Medication Nonadherence: The Role of Cost, Community, and Individual Factors

Clinical Considerations for Healthcare Provider-Administered Lipid-Lowering Medications

Atherosclerotic cardiovascular disease (ASCVD), a leading cause of mortality and morbidity, is associated with a substantial healthcare and economic burden. Reduction of low-density lipoprotein cholesterol (LDL-C) to guideline-recommended goals is crucial in the prevention or management of ASCVD, particularly in those at high risk. Despite the availability of several effective lipid-lowering therapies (LLTs), up to 80% of patients with ASCVD do not reach evidence-based LDL-C goals. This nonattainment may be due to poor adherence to, and lack of timely utilization of, LLTs driven by a range of variables, including polypharmacy, side effects, clinical inertia, costs, and access issues. Inclisiran was approved by the US Food and Drug Administration in 2021 as a novel, twice-yearly, healthcare provider (HCP)-administered LLT. In-office administration allows HCPs more control of drug acquisition, administration, and reimbursement, and may allow for more timely care and increased patient monitoring. In the USA, in-office administered drugs are considered a Medical Benefit and can be acquired and reimbursed using the "buy-and-bill" process. Buy-and-bill is a standard system for medication administration already established in multiple therapeutic areas, including oncology, vaccines, and allergy/immunology. Initiating in-office administration will involve new considerations for clinicians in the cardiovascular specialty, such as the implementation of new infrastructure and processes; however, it could ultimately increase treatment adherence and improve cardiovascular outcomes for patients with ASCVD. This article discusses the potential implications of buy-and-bill for the cardiology specialty and provides a practical guide to implementing HCP-administered specialty drugs in US clinical practice.

Assessing performance of ZCTA-level and Census Tract-level social and environmental risk factors in a model predicting hospital events

Predictive analytics are used in primary care to efficiently direct health care resources to high-risk patients to prevent unnecessary health care utilization and improve health. Social determinants of health (SDOH) are important features in these models, but they are poorly measured in administrative claims data. Area-level SDOH can be proxies for unavailable individual-level indicators, but the extent to which the granularity of risk factors impacts predictive models is unclear. We examined whether increasing the granularity of area-based SDOH features from ZIP code tabulation area (ZCTA) to Census Tract strengthened an existing clinical prediction model for avoidable hospitalizations (AH events) in Maryland Medicare fee-for-service beneficiaries. We created a person-month dataset for 465,749 beneficiaries (59.4% female; 69.8% White; 22.7% Black) with 144 features indexing medical history and demographics using Medicare claims (September 2018 through July 2021). Claims data were linked with 37 SDOH features associated with AH events from 11 publicly-available sources (e.g., American Community Survey) based on the beneficiaries' ZCTA and Census Tract of residence. Individual AH risk was estimated using six discrete time survival models with different combinations of demographic, condition/utilization, and SDOH features. Each model used stepwise variable selection to retain only meaningful predictors. We compared model fit, predictive performance, and interpretation across models. Results showed that increasing the granularity of area-based risk factors did not dramatically improve model fit or predictive performance. However, it did affect model interpretation by altering which SDOH features were retained during variable selection. Further, the inclusion of SDOH at either granularity level meaningfully reduced the risk that was attributed to demographic predictors (e.g., race, dual-eligibility for Medicaid). Differences in interpretation are critical given that this model is used by primary care staff to inform the allocation of care management resources, including those available to address drivers of health beyond the bounds of traditional health care.

Prior Cardiovascular Treatments-A Key Characteristic in Determining Medication Adherence After an Acute Myocardial Infarction

Objective: To investigate long-term adherence to guideline-recommended cardioprotective medications following hospitalization for an acute myocardial infarction (AMI), and identify characteristics associated with adherence.

Methods: An Australian population-based cohort study was used to identify participants who had their first AMI between 2006 and 2014 and were alive after 12 months. Linked routinely collected hospital, and prescription medication claims data was used to study adherence over time. Predictors and rates of adherence to both lipid-lowering medication and renin-angiotensin system blockade at 12 months post-AMI was assessed.

Results: 14,200 people (mean age 69.9 years, 38.7% female) were included in our analysis. At 12 months post-AMI, 29.5% (95% CI: 28.8–30.3%) of people were adherent to both classes of medication. Individuals receiving treatment with both lipid-lowering medication and renin-angiotensin system blockade during the 6 months prior to their AMI were over 9 times more likely to be adherent to both medications at 12 months post-AMI (66.2% 95% CI: 64.8–67.5%) compared to those with no prior medication use (treatment naïve) (7.1%, 95% CI: 6.4–7.9%). Prior cardiovascular treatment was the strongest predictor of long-term adherence even after adjusting for age, sex, education and income.

Conclusions: Despite efforts to improve long-term medication adherence in patients who have experienced an acute coronary event, considerable gaps remain. Of particular concern are people who are commencing guideline-recommended cardioprotective medication at the time of their AMI. The relationship between prior cardiovascular treatments and post AMI adherence offers insight into the support needs for the patient. Health care intervention strategies, strengthened by enabling policies, are needed to provide support to patients through the initial months following their AMI.

A Pilot Program to Teach Pharmacy Students Practical Skills to Navigate Drug Insurance Benefits

Pharmacists must be able to navigate prescription drug coverages to help providers and patients reduce out-of-pocket costs. Traditionally, curricula on drug insurance benefits rely on lectures and lack a practicum that offers students hands-on experience with determining formulary and cost-sharing information. An activity for pharmacy students to update a free public website that summarizes formularies and copayment requirements across major insurers was piloted. Pharmacy students were trained to locate online formularies and identify a drug’s coverage tier, step therapy, prior authorization, and cost-sharing during a 6-week experiential rotation. Students checked formularies from six insurance plans for 250-plus drugs across 15 health conditions. Graduates were surveyed (74% response rate) about the activities’ impact on their learning and ability to navigate drug benefits. Respondents rated the training as helpful in learning whether a drug was covered (100%), or required step therapy or prior authorization (100%). The majority of graduates reported being able to look up formulary coverage (90%), step therapy or prior authorization (90%), and copayment requirements (65%). Our innovative skills-based pilot activity was effective in teaching pharmacy students to navigate insurance formularies, which is essential for helping patients access medications.

Systematic Review of RCTs Assessing the Effectiveness of mHealth Interventions to Improve Statin Medication Adherence: Using the Behaviour-Change Technique Taxonomy to Identify the Techniques That Improve Adherence

Statin non-adherence is a common problem in the management of cardiovascular disease (CVD), increasing patient morbidity and mortality. Mobile health (mHealth) interventions may be a scalable way to improve medication adherence. The objectives of this review were to assess the literature testing mHealth interventions for statin adherence and to identify the Behaviour-Change Techniques (BCTs) employed by effective and ineffective interventions. A systematic search was conducted of randomised controlled trials (RCTs) measuring the effectiveness of mHealth interventions to improve statin adherence against standard of care in those who had been prescribed statins for the primary or secondary prevention of CVD, published in English (1 January 2000-17 July 2020). For included studies, relevant data were extracted, the BCTs used in the trial arms were coded, and a quality assessment made using the Risk of Bias 2 (RoB2) questionnaire. The search identified 17 relevant studies. Twelve studies demonstrated a significant improvement in adherence in the mHealth intervention trial arm, and five reported no impact on adherence. Automated phone messages were the mHealth delivery method most frequently used in effective interventions. Studies including more BCTs were more effective. The BCTs most frequently associated with effective interventions were "Goal setting (behaviour)", "Instruction on how to perform a behaviour", and "Credible source". Other effective techniques were "Information about health consequences", "Feedback on behaviour", and "Social support (unspecified)". This review found moderate, positive evidence of the effect of mHealth interventions on statin adherence. There are four primary recommendations for practitioners using mHealth interventions to improve statin adherence: use multifaceted interventions using multiple BCTs, consider automated messages as a digital delivery method from a credible source, provide instructions on taking statins, and set adherence goals with patients. Further research should assess the optimal frequency of intervention delivery and investigate the generalisability of these interventions across settings and demographics.

Cost-related nonadherence for prescription medications: a cross-sectional study in Jordan

Background: Cost-related nonadherence to medications is a commonly encountered problem posed by many patients, and specifically among elderly patients who use multiple chronic medications. This study aims to explore the prevalence of medication cost-related nonadherence and its predictors in Jordan.Method: A cross-sectional study was conducted between February 2019 and May 2019 in Jordan. The CRN questionnaire was used as a measure to assess the prevalence of cost-related nonadherence. Logistic regression was used to determine predictors of medication cost-related nonadherence.Results: The prevalence rate of CRN was 29.6% (95% CI: 27.0-32.3). Participants who are married or widowed were found to have higher odds of being non-adherent due to medication costs, with an odds ratio of 1.55 (95%CI: 1.19-2.00) and 1.95 (95%CI: 1.20-3.15), respectively. Lower educational level was associated with higher odds of being non-adherent 1.95 (95%CI: 1.25-3.05). Being retired was associated with higher odds of being non-adherent (2.20 (95%CI: 1.49-3.27)).Conclusion: Cost-related nonadherence is a common problem in Jordan and was most prevalent among those with hypertension and diabetes mellitus, low-income, and low levels of education. Our findings could help in developing interventions to improve cost-related medication nonadherence in developing countries.

Association Between Neighborhood-level Socioeconomic Deprivation and the Medication Level Variability Index for Children Following Liver Transplantation

BACKGROUND

Neighborhood socioeconomic deprivation is associated with adverse health outcomes. We sought to determine if neighborhood socioeconomic deprivation was associated with adherence to immunosuppressive medications after liver transplantation.

METHODS

We conducted a secondary analysis of a multicenter, prospective cohort of children enrolled in the medication adherence in children who had a liver transplant study (enrollment 2010-2013). Participants (N = 271) received a liver transplant ≥1 year before enrollment and were subsequently treated with tacrolimus. The primary exposure, connected to geocoded participant home addresses, was a neighborhood socioeconomic deprivation index (range 0-1, higher indicates more deprivation). The primary outcome was the medication level variability index (MLVI), a surrogate measure of adherence to immunosuppression in pediatric liver transplant recipients. Higher MLVI indicates worse adherence behavior; values ≥2.5 are predictive of late allograft rejection.

RESULTS

There was a 5% increase in MLVI for each 0.1 increase in deprivation index (95% confidence interval, -1% to 11%; P = 0.08). Roughly 24% of participants from the most deprived quartile had an MLVI ≥2.5 compared with 12% in the remaining 3 quartiles (P = 0.018). Black children were more likely to have high MLVI even after adjusting for deprivation (adjusted odds ratio 4.0 95% confidence interval, 1.7-10.6).

CONCLUSIONS

This is the first study to evaluate associations between neighborhood socioeconomic deprivation and an objective surrogate measure of medication adherence in children posttransplant. These findings suggest that neighborhood context may be an important consideration when assessing adherence. Differential rates of medication adherence may partly explain links between neighborhood factors and adverse health outcomes following pediatric liver transplantation.

Affordability in individuals' healthcare decision making: A concept analysis

This concept analysis aims to define affordability within the context of healthcare decision making. Affordability is a complex concept that influences an individual's healthcare decision making. In the year's post-Affordable Care Act, the United States has seen an increase in insured individuals, but also an increase in underinsured healthcare consumers. Evidence for the concept attributes was found by searching the Cumulative Index of Nursing and Allied Health Literature, EconLit, Family & Society Studies Worldwide, Humanities Full Text, and PsychINFO databases. Literature was synthesized using the Walker and Avant approach. A new definition was derived with four defining attributes, as well as antecedents and consequences. Three cases are forwarded: the model, borderline, and contrary. In healthcare decision making, affordability is a subjective measure that individuals use in determining the ability to engage in a healthcare service or a durable good transaction. Affordability varies based on circumstances. The context of healthcare decision making of individuals stands in contrast to the decision-making in health systems and to decisions unrelated to one's health. Affordability is a determinant of an individual's ability to engage in a transaction. As such, nurses and policymakers should attempt to understand affordability from the patient's perspective.

Failure to access prescribed pharmaceuticals by older patients with chronic conditions

Objective Medication adherence is a significant public health concern. Australian studies of statins show patients facing the highest copayments are the least likely to be adherent. This study examined whether the association identified between adherence and costs for statins also applies to a wider group of medications prescribed for Australian patients with chronic conditions. Methods Data from 267086 participants in the Sax Institute's 45 and Up Study linked to data from the Pharmaceutical Benefits Scheme (PBS) provided by the Department of Human Services were used. Patients using angiotensin II receptor blockers, angiotensin-converting enzyme inhibitors, glitazones and bisphosphonates were identified and classified according to concessional status and whether they had access to the PBS 'safety net'. Data were analysed using mainly descriptive methods to investigate the association of adherence with cost and other selected covariates. Results Across medications, the group facing the highest copayment was least adherent. Speaking a language other than English at home and facing high levels of psychological distress were also associated with lower levels of adherence. Conclusions As for statins, the main financial determinant of adherence is cost in the form of prescribed copayments, suggesting that this may apply across many medications. What is known about the topic? Previous studies have shown patients' concern about the costs of pharmaceuticals, and more detailed studies of statins show that the lowest adherence relates to patients facing the highest copayments. What does this paper add? This paper provides support for the contention that the results found for statins broadly apply across more medications used by people with chronic conditions. What are the implications for practitioners? Although practitioners cannot affect legislated copayments, they can consider the costs of options for medications for patients with chronic conditions, especially those general patients who have not reached the safety net, and they can be aware that patients from homes where English is not spoken and patients with high levels of psychological distress are also likely to have low adherence without intervention.

If my cholesterol is…then I foresee…: patient accounts of uncertainty

The author examines the talk of patients with high cholesterol as they discuss their experiences of adding a statin to their treatment regimen. The primary objective was to understand patients’ expectations of statins, and their beliefs and feelings as they continued or discontinued use, and to better understand why adherence to a statin regimen is particularly low. While numerous studies report reasons for nonadherence, few apply theory to provide plausible explanations. Analysis of the focus group data revealed three major themes. First, patients do not view high cholesterol as serious in light of other major health problems like diabetes and cancer within the household. Second, patients believe statins are effective in lowering cholesterol but risky. Third, many patients do not understand how high levels of cholesterol are produced in the body and how statins interrupt that process. Problematic integration theory is used to explain the uncertainty patients experience when given a diagnosis of high cholesterol, the use of statins to control it, and the quality of information received about both cholesterol and statins.

Social Determinants of Health in Managed Care Payment Formulas

IMPORTANCE

Managed care payment formulas commonly allocate more money for medically complex populations, but ignore most social determinants of health (SDH).

OBJECTIVE

To add SDH variables to a diagnosis-based payment formula that allocates funds to managed care plans and accountable care organizations.

DESIGN, SETTING, AND PARTICIPANTS

Using data from MassHealth, the Massachusetts Medicaid and Children's Health Insurance Program, we estimated regression models predicting Medicaid spending using a diagnosis-based and SDH-expanded model, and compared the accuracy of their cost predictions overall and for vulnerable populations. MassHealth members enrolled for at least 6 months in 2013 in fee-for-service (FFS) programs (n = 357 660) or managed care organizations (MCOs) (n = 524 607).

EXPOSURES

We built cost prediction models from a fee-for-service program. Predictors in the diagnosis-based model are age, sex, and diagnoses from claims. The SDH model adds predictors describing housing instability, behavioral health issues, disability, and neighborhood-level stressors.

MAIN OUTCOMES AND MEASURES

Overall model explanatory power and overpayments and underpayments for subgroups of interest for all Medicaid-reimbursable expenditures excepting long-term support services (mean annual cost = $5590 per member).

RESULTS

We studied 357 660 people who were FFS participants and 524 607 enrolled in MCOs with a combined 806 889 person-years of experience. The FFS program experience included more men (49.6% vs 43.6%), older patients (mean age of 26.1 years vs 21.6 years), and sicker patients (mean morbidity score of 1.16 vs 0.89) than MCOs. Overall, the SDH model performed well, but only slightly better than the diagnosis-based model, explaining most of the spending variation in the managed care population (validated R2 = 62.4) and reducing underpayments for several vulnerable populations. For example, raw costs for the quintile of people living in the most stressed neighborhoods were 9.6% ($537 per member per year) higher than average. Since greater medical morbidity accounts for much of this difference, the diagnosis-based model underpredicts costs for the most stressed quintile by about 2.1% ($130 per member per year). The expanded model eliminates the neighborhood-based underpayment, as well as underpayments of 72% for clients of the Department of Mental Health (observed costs of about $30 000 per year) and of 7% for those with serious mental illness (observed costs of about $16 000 per year).

CONCLUSIONS AND RELEVANCE

Since October 2016, MassHealth has used an expanded model to allocate payments from a prespecified total budget to managed care organizations according to their enrollees' social and medical risk. Extra payments for socially vulnerable individuals could fund activities, such as housing assistance, that could improve health equity.