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

Prevalence and Factors Associated With Out-of-Pocket Pharmaceutical Expenditure Among Primary Healthcare Patients: Evidence From the Prover Project

OBJECTIVES

This study aimed to determine the prevalence and associated factors of out-of-pocket pharmaceutical expenditure (OOPPE) among primary healthcare patients.

METHODS

The study is part of the Prover Project, an exit survey conducted in 2017 in a large city (population 234 937) in Minas Gerais State, Brazil. A representative sample of patients (n = 1219) from pharmaceutical services based on primary healthcare was selected. Three components of OOPPE were assessed: the general prevalence, the types of medicines purchased (medicines for the treatment of chronic diseases, medicines for the treatment of acute diseases, or herbal medicines), and coverage by the National Health System. The factors associated with OOPPE were examined applying a modified Andersen's behavioral model of health services use. Data were analyzed using descriptive statistics and logistic regression.

RESULTS

The overall prevalence of OOPPE was 77%. Most patients who had OOPPE purchased medicines to treat chronic diseases (94%). In addition, these patients purchased medicines covered by public insurance but were out of stock (85%). OOPPE was associated with enabling factors, such as higher personal income (odds ratio [OR] 1.92; 95% confidence interval [CI] 1.02-3.62), holding health insurance (OR 1.40; 95% CI 1.01-1.95), and higher neighborhood trust (OR 1.34; 95% CI 1.01-1.79), and with need factors, that is, poorer perception of health (OR 1.63; 95% CI 1.20-2.21), multiple comorbidities (OR 1.70; 95% CI 1.18-2.46), and higher number of prescribed medicines (OR 2.84; 95% CI 1.90-4.26).

CONCLUSIONS

We found a high prevalence of OOPPE, identifying individuals more likely to incur these expenses. These findings are useful to inform policy makers from the healthcare system to plan and implement the needed interventions to protect primary care patients from this financial burden.

Out-of-pocket expenses related to aging in place for frail older people: a scoping review

Objective:

The objective of this scoping review was to map and describe the available evidence reporting out-of-pocket expenses related to aging in place for older people with frailty and their caregivers.

Introduction:

As the global population ages, there has been increasing attention on supporting older people to live at home in the community as they experience health and functional changes. Older people with frailty often require a variety of supports and services to live in the community, yet the out-of-pockets costs associated with these resources are often not accounted for in health and social care literature.

Inclusion criteria:

Sources that reported on the financial expenses incurred by older people (60 years or older) with frailty living in the community, or on the expenses incurred by their family and friend caregivers, were eligible for inclusion in the review.

Methods:

We searched for published and unpublished (ie, policy papers, theses, and dissertations) studies written in English or French between 2001 and 2019. The following databases were searched: CINAHL, MEDLINE, Scopus, Embase, PsycINFO, Sociological Abstracts, and Public Affairs Index. We also searched for gray literature in a selection of websites and digital repositories. JBI scoping review methodology was used, and we consulted with a patient and family advisory group to support the relevance of the review.

Results:

A total of 42 sources were included in the review, including two policy papers and 40 research papers. The majority of the papers were from the United States (n = 18), with others from Canada (n = 6), the United Kingdom (n = 3), Japan (n = 2), and one each from Australia, Brazil, China, Denmark, Israel, Italy, The Netherlands, Poland, Portugal, Singapore, South Korea, Taiwan, and Turkey. The included research studies used various research designs, including cross-sectional (n = 18), qualitative (n = 15), randomized controlled trials (n = 2), longitudinal (n = 2), cost effectiveness (n = 1), quasi-experimental (n = 1), and mixed methods (n = 1). The included sources used the term “frailty” inconsistently and used various methods to demonstrate frailty. Categories of out-of-pocket expenses found in the literature included home care, medication, cleaning and laundry, food, transportation, medical equipment, respite, assistive devices, home modifications, and insurance. Five sources reported on out-of-pocket expenses associated with people who were frail and had dementia, and seven reported on the out-of-pocket expenses for caregivers of people with frailty. While seven articles reported on specific programs, there was very little consistency in how out-of-pocket expenses were used as outcome measures. Several studies used measures of combined out-of-pocket expenses, but there was no standard approach to reporting aggregate out-of-pocket expenses.

Conclusions:

Contextual factors are important to the experiences of out-of-pocket spending for older people with frailty. There is a need to develop a standardized approach to measuring out-of-pocket expenses in order to support further synthesis of the literature. We suggest a measure of out-of-pocket spending as a percentage of family income. The review supports education for health care providers to assess the out-of-pocket spending of community-dwelling older people with frailty and their caregivers. Health care providers should also be aware of the local policies and resources that are available to help older people with frailty address their out-of-pocket spending.

Understanding social workers' hidden roles in medication safety for older adults: A qualitative study

Older adults are vulnerable to risks associated with medications. This study explores the roles of Social Workers in facilitating medication safety for older adults. Eight social workers from federally qualified health centers participated in a case-based and interactive medication safety curriculum. They participated in an in-depth, semi-structured interview to explore their roles and strategies in assisting older adults and caregivers with medication management. Findings were transcribed and analyzed. Six themes characterizing social workers' roles in medication management were identified: a) Referral: matching patients and medication-related resources within the health-care system and community; b) Communication: connecting providers, patients, caregivers, and support system; c) Access to medicine: addressing unique needs of each patient to foster their ability to obtain their medicines; d) Social Determinants of Health: investigating the social challenges of each patient and facilitating specific medication management approaches to meet identified needs; e) Engagement: engaging patients in co-developing a treatment plan; f) Caregiver Support: preparing caregivers to assist in medication management. Social workers are trained and well positioned to provide a multi-faceted approach to improve medication management for older adults. Their unique perspectives and skills are important in addressing the complex challenges of medication management.

The Role of a Health Protection Scheme in Health Services Utilization Among Community-Dwelling Older Persons in Ghana

OBJECTIVES

This study examines the relationships between National Health Insurance Scheme (NHIS) enrollment and the frequency and "timing" of health services utilization among community-dwelling older Ghanaians. It also investigates whether the NHIS policy has improved equity in access to health care in later life.

METHODS

Cross-sectional data were derived from an Ageing, Health, Psychological Wellbeing and Health-seeking Behavior Study collected between August 2016 and January 2017 (N = 1,200). Descriptive and bivariate analyses described the sample. Generalized Poisson and logit regression models, respectively estimated the predictors of frequency of health services utilization and time from onset of illness to health facility use and during last illness episode.

RESULTS

Older persons with active NHIS membership frequently used health facilities (β = 0.237, standard error [SE] = 0.0957, p ˂ .005), but the association was largely a function of health-related factors. The NHIS enrollees were more likely to attend health facility earlier (β = 1.347, SE = 0.3437, p ˂ .001) compared with nonenrollees, after adjusting for theoretically relevant covariates. Moreover, given the NHIS enrollment, the rich (eβ = 2.149, SE = 0.240, p ˂ .005), social support recipients (eβ = 1.366, SE = 0.162, p ˂ .05) and those living with relevant others (eβ = 2.699, SE = 0.175, p ˂ .001) were more likely to consume health services.

DISCUSSION

Ghana's NHIS policy generally increases health services utilization but at present lacks the capability to improve equitable access to health care, especially between poor and nonpoor older adults. This may hamper the progress toward universal health coverage (UHC), indicating the need for further refinements in the policy including ways to improve the health status of older persons.

Unfilled Prescriptions of Medicare Beneficiaries: Prevalence, Reasons, and Types of Medicines Prescribed

BACKGROUND

Despite the proven efficacy of prescription regimens in reducing disease symptoms and preventing or minimizing complications, poor medication adherence remains a significant public health problem. Medicare beneficiaries have high rates of chronic illness and prescription medication use, making this population particularly vulnerable to nonadherence. Failure to fill prescribed medication is a key component of nonadherence.

OBJECTIVES

To (1) determine the rates of self-reported failure to fill at least 1 prescription among a sample of Medicare beneficiaries in 2004, (2) identify the reasons for not filling prescribed medication, (3) examine the characteristics of Medicare beneficiaries who failed to fill their prescription(s), and (4) identify the types of medications that were not obtained.

METHODS

The study is a secondary analysis of the 2004 Medicare Current Beneficiary Survey (MCBS), an ongoing national panel survey conducted by the Centers for Medicare & Medicaid Services (CMS). Medicare beneficiaries living in the community (N = 14,464) were asked: "During the current year [2004], were there any medicines prescribed for you that you did not get (please include refills of earlier prescriptions as well as prescriptions that were written or phoned in by a doctor)?" Those who responded "yes" to this question (n = 664) were asked to identify the specific medication(s) not obtained. Rates of failure to fill were compared by demographic and income categories and for respondents with versus without self-reported chronic conditions, identified by asking respondents if they had ever been told by a doctor that they had the condition. Weighted population estimates for nonadherence were calculated using Professional Software for SUrvey DAta ANalysis for Multi-stage Sample Designs (SUDAAN) to account for the MCBS multistage stratified cluster sampling process. Unweighted counts of the prescriptions not filled by therapeutic class were calculated using Statistical Analysis Software (SAS).

RESULTS

In 2004, an estimated 1.6 million Medicare beneficiaries (4.4%) failed to fill or refill 1 or more prescriptions. The most common reasons cited for failure to fill were: "thought it would cost too much" (55.5%), followed by "medicine not covered by insurance" (20.2%), "didn't think medicine was necessary for the condition" (18.0%), and "was afraid of medicine reactions/contraindications" (11.8%). Rates of failure to fill were significantly higher among Medicare beneficiaries aged 18 to 64 years eligible through Social Security Disability Insurance (10.4%) than among beneficiaries aged 65 years or older (3.3%, P < 0.001). Rates were slightly higher for women than for men (5.0 vs. 3.6%, P = 0.001), for nonwhite than for white respondents (5.5% vs. 4.2%, P = 0.010), and for dually eligible Medicaid beneficiaries than for those who did not have Medicaid coverage (6.3% vs. 4.0% P = 0.001). Failure-to-fill rates were significantly higher among beneficiaries with psychiatric conditions (8.0%, P < 0.001); arthritis (5.2%, P < 0.001); cardiovascular disease (5.2%, P = 0.003); and emphysema, asthma, or chronic obstructive pulmonary disease (6.6%, P < 0.001) than among respondents who did not report those conditions, and the rate for respondents who reported no chronic conditions was 2.5%. Rates were higher for those with more self-reported chronic conditions (3.2%, 4.0%, 4.3%, and 5.9% for those with 1, 2, 3, and 4 or more conditions, respectively, P < 0.001). Among the prescriptions not filled (993 prescriptions indentified by 664 respondents), central nervous system agents, including nonsteroidal anti-inflammatory drugs, were most frequently identified (23.6%, n = 234), followed by cardiovascular agents (18.3%, n = 182) and endocrine/metabolic agents (6.5%, n = 65). Of the reported unfilled prescriptions, 8.1% were for antihyperlipidemic agents, 5.4% were for antidepressant drugs, 4.6% were for antibiotics, and 29.9% were for unidentified therapy classes.

CONCLUSION

Most Medicare beneficiaries fill their prescriptions, but some subpopulations are at significantly higher risk for nonadherence associated with unfilled prescriptions, including working-age beneficiaries, dual-eligible beneficiaries, and beneficiaries with multiple chronic conditions. Self-reported unfilled prescriptions included critical medications for treatment of acute and chronic disease, including antihyperlipidemic agents, antidepressants, and antibiotics.

DISCLOSURES

This study was funded by the U.S. Department of Education's National Institute on Disability and Rehabilitation Research, Field Initiated Research Grant H133G070055. However, the analysis and the interpretation of these findings do not necessarily represent the policy of the Department of Education and are not endorsed by the federal government. All authors contributed approximately equally to the study concept and design. Tuleu performed the majority of the data collection, with assistance from Kennedy. Kennedy interpreted the data, with assistance from Tuleu and Mackay. Kennedy and Mackay wrote the majority of the manuscript, with assistance from Tuleu. Kennedy made the majority of the changes in revision of the manuscript.

Primary medication non-adherence at Counties Manukau Health Emergency Department (CMH-ED), New Zealand: an observational study

OBJECTIVES

To measure primary medication non-adherence (failure to fill prescription medicines) in patients discharged from the emergency department (ED), and to determine whether sociodemographic factors, smoking status and access to a general practitioner affect prescription filling. Little is known about primary medication non-adherence in EDs, and less so in New Zealand (NZ). Identifying reasons for non-adherence will enable development of strategies to improve adherence and reduce morbimortality.

DESIGN AND SETTING

An observational study based on patient data from the ED of a large public hospital in South Auckland, NZ.

PARTICIPANTS

Data were collected from 1600 patients discharged between 28 April-6 May and 28 July-9 August 2014. Data were included if patients were residents within the Auckland Regional Public Health Service boundaries, admitted to ED and discharged with a prescription. Data were excluded if patients were admitted to another ward, transferred to another hospital or left the ED without seeing a doctor.

RESULTS

992 patients were included in the study, the majority were under 10 years (32.6%), of Pacific Island descent (42.8%), NZ-born (67.7%) and living in the most socioeconomically deprived areas (78.1%). Almost 50% of patients failed to fill all prescription medications. Simple linear regression analysis indicated that non-adherence was significant for those 10-24 years (n=236; adherence=47.2%; p<0.05), of NZ Māori ethnicity (n=175; 51.3%; p=0.01), unemployed (n=77; 46.8%; p<0.01), homemakers (n=66; 45.7%; p<0.01), students (n=228; 55.6%; p<0.05) and cigarette smokers (n=139; 50.3%; p<0.01). Following multivariable analysis, the strongest predictors for non-adherence were those aged between 10 and 17 years (n=116; p<0.01), the unemployed (n=77; p=0.01) and homemakers (n=66; p=0.01).

CONCLUSIONS

Age and occupation were the greater predictors of non-adherence; however, no other significant differences were found. Since this study, changes to prescription co-payments have been made. Further research is warranted to assess whether this change has more recently affected the rates of non-adherence.

Musculoskeletal Pain Medication Use in Middle Age and Older Adults in 15 European Countries and Israel

BACKGROUND

The experience of musculoskeletal pain is widespread among adults and entails high costs to both individuals and society. Few studies look at disparities in pain management.

AIMS

To examine factors associated with the presence of musculoskeletal pain and the use of pain medication use among individuals aged 50+.

DESIGN

Cross-sectional analysis of data from the SHARE.

PARTICIPANTS

64,281 community-dwelling individuals in 15 European countries and Israel.

METHODS

Bivariate analysis and logistic regression were used to identify factors associated with the presence of musculoskeletal pain and pain medication use.

RESULTS

Among our population, the prevalence of musculoskeletal pain at the time of the survey was 40.1%. Women had more pain than men (odds ratio [OR] = 1.477, confidence interval [CI] = 1.428-1.528), those who were 60-69 years old had less pain than younger individuals (OR = 0.927, CI = 0.883-0.973), whereas those who were 80+ years old had more pain than younger individuals (OR = 1.280, CI = 1.199-1.367). About 50% of those with musculoskeletal pain take no medication to manage it. Predictors of pain medication use include male sex (OR = 1.468, CI = 1.389-1.553), more education (OR = 1.034, CI = 1.023-1.041), and better ability to cope economically (OR = 1.446, CI = 1.368-1.527). Those over 70 are less likely than younger individuals to be taking medication to manage their pain (70-79: OR = 0.822, CI = 0.761-0.887), (80+: OR = 0.619, CI = 0.566-0.677).

CONCLUSIONS

Nurses should be aware of the association of education and income with pain-medication use, which suggests that pain medication use is less accessible to those with fewer resources. Pain is a significant public-health problem, and access to medicine deserves attention from nurses, healthcare workers and policymakers.

Subjective perceptions of unmet need for health care in Europe among social groups: Findings from the European social survey (2014) special module on the social determinants of health

Background

Unmet need can be defined as the individually perceived subjective differences between services judged necessary to deal with health problems and the services actually received. This study examines what factors are associated with unmet need, as well as how reasons for unmet need are distributed across socioeconomic and demographic groups in Europe.

Methods

Multilevel logistic regression models were employed using data from the 7th round of the European Social Survey, on people aged 25–75. Self-reported unmet need measured whether respondents had been unable to get medical consultation or treatment in the last 12 months. Reasons for unmet need were grouped into three categories: availability, accessibility and acceptability. Health status was measured by self-reported health, non-communicable diseases and depressive symptoms.

Results

Two-thirds of all unmet need were due waiting lists and appointment availability. Females and young age groups reported more unmet need. We found no educational inequalities, while financial strain was found to be an important factor for all types of unmet need for health care in Europe. All types of health care use and poor health were associated with unmet need. Low physician density and high out-of-pocket payments were found to be associated with unmet need due to availability.

Conclusion

Even though health care coverage is universal in many European welfare states, financial strain appeared as a major determinant for European citizens’ access to health care. This may suggest that higher income groups are able to bypass waiting lists. European welfare states should, therefore, intensify their efforts in reducing barriers for receiving care.

Out-of-Pocket Payments and Subjective Unmet Need of Healthcare

We present a critical review of the literature that discusses the link between the level of out-of-pocket payments in developed countries and the share of people in these countries reporting that they postpone or forgo healthcare for financial reasons. We discuss the pros and cons of measuring access problems with this subjective variable. Whereas the quantitative findings in terms of numbers of people postponing care must be interpreted with utmost caution, the picture for the vulnerable groups in society is reasonably robust and unsurprising: people with low incomes and high morbidity and incomplete (or non-existent) insurance coverage are most likely to postpone or forgo healthcare for financial reasons. It is more surprising that people with high incomes and generous insurance coverage also report that they postpone care. We focus on some policy-relevant issues that call for further research: the subtle interactions between financial and non-financial factors, the possibility of differentiation of out-of-pocket payments between patients and between healthcare services, and the normative debate around accessibility and affordability.

Gender Differences in Out-of-Pocket Prescription Drug Expenditures Among the Elderly

Many elderly in the United States face high out-of-pocket prescription drug (OOP-PD) expenditures, with elderly women being disproportionably affected. Using Medicare Current Beneficiary Survey data for 1992 to 2000, the authors examined the gender differences in OOP-PD expenditures and burden among community-dwelling elderly Medicare beneficiaries. Oaxaca-Blinder decomposition techniques were used to evaluate the contribution of observed demographic, socioeconomic, and utilization factors on the gender gap in OOP-PD expenditures and burden. Among observed characteristics, differences in utilization and supplemental insurance coverage were the major drivers of the gender gap in OOP-PD expenditures and burden. Unobservable factors contributed to the majority of the gender gap in OOP-PD expenditures.

Functional Limitations, Medication Support, and Responses to Drug Costs among Medicare Beneficiaries

OBJECTIVE

Standard Medicare Part D prescription drug benefits include substantial and complex cost-sharing. Many beneficiaries also have functional limitations that could affect self-care capabilities, including managing medications, but also have varying levels of social support to help with these activities. We examined the associations between drug cost responses, functional limitations, and social support.

DATA SOURCES AND STUDY SETTING

We conducted telephone interviews in a stratified random sample of community-dwelling Medicare Advantage beneficiaries (N = 1,201, response rate = 70.0%). Participants reported their functional status (i.e., difficulty with activities of daily living) and social support (i.e., receiving help with medications). Drug cost responses included cost-reducing behaviors, cost-related non-adherence, and financial stress.

STUDY DESIGN

We used multivariate logistic regression to assess associations among functional status, help with medications, and drug cost responses, adjusting for patient characteristics.

PRINCIPAL FINDINGS

Respondents with multiple limitations who did not receive help with their medications were more likely to report cost-related non-adherence (OR = 3.2, 95% CI: 1.2-8.5) and financial stress (OR = 2.4, 95% CI: 1.3-4.5) compared to subjects with fewer limitations and no help; however, those with multiple limitations and with medication help had similar odds of unfavorable cost responses as those with fewer limitations.

CONCLUSION

The majority of beneficiaries with functional limitations did not receive help with medications. Support with medication management for beneficiaries who have functional limitations could improve adherence and outcomes.

Medicare Part D coverage gap: race, gender, and cost-related medication nonadherence

This study examined whether the Medicare Part D coverage gap directly and indirectly affects the relationship between race, gender, and cost-related nonadherence (CRN). Using a nationally representative sample (N = 1,157), this study found that racial disparities in CRN existed under Medicare Part D. However, reaching the coverage gap mediated differences in CRN between older Blacks and Whites. The coverage gap was associated with CRN and poorer health and lower income were associated with CRN after accounting for coverage gap status. Findings highlight the need to help vulnerable populations avoid CRN and for greater consideration of racial inequities in future policy decisions.

Impact of Medicare Part D on coverage, access, and disparities among new jersey seniors

The authors used a population-based survey of New Jersey residents to assess outcomes associated with implementation of the Medicare Part D program. Between 2001 and 2009, there was a 24% increase in prescription drug coverage among elderly individuals, but also an increase in cost-related access problems. Compared with the pre-Part D period, seniors reporting access problems post-Part D were less likely to be uninsured and more likely to be publicly insured. Cost-related access disparities among elderly Blacks and Hispanics relative to elderly Whites persisted from 2001 to 2009, and were partly driven by ongoing disparities related to low income. Such cost-based access problems 3 years into implementation implies that they are not transitory and may reflect inadequate subsidy levels alongside the importance of physician advice about prescriptions in ensuring low-cost medication options for vulnerable patients. Finally, the findings, may also reflect success in enrolling high-need seniors into Part D.

Forgone care and financial burden due to out-of-pocket payments within the German health care system

BACKGROUND

The amount of out-of-pocket (OOP) payments within the German health care system has risen steadily within the last years. OOP payments aim to strengthen patients' cost awareness and try to restrict the demand on medical necessary treatments. However, besides the intended decline of non-induced health care services there's a risk that people also forgo necessary treatments because the utilization of health care services depends not only on need-factors but also on the ability to pay for it. Therefore, this paper aims to analyze the determinants of the total amount of OOP payments, the financial burden caused by OOP payments and the relinquishment of health care services due to OOP payments.

DATA AND METHODS

The empirical analysis is based on cross-sectional data of the German subsample (n = 2851) of the Survey of Health, Ageing and Retirement in Europe (SHARE). SHARE is a representative panel study among private households with persons above the age of 50 years and covers a wide range of topics, e.g. health behavior, health status and information about the socio-economic status. The analysis of the independent variables "total amount of OOP payments", "financial burden due to OOP payments" and "forgone care" is carried out by the means of descriptive as well as multivariate regression methods.

RESULTS

Individuals with low income as well as people suffering from chronic illnesses face a higher financial burden and forgo health care services more frequently at the same time. E.g. the financial burden of people who belong to the lowest income quintile is about eight times higher compared to individuals who belong to the highest quintile. The probability of forgone care for this group is about 5.6 percentage points higher [95% CI: 5.2 - 6.0].

CONCLUSION

Especially for the group of people with chronic illnesses and low-income earners it cannot be ruled out that they also forgo necessary medical treatments due to the relatively high financial burden they face. Hence, it is required to facilitate the access to necessary care for these groups.

Inequalities in out-of-pocket payments for health care services among elderly Germans--results of a population-based cross-sectional study

Introduction

In order to limit rising publicly-financed health expenditure, out-of-pocket payments for health care services (OOPP) have been raised in many industrialized countries. However, higher health-related OOPP may burden social subgroups unequally. In Germany, inequalities in OOPP have rarely been analyzed. The aim of this study was to examine OOPP of the German elderly population in the different sectors of the health care system. Socio-economic and morbidity-related determinants of inequalities in OOPP were analyzed.

Methods

This cross-sectional analysis used data of N = 3,124 subjects aged 57 to 84 years from a population-based prospective cohort study (ESTHER study) collected in the Saarland, Germany, from 2008 to 2010. Subjects passed a geriatric assessment, including a questionnaire for health care utilization and OOPP covering a period of three months in the following sectors: inpatient care, outpatient physician and non-physician services, medical supplies, pharmaceuticals, dental prostheses and nursing care. Determinants of OOPP were analyzed by a two-part model. The financial burden of OOPP for certain social subgroups (measured by the OOPP-income-ratio) was investigated by a generalized linear model for the binomial family.

Results

Mean OOPP during three months amounted to €119, with 34% for medical supplies, 22% for dental prostheses, 21% for pharmaceuticals, 17% for outpatient physician and non-physician services, 5% for inpatient care and 1% for nursing care. The two-part model showed a significant positive association between income (square root equivalence scale) and total OOPP. Increasing morbidity was associated with significantly higher total OOPP, and in particular with higher OOPP for pharmaceuticals. Total OOPP amounted to about 3% of disposable income. The generalized linear model for the binomial family showed a significantly lower financial burden for the wealthiest quintile as compared to the poorest one.

Conclusions

This is the first study providing evidence of inequalities in OOPP in the German elderly population. Socio-economic and morbidity-related inequalities in OOPP and the resulting financial burden could be identified. The results of this study may contribute to the discussion about the mechanisms causing the observed inequalities and can thus help decision makers to consider them when adapting future regulations on OOPP.

Social capital and under-utilization of medication for financial reasons among elderly women: evidence from two Brazilian health surveys

This cross-sectional study assesses the prevalence and examines the role of social and demographic factors, health conditions, health system characteristics and contextual factors of under-utilization of medication for financial reasons among elderly women. Participants in the Greater Metropolitan Belo Horizonte Health Survey (GMBH) and the eleventh phase of the Bambuí Cohort Study of the Elderly were assessed. Among elderly women in the GMBH, the prevalence of under-utilization was 11.4%, and in Bambuí, the rate was 5.4%. Self-perception of health (OR, 3.46; 95%CI, 1.32_9.10); daily life limitations (OR, 2.75; 95% CI, 1.31-5.78) and perception of help (OR, 2.36; 95% CI, 1.07-5.25) had independent associations with under-utilization among GMBH residents. A poor perception of both cohesion in the neighborhood (OR, 2.38; 95% CI, 1.02-5.56) and the physical environment (OR, 2.58; 95% CI, 1.10-6.03) significantly increased the likelihood of under-utilization among Bambuí residents. These results provide important clues to identifying possible risk factors for under-utilization, highlighting the need to develop strategies targeting the amplification of the involvement between elderly women and their community to reduce the extent of under-utilization in later life.

Cost-related nonadherence by medication type among Medicare Part D beneficiaries with diabetes

BACKGROUND

Despite the rollout of Medicare Part D, cost-related nonadherence (CRN) among older adults remains a problem.

OBJECTIVES

To examine the rate and correlates of self-reported CRN among a population of older persons with diabetes.

RESEARCH DESIGN

Cross-sectional.

SUBJECTS

A total of 1264 Part D patients with diabetes, who entered the coverage gap in 2006.

MEASURES

Initial administrative medication lists were verified in computer-assisted telephone interviews, in which participants brought their medication bottles to the phone. Medications were classified into cardiometabolic (diabetes, hypertension, cholesterol-lowering), symptom relief, and "other." Participants were asked if they had any CRN during 2006, and if so to which medication/s. We used the person-medication dyad as the unit of analysis, and tested a multivariate random effects logistic regression model to analyze the correlates of CRN.

RESULTS

Approximately 16% of participants reported CRN. CRN was more frequent for cholesterol-lowering medications (relative risk, 1.54; 95% confidence interval, 1.01-2.32) compared with medications taken for symptom relief. CRN was reported less frequently with increasing age above 75 years, compared with patients between 65 and 69. In addition, compared with those with incomes of ≥$40,000, CRN risk for those with incomes of <$25,000 was markedly higher (relative risk, 3.05; 95% confidence interval, 1.99-4.65).

CONCLUSIONS

In summary, we found high rates of CRN among Medicare beneficiaries with diabetes, particularly those with lower incomes. We observed more frequent CRN for cholesterol-lowering medications as compared with medications for symptom relief. Efforts to ensure medication affordability for this population will be important in boosting adherence to key medications.

Perceptions of generic drug discount programs among low-income women: a qualitative study

PURPOSE

Increasing the awareness and use of generic drug discount programs (GDDP) may improve access to essential prescription drugs. However, little is known about public perceptions of GDDPs. The purpose of this study is to understand the perceptions and utilization patterns of low-income women regarding GDDP.

METHODS

Using a purposive sampling strategy, we conducted seven focus groups with a total of 50 participants using a semistructured guide to assess awareness and utilization of GDDP. Transcripts of the focus groups were systematically analyzed across groups with a general inductive approach for qualitative data analysis.

RESULTS

Five major categorical themes emerged from the focus group content analysis: 1) Perceived differences between generic and brand-name prescription drugs, 2) barriers to utilizing GDDP, 3) lack of adequate communication between pharmacy, physician and patient about GDDP, 4) perceived health impact of utilizing GDDPs, and 5) perceived health care savings. Most participants indicated that they perceive no difference between generic and brand-name prescription drugs. Lack of awareness was indicated as a barrier to utilization. There was general agreement among participants that GDDP can help to maintain health while saving money.

CONCLUSION

Study participants demonstrated generally favorable perceptions regarding GDDPs. Our findings underscore the need for policies that encourage expansion of the GDDP formulary and increasing awareness and utilization of GDDP.

Adherence and medication management by the elderly

AIMS AND OBJECTIVES

The purpose of this study was to explore the strategies used for medication management by elderly who live at home.

BACKGROUND

Non-adherence to chronic medication is a common problem among the elderly with chronic conditions. Many studies have been developed, but it did not progress in solving this multidisciplinary health care problem. The causes of non-adherence by the elderly are multiple and complex.

DESIGN

Descriptive qualitative design.

METHODS

Data were collected by two focus groups. The content of discussion was analysed from verbatim transcript and identifying categories and sub-categories emerged, leading to the construction of a diagram analysis.

RESULTS

The finding indicated the strategies and the interpretation of people aged 65 or more and with chronic illness, managing their medication. Four content categories emerged: to live with drugs, taking medication, belief about drugs and relationship with health professionals.

CONCLUSION

The study enabled us to identify and understand, by giving a 'voice' to the elderly, that living with drugs is a dynamic and complex process and that taking medication is perceived by older people as a consequence of their ageing, which requires them to include that process in their lives as a habit implying changes in their daily routines. The elderly suggest that the relationship with health professionals is essential in medication management and they reported that the information given by the nurse during consultation is very important.

RELEVANCE TO CLINICAL PRACTICE

The relationship with nurses in particular is an important issue for the older people. Understanding the factors of adherence and helping people are important areas of research in nursing. The quality of this relationship may be the key to increasing adherence in this group of people.

Cost-related nonadherence to prescribed medication therapy among Medicare Part D beneficiaries with end-stage renal disease

PURPOSE

Medication nonadherence due to cost issues among community-dwelling patients with end-stage renal disease (ESRD) enrolled in Medicare prescription drug plans was evaluated.

METHODS

Demographic and health status data were collected on 1329 patients with ESRD enrolled in Medicare Part D prescription drug plans who responded to a Centers for Medicare and Medicaid Services consumer survey in early 2007. The survey data were assessed for self-reported cost-related nonadherence (CRN), defined as delaying or not filling a prescription due to cost concerns. Multivariate logistic regression analysis was performed to evaluate CRN risk relative to patient demographic characteristics, socioeconomic status, other chronic conditions, health behaviors, and access to health care services.

RESULTS

Overall, survey respondents with ESRD were significantly more likely than those without ESRD to report CRN in the prior six months (unadjusted odds ratio [OR], 2.34; 95% confidence interval [CI], 2.00-2.75). After controlling for potential confounding factors such as other chronic conditions, the data analysis continued to show a significant association between ESRD and an increased risk of CRN (adjusted OR, 1.23; 95% CI, 1.07-1.41). Black race and receipt of Medicare Part D Low-Income Subsidy assistance were significant independent predictors of CRN for respondents with ESRD.

CONCLUSION

In early 2007, 31% of survey respondents with ESRD enrolled in Medicare Part D drug plans reported CRN in the preceding six months. After adjusting for potential confounders, respondents with ESRD remained 23% more likely than respondents without ESRD to report CRN in the preceding six months.

Sources of drug coverage among Medicare beneficiaries with ESRD

Despite extensive use of prescription medications in ESRD, relatively little is known about the participation of Medicare ESRD beneficiaries in the Part D program. Here, we quantitated the sources of drug coverage among ESRD beneficiaries and explored the Part D plan preferences of ESRD beneficiaries with regard to deductibles, coverage gaps, and monthly premiums. We obtained data on beneficiary sources of creditable coverage, characteristics of Part D plans, demographics, and residence from the Centers for Medicare and Medicaid Chronic Condition Data Warehouse and identified beneficiaries with ESRD from the US Renal Data System. We found that a substantial proportion (17.0%) of ESRD beneficiaries lacked a known source of creditable drug coverage in 2007 and 64.3% were enrolled in Part D. Of those enrolled, 72% received the Medicare Part D low-income subsidy. ESRD beneficiaries who enrolled in standalone Part D plans without the assistance of the low-income subsidy tended to prefer more comprehensive coverage options. In conclusion, more outreach is needed to ensure that beneficiaries who lack coverage obtain the coverage they need and that ESRD beneficiaries join the best plans for managing their disease and accompanying comorbid conditions.

Delay in seeing a doctor due to cost: disparity between older adults with and without disabilities in the United States

OBJECTIVE

To examine the disparity in delaying seeing a doctor due to cost between older adults with and without disabilities, and whether the disparity could be explained by health and financial variables.

DATA SOURCES

Nationally representative sample of community-dwelling adults aged ≥65 who have health insurance and a usual source of care from the 2006 Behavioral Risk Factor Surveillance System (n = 85,015).

STUDY DESIGN

This cross-sectional study used sequential logistic regression models to examine the associations of delaying seeing a doctor due to cost with disability status, including demographic, health, and financial variables.

PRINCIPAL FINDINGS

Older adults with disabilities had significantly higher odds of delaying seeing a doctor due to cost compared to older adults without disabilities after controlling for demographic, health, and financial factors. Although health and financial variables collectively attenuated the disparity, they did not fully explain the disparity.

CONCLUSIONS

Despite having health insurance and a usual source of care, older adults with disabilities encountered greater economic difficulties in seeing a doctor than their counterparts without disabilities. Policy makers should continue addressing the economic burden to improve timely visits to health care providers.

Perceptions of social capital and cost-related non-adherence to medication among the elderly

The aim of this study was to examine the association between social capital and cost-related non-adherence (CRN) in an elderly population, using data from 1,134 respondents to the Greater Metropolitan Belo Horizonte Health Survey. CRN was lower for those elderly with a better perception of attachment to their neighbourhoods (PR = 0.68; 95%CI: 0.50-0.94), with more social contacts (one to five, PR = 0.49; 95%CI: 0.30-0.80 and more than five, PR = 0.42; 95%CI: 0.26-0.67), and with private health insurance coverage (PR = 0.64; 95%CI: 0.45-0.93). Meanwhile, CRN was significantly higher for those with fair to poor self-rated health (PR =1.66; 95%CI: 0.95-2.90 and PR = 2.62; 95%CI: 1.46-4.71 respectively), with multiple comorbidities (two, PR = 3.45; 95%CI: 1.38-8.62 and three or more, PR = 4.42; 95%CI: 1.74-11.25), and with a lower frequency of physician-patient dialogue about health/treatment (rarely/never, PR = 1.91; 95%CI: 1.16-3.13). These findings highlight the need to take into account the social context in future research on CRN.

Medication cost problems among chronically ill adults in the US: did the financial crisis make a bad situation even worse?

A national internet survey was conducted between March and April 2009 among 27,302 US participants in the Harris Interactive Chronic Illness Panel. Respondents reported behaviors related to cost-related medication non-adherence (CRN) and the impacts of medication costs on other aspects of their daily lives. Among respondents aged 40-64 and looking for work, 66% reported CRN in 2008, and 41% did not fill a prescription due to cost pressures. More than half of respondents aged 40-64 and nearly two-thirds of those in this group who were looking for work or disabled reported other impacts of medication costs, such as cutting back on basic needs or increasing credit card debt. More than one-third of respondents aged 65+ who were working or looking for work reported CRN. Regardless of age or employment status, roughly half of respondents reporting medication cost hardship said that these problems had become more frequent in 2008 than before the economic recession. These data show that many chronically ill patients, particularly those looking for work or disabled, reported greater medication cost problems since the economic crisis began. Given links between CRN and worse health, the financial downturn may have had significant health consequences for adults with chronic illness.

Beliefs that influence cost-related medication non-adherence among the "haves" and "have nots" with chronic diseases

BACKGROUND AND OBJECTIVE

Some patients continue taking their medication as prescribed despite serious financial pressures, while others with the ability to pay forego treatment due to cost concerns. The primary goal of this study was to explore how patients' beliefs about the necessity of treatment and treatment side effects, influence cost-related non-adherence (CRN).

METHODS

27,302 participants in the Harris Interactive Chronic Illness Panel completed an internet survey. The current study focused on two subsamples representing: (a) the most economically-vulnerable survey respondents (ie, individuals with household incomes of US$25,000 per year or less and monthly out-of-pocket medication costs of at least US$60, n = 1321); and (b) respondents who were the most likely to have the financial resources to pay for medications (ie, those with incomes of US$125,000 or more and monthly medication costs of less than US$60.00, n = 1195). Multivariate models were constructed for each group to determine the independent impact on CRN of perceived need for medications and side-effect concerns. Increased risk for CRN associated with depression and asthma diagnoses also was examined.

RESULTS

Twenty-one percent of economically vulnerable respondents reported continuing to take their medication as prescribed despite serious cost pressures, while 14% of high-income respondents reported CRN despite apparently manageable out-of-pocket costs. Both low perceived need for medications and concerns about side-effects affected CRN risk in low-income and high-income groups. Within groups of both low-income and high-income respondents, depression and asthma significantly increased patients' odds of reporting CRN.

CONCLUSION

Beyond objective financial measures, CRN is influenced by patient beliefs, which can influence the perceived value of prescription drugs. Addressing these beliefs, as well as the unique adherence concerns of patients with depression and asthma, could decrease CRN rates even if cost pressures themselves cannot be reduced.

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.

Income-, education- and gender-related inequalities in out-of-pocket health-care payments for 65+ patients - a systematic review

Background

In all OECD countries, there is a trend to increasing patients' copayments in order to balance rising overall health-care costs. This systematic review focuses on inequalities concerning the amount of out-of-pocket payments (OOPP) associated with income, education or gender in the Elderly aged 65+.

Methods

Based on an online search (PubMed), 29 studies providing information on OOPP of 65+ beneficiaries in relation to income, education and gender were reviewed.

Results

Low-income individuals pay the highest OOPP in relation to their earnings. Prescription drugs account for the biggest share. A lower educational level is associated with higher OOPP for prescription drugs and a higher probability of insufficient insurance protection. Generally, women face higher OOPP due to their lower income and lower labour participation rate, as well as less employer-sponsored health-care.

Conclusions

While most studies found educational and gender inequalities to be associated with income, there might also be effects induced solely by education; for example, an unhealthy lifestyle leading to higher payments for lower-educated people, or exclusively gender-induced effects, like sex-specific illnesses. Based on the considered studies, an explanation for inequalities in OOPP by these factors remains ambiguous.

Medication nonfulfillment rates and reasons: narrative systematic review

BACKGROUND

The literature on nonfulfillment of prescription medications spans over three decades of work. There is a wide variation in reported nonfulfillment rates, but no previous study has systematically reviewed this literature to explore the reasons behind this variation.

OBJECTIVE

The objective of this study was to review estimates of medication nonfulfillment rates and published reasons for nonfulfillment and explore whether nonfulfillment rates vary by study variables.

METHODS

Articles were identified through searches conducted on MEDLINE, CINAHL, Psych Info, and EMBASE, and review of relevant reference citations. Methodological variables, nonfulfillment rate, and unit of analysis (i.e., patient or prescription) were abstracted from each article selected for review. Mean and median nonfulfillment rates for groups categorized by unit of analysis and selected methodological variables (method for assessing nonfulfillment, sample characteristics, disease subgroup, sample size, country of data collection, recall period or time allowed before classifying as nonfulfillment, and year of study) were calculated. Reasons for nonfulfillment were abstracted from all articles that included a relevant discussion.

FINDINGS

A total of 79 studies reporting pure nonfulfillment rates (59 at the patient level and 20 at the prescription level) and six studies reporting nonfulfillment rates in combination with nonpersistence rates were included. There was a wide variation in nonfulfillment rates reported by the studies - from 0.5% to 57.1%. The three primary reasons for nonfulfillment identified from this review were perceived concerns about medications, lack of perceived need for medications, and medication affordability issues.

CONCLUSION

To the best of the authors' knowledge, this study is the first narrative systematic review on nonfulfillment of prescription medications. Despite the wide variation in individual study rates, the mean and median rates across different modes of data collection and sources of data were in a relatively narrow range (11% to 19%) and surprisingly close to the overall mean (16.4%) and median (15%.0) rates for all studies. The reasons for nonfulfillment identified through this review address barriers to nonfulfillment at the patient, physician, and health system level and thus bear important implications for policy makers.

Medication adherence is a mediator of the relationship between ethnicity and event-free survival in patients with heart failure

BACKGROUND

Rehospitalization rates are higher in African American than Caucasian patients with heart failure (HF). The reasons for the disparity in outcomes between African Americans and Caucasians may relate to differences in medication adherence. To determine whether medication adherence is a mediator of the relationship between ethnicity and event-free survival in patients with HF.

METHODS AND RESULTS

Medication adherence was monitored longitudinally in 135 HF patients using the Medication Event Monitoring System. Events (emergency department visits for HF exacerbation, HF and cardiac rehospitalization, and all-cause mortality) were obtained by interview and hospital data base review. A series of regression models and survival analyses was conducted to determine whether medication adherence mediated the relationship between ethnicity and event-free survival. Event-free survival was significantly worse in African Americans than Caucasians. Ethnicity was a predictor of medication adherence (P=.011). African Americans were 2.57 times more likely to experience an event than Caucasians (P=.026). Ethnicity was not a predictor of event-free survival after entering medication adherence in the model (P=.06).

CONCLUSIONS

Medication adherence was a mediator of the relationship between ethnicity and event-free survival in this sample. Interventions designed to reduce barriers to medication adherence may decrease the disparity in outcomes.

Estudo de base populacional da subutilização de medicamentos por motivos financeiros entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil

O objetivo deste trabalho foi estimar a prevalência e avaliar os fatores associados à subutilização de medicamentos por motivos financeiros em amostra representativa de 1.134 idosos, residentes na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. A prevalência da subutilização foi de 12,9%, estando independentemente associada à renda pessoal mensal inferior a dois salários mínimos (RP = 0,57; IC95%: 0,34-0,97), à filiação a plano privado de saúde (RP = 0,68; IC95%: 0,46-0,99), à freqüência com que o profissional de saúde esclareceu sobre a saúde/tratamento (raramente/nunca, RP = 1,79; IC95%: 1,10-2,90), à auto-avaliação de saúde (razoável, RP = 1,66; IC95%: 0,95-2,90 e ruim/muito ruim, RP = 2,49; IC95%: 1,38-4,48) e ao número de condições crônicas (uma, RP = 2,51; IC95%: 0,99-6,35; duas, RP = 3,51; IC95%: 1,40-8,72 e três ou mais, RP = 4,52; IC95%: 1,79-11,41). Os resultados confirmam a importância dos aspectos sócio-econômicos para a subutilização, mas indicam que sua determinação também está ligada à qualidade da comunicação médico-paciente. Evidencia-se ainda uma situação de risco para idosos em piores condições de saúde.

The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease

OBJECTIVE

To conceptualize, develop, and provide preliminary psychometric evidence for the Adherence Estimator--a brief, three-item proximal screener for the likelihood of non-adherence to prescription medications (medication non-fulfillment and non-persistence) for chronic disease.

RESEARCH DESIGN AND METHODS

Qualitative focus groups with 140 healthcare consumers and two internet-based surveys of adults with chronic disease, comprising a total of 1772 respondents, who were self-reported medication adherers, non-persisters, and non-fulfillers. Psychometric tests were performed on over 150 items assessing 14 patient beliefs and skills hypothesized to be related to medication non-adherence along a proximal-distal continuum. Psychometric tests included, but were not limited to, known-groups discriminant validity at the scale and item level. The psychometric analyses sought to identify: (1) the specific multi-item scales that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters) and, (2) the single best item within each prioritized multi-item scale that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters).

RESULTS

The two rounds of psychometric testing identified and cross-validated three proximal drivers of self-reported adherence: perceived concerns about medications, perceived need for medications, and perceived affordability of medications. One item from each domain was selected to include in the Adherence Estimator using a synthesis of psychometric results gleaned from classical and modern psychometric test theory. By simple summation of the weights assigned to the category responses of the three items, a total score is obtained that is immediately interpretable and completely transparent. Patients can be placed into one of three segments based on the total score--low, medium, and high risk for non-adherence. Sensitivity was 88%--of the non-adherers, 88% would be accurately classified as medium or high risk by the Adherence Estimator. The three risk groups differed on theoretically-relevant variables external to the Adherence Estimator in ways consistent with the hypothesized proximal-distal continuum of adherence drivers.

CONCLUSIONS

The three-item Adherence Estimator measures three proximal beliefs related to intentional non-adherence (medication non-fulfillment and non-persistence). Preliminary evidence of the validity of the Adherence Evidence supports its intended use to segment patients on their propensity to adhere to a newly-prescribed prescription medication. The Adherence Estimator is readily scored and is easily interpretable. Due to its brevity and transparency, it should prove to be practical for use in everyday clinical practice and in disease management for adherence quality improvement. Study limitations related to sample representation and self reports of chronic disease and adherence behaviors were discussed.

Gender differences in predictors of late-life health insurance knowledge

For many older adults having access to affordable health care is a major concern. The present study's goal was to examine what factors were related to individuals' knowledge of late-life health insurance. A total of 131 women and 116 men (all aged 55-71) answered questions about private, Medicare, Medigap, and long-term care insurances. In addition, they answered demographic, personality, and health status questions. Results revealed that different factors are related to men's and women's knowledge of late-life health insurance options implying genderspecific educational interventions would be more effective than current educational interventions.

Burden of Common Multiple-Morbidity Constellations on Out-of-Pocket Medical Expenditures Among Older Adults

PURPOSE

On average, adults aged 60 years or older have 2.2 chronic diseases, contributing to the over 60 million Americans with multiple morbidities. We aimed to understand the financial implications of the most frequent multiple morbidities among older adults.

DESIGN AND METHODS

We analyzed Health and Retirement Study data, determining out-of-pocket medical expenses from 1998 and 2002 separately and examining differences in the impact of multiple-morbidity constellations on these expenses. We paid particular attention to the most common disease constellations - hypertension, arthritis, and heart disease.

RESULTS

An increasing prevalence of multiple morbidity (58% compared with 70% of adults had two or more chronic conditions in 1998 and 2002, respectively) was accompanied by escalating out-of-pocket expenditures (2,164 dollars in 1998, increasing by 104% to 3,748 dollars in 2002). Individuals with two, three, and four chronic conditions had health care expenditure increases of 41%, 85%, and 100%, respectively, over 4 years. Such patterns were particularly noticeable among the oldest old, those with higher educational attainment, and women, although having supplementary health insurance or Medicaid mitigated these expenses. Finally, there were significant differences in out-of-pocket expenditure levels among the multiple-morbidity combinations.

IMPLICATIONS

Increasing rates of multiple morbidities in conjunction with escalating health care costs and stable or declining incomes among elders warrant creative attention from providers, researchers, and policy makers. Further understanding how specific multiple-morbidity constellations impact out-of-pocket spending moves us closer to effective interventions to support vulnerable elders.

Patients at-risk for cost-related medication nonadherence: a review of the literature

OBJECTIVE

Up to 32% of older patients take less medication than prescribed to avoid costs, yet a comprehensive assessment of risk factors for cost-related nonadherence (CRN) is not available. This review examined the empirical literature to identify patient-, medication-, and provider-level factors that influence the relationship between medication adherence and medication costs.

DESIGN

We conducted searches of four databases (MEDLINE, CINAHL, Sciences Citations Index Expanded, and EconLit) from 2001 to 2006 for English-language original studies. Articles were selected if the study included an explicit measure of CRN and reported results on covarying characteristics.

MAIN RESULTS

We found 19 studies with empirical support for concluding that certain patients may be susceptible to CRN: research has established consistent links between medication nonadherence due to costs and financial burden, but also to symptoms of depression and heavy disease burden. Only a handful of studies with limited statistical methods provided evidence on whether patients understand the health risks of CRN or to what extent clinicians influence patients to keep taking medications when faced with cost pressures. No relationship emerged between CRN and polypharmacy.

CONCLUSION

Efforts to reduce cost-related medication nonadherence would benefit from greater study of factors besides the presence of prescription drug coverage. Older patients with chronic diseases and mood disorders are at-risk for CRN even if enrolled in Medicare's new drug benefit.

Study on Variations in Price of Prescription Medicines in Thailand

There are evidences describing that the prices of prescription medicines can affect users, suppliers, and, in particular, payers in the health care system. Despite the significant effects of prices, the information regarding their characteristics is scarce. The objective of this study was to examine the prices and price variations of prescription medicines in an actual setting. A cross-sectional study on the prices of prescription medicines listed in a hospital formulary was undertaken. The medicines (n=1531) listed in the formulary were recorded according to the category of the medicine (essential or non-essential medicines), manufacturer types (local or foreign), dosage forms, therapeutic classifications (classes), and prices per unit in Baht. This study used coefficients of relative variations (CRVs) to determine the extent of price variations. Results revealed that the mean prices of non-essential and foreign medicines were significantly greater than those of its counterparts by 1.7 and 21.2 times, respectively. On an average, the classes with the highest prices were blood-related, antineoplastic, and endocrinological agents, while those with the lowest prices were the psychotherapeutic, CNS, and cardiovascular agents. The majority of the medicines (37%) were in the price range of >10-100 Baht. The price variations of different classes of medicines varied from about 100% to 600%. The mean price and CRV levels (low and high) formed four groups of medicines with different risks of high prices and variations to payers. In conclusion, the prices are associated with the category and manufacturer type. The prices and their variations could be used to distinguish the classes of medicines that possess different risks of high prices and variations to payers. Identifying the classes with high prices and high variations, high prices and low variations, and low prices and high variations is necessary for careful intervention to reduce the effect of prices and their variations on payers.

A cross-national study of prescription nonadherence due to cost: data from the Joint Canada-United States Survey of Health

BACKGROUND

In Canada and the United States, patients who have difficulty paying for prescribed medications are less likely to obtain them and may experience increased risks for morbidity and mortality and/or increased health care costs due to nonadherence. As prescription drug costs have risen, the ability to pay for medications has emerged as a critical public health issue.

OBJECTIVES

The objectives of this study were to estimate the rates of cost-associated nonadherence in Canada and the United States, and to identify factors that predict cost-associated nonadherence in both countries.

METHODS

This original analysis used data from the 2002/2003 Joint Canada-US Survey of Health, a household phone survey jointly conducted by Statistics Canada (Ottawa, Ontario, Canada) and the US National Center for Health Statistics (Hyattsville, Maryland). The sample included 3505 adults in Canada and 5183 adults in the United States. Weighted group comparisons and logistic regression analyses were used to identify population factors predictive of cost-associated prescription nonadherence.

RESULTS

Residents of Canada were much less likely than residents of the United States to report cost-associated nonadherence (5.1% vs 9.9%; P < 0.001). Americans without health insurance (28.2%) and Americans and Canadians without prescription-drug coverage (16.2%) were significantly more likely than those with insurance (6.2%) to report cost-associated nonadherence (P < 0.001). In addition to country of residence and insurance coverage, significant risk factors predictive of nonadherence were young age, poor health, chronic pain, and low household income.

CONCLUSIONS

The results of this analysis suggest that people with low incomes and inadequate insurance, as well as those with poor health and/or chronic symptoms, are more likely to report failing to fill a prescription due to cost. The overall rate of cost-associated nonadherence was significantly higher in the United States than in Canada, even when other person-level factors were controlled for, including health insurance and prescription-drug coverage.

Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy

BACKGROUND

The factors influencing medication adherence have not been fully elucidated. Inadequate health literacy skills may impair comprehension of medical care instructions, and thereby reduce medication adherence.

OBJECTIVES

To examine the relationship between health literacy and medication refill adherence among Medicare managed care enrollees with cardiovascular-related conditions.

RESEARCH DESIGN

Prospective cohort study.

SUBJECTS

New Medicare enrollees from 4 managed care plans who completed an in-person survey and were identified through administrative data as having coronary heart disease, hypertension, diabetes mellitus, and/or hyperlipidemia (n=1,549).

MEASURES

Health literacy was determined using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Prospective administrative data were used to calculate the cumulative medication gap (CMG), a valid measure of medication refill adherence, over a 1-year period. Low adherence was defined as CMG> or =20%.

RESULTS

Overall, 40% of the enrollees had low refill adherence. Bivariate analyses indicated that health literacy, race/ethnicity, education, and regimen complexity were each related to medication refill adherence (P<.05). In unadjusted analysis, those with inadequate health literacy skills had increased odds (odds ratio [OR]=1.37, 95% confidence interval [CI]: 1.08 to 1.74) of low refill adherence compared with those with adequate health literacy skills. However, the OR for inadequate health literacy and low refill adherence was not statistically significant in multivariate analyses (OR=1.23, 95% CI: 0.92 to 1.64).

CONCLUSIONS

The present study suggests, but did not conclusively demonstrate, that low health literacy predicts poor refill adherence. Given the prevalence of both conditions, future research should continue to examine this important potential association.