopping around for cheapest prices, and using the Veteran's Administration.

CONCLUSIONS

Overall, rural older adults encounter various barriers to accessing needed health care. Qualitative methodology allows rural elders to have a voice to expound on their experiences. Research can contribute valuable information to shape policy by providing a forum where older adults can express their concerns about the current health care delivery system.

A conceptually based approach to understanding chronically ill patients' responses to medication cost pressures

Prescription medications enhance the well-being of most chronically ill patients. Many individuals, however, struggle with how to pay for their treatments and as a result experience problems with self-care and health maintenance. Although studies have documented that high out-of-pocket costs are associated with medication non-adherence, little research on prescription cost sharing has been theoretically grounded in knowledge of the more general determinants of patients' self-management behaviors and chronic disease outcomes. We present a conceptual framework for understanding the influence of patient, medication, clinician, and health system factors on individuals' responses to medication costs. We review what is known about how these factors influence medication adherence, identify possible strategies through which clinicians, health systems, and policy-makers may assist patients burdened by their medication costs, and highlight areas in need of further research. Although medication costs represent a burden to chronically ill patients worldwide, most patients report using their medication as prescribed despite the costs, and others report cost-related underuse despite an apparent ability to afford those treatments. The cost-adherence relationship is modified by contextual factors, including patients' characteristics (e.g., age, ethnicity, and attitudes toward medications), the type of medications they are using (e.g., the complexity of dosing and the drug's clinical target), clinician factors (e.g., choice of first-line agent and communication about medication costs), and health system factors (e.g., efforts to influence clinicians' prescribing and to help patients apply for financial assistance programs). Understanding these relationships will enable clinicians and policy-makers to better design pharmacy benefits and assist patients in taking their medication as prescribed. The next generation of studies examining the consequences of prescription drug costs should expand our knowledge of the ways in which these co-factors influence patients' responses to medication cost pressures.

Effects of a medication assistance program on health outcomes in patients with type 2 diabetes mellitus

PURPOSE

The effects of a clinic-based medication assistance program (MAP) on the health outcomes and medication use of patients with type 2 diabetes mellitus were studied.

METHODS

In this retrospective analysis, data from the University of Arkansas for Medical Sciences pharmacy-managed MAP and outpatient pharmacy databases were collected for adult patients with type 2 diabetes mellitus who were monitored in the university's internal medicine clinic one year before and after enrollment in the MAP. Data on patient demographics, medication use, and disease indicators (glycosylated hemoglobin [HbA(1c)], high-density-lipoprotein [HDL] cholesterol, low-density-lipoprotein [LDL] cholesterol, total cholesterol, triglyceride, and blood pressure levels) were collected for the year before enrollment and for one year after enrollment. Statistical analyses were conducted using descriptive analyses, paired t tests, and the Wilcoxon signed rank test.

RESULTS

Of the 401 patients enrolled in the internal medicine clinic who were enrolled in the MAP, sufficient data were available for 52 patients, of whom 73% were women, 50% were African American, and 48% were white. Their mean age was 59 years. All were self-paying customers, with 67.3% receiving Medicare benefits. Patients received more prescription medications (p < 0.001) and antihyperglycemic medications (p = 0.001) after enrollment in the program. Mean HbA(1c) and LDL cholesterol levels decreased significantly after enrollment (p < 0.001 for both). Mean HDL cholesterol levels and systolic and diastolic blood pressure measurements did not change significantly.

CONCLUSION

A clinic-based MAP managing the use of pharmaceutical manufacturers' drug assistance programs increased indigent patients' access to antihyperglycemic medications and improved patients' clinical outcomes.

Cost and utilization impacts of oral antihistamines in the California Medi-Cal program

OBJECTIVES

Newer oral allergic rhinitis (AR) medications, the second-generation antihistamines (SGAs) have gained widespread acceptance because of their efficacy and reduced side effects relative to first-generation antihistamines (FGAs). There are no empirical studies comparing the costs of treatment of SGAs relative to FGAs.

METHODS

We analyzed data from a 20% beneficiary sample (approximately 120,000 continuously enrolled beneficiaries per year) for the Medi-Cal Fee-for-Service program during 1999 to 2000. AR medications available under Medi-Cal included three SGA medications (loratadine, fexofenadine, and cetirizine) and over 200 FGA products containing either diphenhydramine or chlorpheniramine or both. Because multiple medications were evaluated, a sample selection model was estimated using a two-stage multinomial logistic--variance components regression framework.

RESULTS

SGA medications have significantly lower total direct health-care treatment costs per patient than FGA medications with costs ranging from US 347 dollars to US 448 dollars less (P < 0.001), despite higher AR medication costs. Total drug expenditures were also not significantly different for patients using SGA or FGA medications despite SGA prescriptions averaging US 47 dollars higher than FGAs. Emergency department visits, inpatient admissions and physician office visits were also significantly lower for patients using SGA medications.

CONCLUSIONS

Significant cost and utilization reductions were associated with all of the SGA medications relative to FGA drugs, despite their higher acquisition costs. If facing higher copayments for prescription AR drugs, many patients, particularly lower income patients, may choose cheaper over-the-counter (OTC) FGAs rather than SGAs. Our analysis finds this might lead to increased overall health-care treatment costs, unless Medicaid and health insurance plans subsidize OTC AR medications.

Effects of noncardiovascular comorbidities on antihypertensive use in elderly hypertensives

Although the benefits of antihypertensive drugs have been clearly established, they remain underused by vulnerable older populations. We examined whether the presence of noncardiovascular comorbidity deters use of antihypertensives in elderly with hypertension. We conducted a retrospective cohort study among 51,517 patients > or =65 years of age in the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE) Program during 1999 and 2000. All were hypertensive and had diagnoses and used treatments during 1999 to qualify for entry into 1 of the following 5 mutually exclusive cohorts: asthma/chronic obstructive pulmonary disease (COPD), depression, gastrointestinal (GI) disorders, osteoarthritis, or none of the 4 comorbidities. Proportions using antihypertensives in 2000 were assessed. Logistic regression analysis was used to identify the independent effects on antihypertensive use of the 4 comorbidities of interest, sociodemographic characteristics, other cardiovascular and noncardiovascular comorbidity, and health care utilization variables. After adjustments in multivariable analyses, antihypertensive use was consistently lower in patients with asthma/COPD (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.40 to 0.47), depression (OR, 0.50; 95% CI, 0.45 to 0.55), GI disorders (OR, 0.59; 95% CI, 0.54 to 0.64), and osteoarthritis (OR, 0.63; 95% CI, 0.59 to 0.67) relative to those without these conditions. Reduced antihypertensive use was also associated with older age, female gender, white race, more severe other comorbidities, absence of some cardiovascular indications, hospitalizations, nursing home care, physician visits, and use of fewer other medications. Highly prevalent, noncardiovascular conditions appear to deter use of antihypertensives in elderly with hypertension.

Effect of difficulty affording health care on health status after coronary revascularization

BACKGROUND

An objective of the United States' Healthy People 2010 Initiative is to eliminate disparities based on socioeconomic status. We assessed the effect of difficulty affording health care on the health status (symptoms, function, and quality of life) of patients treated with percutaneous coronary intervention or CABG.

METHODS AND RESULTS

A consecutive, single-center cohort of 480 patients undergoing coronary revascularization received the Seattle Angina Questionnaire at the time of their procedure and at subsequent monthly intervals for 6 months. At baseline, patients who reported somewhat of a burden to a severe burden in affording health care had significantly lower scores on the Seattle Angina Questionnaire (mean+/-SD) with respect to angina (55+/-29 versus 68+/-25, P<0.0001), physical limitation (55+/-26 versus 72+/-24, P<0.0001), and quality of life (46+/-22 versus 56+/-22, P<0.0001) than those who did not perceive healthcare costs to be burdensome. Although both groups of patients improved after revascularization, poorer health status persisted among those with difficulty affording health care after percutaneous coronary intervention (6-month mean+/-SE: angina 79+/-2.5 versus 88+/-1.9, P=0.002; physical function 61+/-2.7 versus 80+/-2.0, P<0.0001; quality of life 67+/-2.4 versus 82+/-1.8, P<0.0001) but not after CABG (angina 91+/-2.5 versus 93+/-1.6, P=0.47; physical function 75+/-3.4 versus 81+/-2.2, P=0.13; quality of life 84+/-3.1 versus 84+/-2.0, P=0.81). Similar differences remained after adjustment for demographic and clinical characteristics.

CONCLUSIONS

Patients reporting difficulty affording health care have worse health status at the time of coronary revascularization. A persistent disparity exists after percutaneous but not surgical revascularization. Additional inquiry into the mechanism of this disparity is needed so that the goals of equitable health care, irrespective of treatment strategy, can be achieved.

Pharmacy utilization and the Medicare Modernization Act

To control expenditures and use medications appropriately, the Medicare drug coverage program has established pharmacy utilization management (PUM) measures. This article assesses the effects of these strategies on the care of seniors. The literature suggests that although caps on drug benefits lower pharmaceutical costs, they may also increase the use of other health care services and hurt health outcomes. Our review raises concerns regarding the potential unintended effects of the Medicare drug program's PUM policies for beneficiaries. Therefore, the economic and clinical impact of PUM measures on seniors should be studied further to help policymakers design better drug benefit plans.

Reports of financial disability predict functional decline and death in older patients discharged from the hospital

BACKGROUND

The financial ability to pay for food and medical care is needed to maintain health in older persons following a serious illness. Therefore, we hypothesize that the inability to pay for basic needs, which we call financial disability, predicts adverse health outcomes in older patients discharged from the hospital.

OBJECTIVES

To determine the frequency of reported financial disability in older adults being discharged from a hospital, to determine patient characteristics associated with financial disability, and to examine the relationship between financial disability and functional decline and mortality.

DESIGN

Prospective cohort study.

SETTING/PARTICIPANTS

Two thousand two hundred patients 70 years and older admitted to the general medicine services at two teaching hospitals in Ohio.

MAIN OUTCOME MEASURES

Respondents were interviewed at the time of discharge to determine patients' financial ability to pay for 6 needs: groceries, general bills, medications, medical bills, a small emergency, and a major emergency. We determined functional decline in ability to perform activities of daily living from discharge to 90 days post-hospital discharge, and death 1 year after hospital discharge.

RESULTS

Financial disability was reported to be severe (unable to pay for 3-6 needs) for 21% of patients and moderate (unable to pay for 1-2 needs) for 36%. Financial disability was more common and more severe (P<.001) in persons with an annual household income less than $10,000, in persons with fewer than 12 years of formal education, in African Americans, and in women. In patients with no financial disability, moderate financial disability, and severe financial disability, functional decline 3 months after hospital discharge occurred in 15%, 20%, and 25%, respectively (P=.001), and 1-year mortality rates were 24%, 27%, and 32%, respectively (P=.002). After adjustment for potential confounders, the association of financial disability with functional decline (P=.003) and mortality (P=.02) remained significant.

CONCLUSION

Reports of financial disability at hospital discharge identified vulnerable older adults with increased risk for functional decline and death. Interventions that alleviate financial disability may improve health outcomes in older adults discharged from hospital.

Elders who delay medication because of cost: health insurance, demographic, health, and financial correlates

PURPOSE

Prescription medication use is essential to the health and well-being of many elderly persons. However, the cost of medications may be prohibitive and contribute to noncompliance with medical recommendations. This study identifies community-dwelling elders who reported a delay in medication use because of prescription medication cost.

DESIGN AND METHODS

This was a cross-sectional study of a nationwide sample of 6,535 elders participating in the Asset and Health Dynamics Among the Oldest Old (AHEAD) study. Participants reported if they had taken less medication than prescribed or if they had not filled prescriptions because of cost in the past 2 years. This response was then compared with the self-report of multiple variables, including demographic, health status, health insurance coverage, and financial variables.

RESULTS

Elders who were most vulnerable to medication delay as a result of cost included those with Medicare coverage only, low income, high out-of-pocket prescription costs, and poor health as well as African American elders and those aged 65-80 years.

IMPLICATIONS

This study provides important information about community-dwelling elders that reported a delay in medication use because of cost. As a Medicare prescription benefit has been passed, it will be important to monitor how these changes affect the elders identified at risk for medication delay.

Inappropriate Medication Use and Health Outcomes in the Elderly

Inappropriate medication use is a major problem for the elderly. Although increasing attention has been paid to inappropriate prescription medication use, most previous research has been limited to the investigation of prevalence and trends. Few studies provide the empirical evidence for the adverse effect of inappropriate medication use on health outcomes at the national level. This study is the first attempt to assess the relationship between inappropriate prescription use and health status for the elderly in the United States. Based on the 1996 Medical Expenditure Panel Survey, inappropriate medication use in a national representative elderly population was first identified using Beers criteria. A survey type of ordered probit model was then estimated to quantify the effect of inappropriate drug use on patient self-perceived health status measured using a five-point scale (poor, fair, good, very good, and excellent). After controlling for a set of possible confounding factors, it was found that individuals using inappropriate medications in Round 1 were more likely than those not using inappropriate medications to report poorer health status in Round 2. Other risk factors for poor health status include a higher number of prescriptions, being black, having low education, and having one or more chronic diseases. This study provides strong evidence of a significant adverse effect of inappropriate medication use on patient health status. These findings lend partial support to the use of Beers criteria in assessing the quality of prescribing and the appropriateness of medication use in the elderly population.

Out-of-pocket health care expenditures among older Americans with dementia

The number of older individuals with dementia will likely increase significantly in the next decades, but there is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by cognitively impaired individuals and their families. We used data from the 1993 and 1995 Asset and Health Dynamics Study, a nationally representative longitudinal survey of older Americans, to determine the OOPE for individuals with and without dementia. Dementia was identified in 1993 using a modified version of the Telephone Interview for Cognitive Status for self-respondents, and proxy assessment of memory and judgment for proxy respondents. In 1995, respondents reported OOPE over the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. The adjusted mean annual OOPE was 1,350 US dollars for those without dementia, 2,150 US dollars for those with mild/moderate dementia, and 3,010 US dollars for those with severe dementia (p < 0.01). Expenditures for hospital/nursing home care (1,770 per year US dollars) and prescription medications (800 per year US dollars) were the largest OOPE components for those with severe dementia. We conclude that dementia is independently associated with significantly higher OOPE for medical care compared with those with normal cognitive function. Severe dementia is associated with a doubling of OOPE, mainly due to higher payments for long-term care. Given that the number of older Americans with dementia will likely increase significantly in the coming decades, changes in public funding aimed at reducing OOPE for both long-term care and prescription medications would have considerable impact on individuals with dementia and their families.

The health effects of restricting prescription medication use because of cost

BACKGROUND

High out-of-pocket expenditures for prescription medications could lead people with chronic illnesses to restrict their use of these medications. Whether adults experience adverse health outcomes after having restricted medication use because of cost is not known.

METHODS

We analyzed data from 2 prospective cohort studies of adults who reported regularly taking prescription medications using 2 waves of the Health and Retirement Study (HRS), a national survey of adults aged 51 to 61 in 1992, and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older in 1993 (n = 7991). We used multivariable logistic and Poisson regression models to assess the independent effect on health outcomes over 2 to 3 years of follow up of reporting in 1995-1996 having taken less medicine than prescribed because of cost during the prior 2 years. After adjusting for differences in sociodemographic characteristics, health status, smoking, alcohol consumption, body mass index (BMI), and comorbid chronic conditions, we determined the risk of a significant decline in overall health among respondents in good to excellent health at baseline and of developing new disease-related adverse outcomes among respondents with cardiovascular disease, diabetes, arthritis, and depression.

RESULTS

In adjusted analyses, 32.1% of those who had restricted medications because of cost reported a significant decline in their health status compared with 21.2% of those who had not (adjusted odds ratio [AOR], 1.76; confidence interval [CI], 1.27-2.44). Respondents with cardiovascular disease who restricted medications reported higher rates of angina (11.9% vs. 8.2%; AOR, 1.50; CI, 1.09-2.07) and experienced higher rates of nonfatal heart attacks or strokes (7.8% vs. 5.3%; AOR, 1.51; CI, 1.02-2.25). After adjusting for potential confounders, we found no differences in disease-specific complications among respondents with arthritis and diabetes, and increased rates of depression only among the older cohort.

CONCLUSIONS

Cost-related medication restriction among middle-aged and elderly Americans is associated with an increased risk of a subsequent decline in their self-reported health status, and among those with preexisting cardiovascular disease with higher rates of angina and nonfatal heart attacks or strokes. Such cost-related medication restriction could be a mechanism for worse health outcomes among low-income and other vulnerable populations who lack adequate insurance coverage.

Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care

BACKGROUND

Chronically ill patients often experience difficulty paying for their medications and, as a result, use less than prescribed.

OBJECTIVES

The objectives of this study were to determine the relationship between patients with diabetes' health insurance coverage and cost-related medication underuse, the association between cost-related underuse and health outcomes, and the role of comorbidity in this process.

RESEARCH DESIGN

We used a patient survey with linkage to insurance information and hemoglobin A1C (A1C) test results.

PATIENTS

We studied 766 adults with diabetes recruited from 3 Veterans Affairs (VA), 1 county, and 1 university healthcare system.

MAIN OUTCOMES

Main outcomes consisted of self-reported medication underuse as a result of cost, A1C levels, symptom burden, and Medical Outcomes Study 12-Item Short-Form physical and mental functioning scores.

RESULTS

Fewer VA patients reported cost-related medication underuse (9%) than patients with private insurance (18%), Medicare (25%), Medicaid (31%), or no health insurance (40%; P <0.0001). Underuse was substantially more common among patients with multiple comorbid chronic illnesses, except those who used VA care. The risk of cost-related underuse for patients with 3+ comorbidities was 2.8 times as high among privately insured patients as VA patients (95% confidence interval, 1.2-6.5), and 4.3 to 8.3 times as high among patients with Medicare, Medicaid, or no insurance. Individuals reporting cost-related medication underuse had A1C levels that were substantially higher than other patients (P <0.0001), more symptoms, and poorer physical and mental functioning (all P <0.05).

CONCLUSIONS

Many patients with diabetes use less of their medication than prescribed because of the cost, and those reporting cost-related adherence problems have poorer health. Cost-related adherence problems are especially common among patients with diabetes with comorbid diseases, although the VA's drug coverage may protect patients from this increased risk.

Out-of-pocket health-care expenditures among older Americans with cancer

OBJECTIVE

There is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by elderly individuals with cancer. We sought to quantify OOPE for community-dwelling individuals age 70 or older with: 1) no cancer (No CA), 2) a history of cancer, not undergoing current treatment (CA/No Tx), and 3) a history of cancer, undergoing current treatment (CA/Tx).

METHODS

We used data from the 1995 Asset and Health Dynamics Study, a nationally representative survey of community-dwelling elderly individuals. Respondents identified their cancer status and reported OOPE for the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. Using a multivariable two-part regression model to control for differences in sociodemographics, living situation, functional limitations, comorbid chronic conditions, and insurance coverage, the additional cancer-related OOPE were estimated.

RESULTS

Of the 6370 respondents, 5382 (84%) reported No CA, 812 (13%) reported CA/No Tx, and 176 (3%) reported CA/Tx. The adjusted mean annual OOPE for the No CA, CA/No Tx, and CA/Tx groups were 1210 dollars, 1450 dollars, and 1880 dollars, respectively (P < .01). Prescription medications (1120 dollars per year) and home care services (250 dollars) accounted for most of the additional OOPE associated with cancer treatment. Low-income individuals undergoing cancer treatment spent about 27% of their yearly income on OOPE compared to only 5% of yearly income for high-income individuals with no cancer history (P < .01).

CONCLUSIONS

Cancer treatment in older individuals results in significant OOPE, mainly for prescription medications and home care services. Economic evaluations and public policies aimed at cancer prevention and treatment should take note of the significant OOPE made by older Americans with cancer.

Moving forward way: Medicare prescription drug coverage

Nursing is multidimensional, interactive, interdisciplinary, and complex. Almost anything that can be said about nursing can be said another way. Some things worth being said and heard will not follow the norms of journal presentation. A forum accommodates the emerging voice, the new format, the innovative approach. Nursing Forum, in an effort to honor the independent voice in nursing, presents here the voice who elects to enter the dialogue, but who does so "in another way."

State-based versus federal-based approaches to reducing the Medicare pharmaceutical coverage gap

A state-based approach, such as the Immediate Helping Hand proposal put forward by the Bush administration, is likely to be less effective than a federal-based approach at reducing the Medicare pharmaceutical coverage gap. In addition, the voluntary nature of a state-based approach, coupled with variations across states in existing coverage benefits and the limited reach of state pharmacy assistance programs, would likely lead to a perpetuation of uneven coverage. This article argues in favor of adding a federal-based universal prescription drug benefit to Medicare on the grounds of both equity and empirical evidence. Adding a universal drug benefit to the currently existing Medicare program would extend application of the social insurance concept across hospital care, physician service, and prescription drug coverage components of Medicare. As a result, a more equitable distribution of prescription drug coverage would be promoted while mitigating the effects of selection risk.

Physician and practice characteristics associated with the early utilization of new prescription drugs

BACKGROUND

Prescription of new drugs contributes to substantial increases in annual drug expenditures. A small proportion of physicians appear to be early users of new prescription drugs and little is known about their characteristics.

OBJECTIVE

To estimate the initial utilization rate of new prescription drugs among physicians, and the physician and practice characteristics associated with early use.

DESIGN

Cumulative prospective assessment over a 5 year period (1989-1994) of new drug utilization rates in a randomly selected cohort of Quebec physicians.

PARTICIPANTS

1661 physicians and 669,867 elderly patients.

OUTCOME

Prescribing rate of 20 new drugs, in 6 therapeutic categories, to elderly patients in the first 6 months after inclusion in the Quebec formulary.

RESULTS

The 20 new drugs were prescribed by 1.3-22.3% of physicians, and there was an 8 to 17-fold difference in new drug utilization rates among prescribers. Characteristics associated with higher rates of utilization differed for general practitioners and specialists. Male general practitioners, and physicians graduating from the most recently established medical school in the province, had higher rates of new drug utilization, whereas recent graduation was only associated with higher utilization rates among specialists. Practice volume was associated with higher rates of utilization among GPs. For both GPs and specialists, having a high proportion of elderly in one's practice and a rural or remote practice location was associated with lower utilization rates.

CONCLUSIONS

Physician sex, specialty, medical school, years since graduation, practice location, volume, and relative proportion of elderly in the physician's practice influence the utilization of new drugs.