The economic consequences of noncompliance in cardiovascular disease and related conditions: a literature review

Improved medication adherence in COPD patients using tiotropium or tiotropium olodaterol with the HealthPrize digital behavior change program

OBJECTIVE

To assess the impact of the HealthPrize RespiPoints™ program on treatment adherence and persistence in adults with chronic obstructive pulmonary disease (COPD).

METHODS

In this retrospective cohort study, program participants and nonparticipants receiving tiotropium bromide (TIO) or TIO and olodaterol between 1 January 2015-31 March 2020 were propensity score matched (PSM), from the linked database of the HealthPrize patient list and IQVIA PharMetrics® Plus. Treatment adherence, persistence, healthcare resource utilization, and costs were compared. Multivariable logistic regression models assessed the odds of adherence (≥80% proportion of days covered [PDC]), adjusted risk of discontinuation, and adjusted total healthcare costs.

RESULTS

Program participants (n = 262) demonstrated a 44% greater adherence during followup than nonparticipants (n = 262) (mean [standard deviation] PDC: 0.72 [0.27] vs 0.50 [0.36], p < 0.0001). Participants had higher odds of adherence vs nonparticipants (adjusted odds ratio: 2.51; 95% confidence interval: 1.72-3.66, p < 0.0001) and a lower percentage of participants discontinued their index medication (19.85% vs 33.59%, p = 0.0004). Fewer participants were hospitalized during follow-up (13.74% vs 17.56%, p = 0.23); adjusted total medical costs were 24% lower (p = 0.08). Higher pharmacy costs partially offset lower healthcare costs.

CONCLUSIONS

Program participants showed improved COPD medication adherence and persistence compared to nonparticipants.

Real price of health-experiences of out-of-pocket costs in Australia: protocol for a systematic review

INTRODUCTION

Australians have substantial out-of-pocket (OOP) health costs compared with other developed nations, even with universal health insurance coverage. This can significantly affect access to care and subsequent well-being, especially for priority populations including those on lower incomes or with multimorbidity and chronic illness. While it is known that high OOP healthcare costs may contribute to poorer health outcomes, it is not clear exactly how these expenses are experienced by people with chronic illnesses. Understanding this may provide critical insights into the burden of OOP costs among this population group and may highlight policy gaps.

METHOD AND ANALYSIS

A systematic review of qualitative studies will be conducted using Pubmed, CINAHL Complete (EBSCO), Cochrane Library, PsycINFO (Ovid) and EconLit from date of inception to June 2022. Primary outcomes will include people's experiences of OOP costs such as their preferences, priorities, trade-offs and other decision-making considerations. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and methodological appraisal of included studies will be assessed using the Critical Appraisal Skills Programme. A narrative synthesis will be conducted for all included studies.

ETHICS AND DISSEMINATION

Ethics approval was not required given this is a systematic review that does not include human recruitment or participation. The study's findings will be disseminated through conferences and symposia and shared with consumers, policymakers and service providers, and published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022337538.

Impact of depression on adherence to lenalidomide plus low-dose dexamethasone in patients with relapsed or refractory myeloma

PURPOSE

While continued lenalidomide and low-dose dexamethasone (Rd) treatment could improve survival outcomes for multiple myeloma (MM), the association of depression on the adherence to Rd regimen in myeloma patients has never been studied even though depression is a common symptom among MM patients. This study aims to evaluate the impact of depression prior to Rd treatment on adherence to the treatment among patients with MM.

METHODS

This multicenter cohort study was conducted from January 2015 to October 2018 at five tertiary hospitals in Korea. Patients who completed fewer than 4 cycles, 4-11 cycles, and more than 12 cycles were categorized as the poor adherence group (PAG), moderate adherence group (MAG), and good adherence group (GAG), respectively.

RESULTS

Among141 patients, 41.8% of them had depression before beginning Rd treatment and 46% of participants were in the GAG. Compared with patients in the GAG (30.3%), patients in the PAG were more likely to have depression at baseline (90.0%) and had the higher distress scores (6.35 vs. 4.28, P < 0.01). Presence of depression prior to Rd treatment was significantly associated with poor adherence (IRR = 6.67, 95% CI = 1.45, 30.61) after adjusting for age, sex, education, ECOG, ISS stage, number of previous treatments, and disease status prior to Rd treatment.

CONCLUSIONS

Patients with depression had a substantially high risk of poor adherence compared to patients without depression. Given that Rd treatment is mainly offered by outpatient clinics, active interventions to reduce depression should be considered for MM patients prior to Rd treatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Testing urban wastewater to assess compliance with prescription data through wastewater-based epidemiology: First case study in Italy

Sub-optimal adherence to pharmacological therapy is one of the main reasons for poor effectiveness, reducing the patient's quality of life and affecting health-care economics. This study investigated the possibility for a wastewater-based epidemiology approach to assess the overall adherence of a population to some pharmacological therapies in a defined area. We selected specific active ingredients and their main urinary metabolites (biomarkers) according to the best practice protocol available and we measured them for the first time in urban wastewater. We conducted this first case study in Italy, considering the whole country and two Italian regions by sampling for five days six cities from north to south. Liquid chromatography tandem mass spectrometry was used to measure the biomarkers in raw wastewater, developing and validating specific analytical methods. We used concentrations measured in influent wastewater, together with a careful review of the excretion profile of the active ingredients selected, to back-calculate consumption (measured consumptions - MC) which were then compared with consumptions calculated from medical prescriptions (expected consumptions - EC) reported annually by the Italian Medicine Agency. In general there was a rough correlation between MC and EC, with ratios sometimes close to unity and always within a 0.3-3.0 range. Interpretation of the results suffers some biases, which are case-by-case discussed in detail, but inclusion of measurements of the urinary metabolites together with the active ingredients gave a fuller understanding of the results.

Evaluating Medication Habits in Medical Mission Patients: A Cross-Sectional Study

Background

Short-term medical missions (STMMs) are a highly debated and largely understudied form of international volunteer work. With growing dedication to health care abroad, research evaluating their impact is crucial to ensure continued interventions are effective in improving medical care. STMM care varies in length, frequency, size, location, services offered, and country of origin and destination. This makes systematic evaluation of STMMs difficult. In addition, the transient nature of patient visits makes trending STMM’s impact on long-term health outcomes complex.

Despite intermittent availability, primary care missions offering pharmaceutical supplies have the unique opportunity to provide continued care to the community via free prescription supplies each visit. Given the challenges with measuring long-term outcomes in this population, it is unknown if these donated medications have any impact on patient health outcomes. As medication noncompliance is known to hinder health outcomes, our study chose to evaluate patient medication habits to see if these prescription supplies were being utilized appropriately. To our knowledge, no study has surveyed medical mission patients to explore their access and utilization of medication.

Methods

A cross-sectional study was conducted using a patient survey to identify risks and/or factors associated with medication noncompliance in patients visiting the medical mission, Waves of Health (WOH). For over 10 years, WOH has organized biannual seven-day trips to the Dominican Republic. The multi-question survey was translated into the native language, Spanish with Dominican dialect. Noncompliance was defined through the survey question “Did you run out of your prescription medication at all during the past year?” Spanish speaking participants, of both sexes and age ≥18 years old, who visited the mission clinic in November 2019 met inclusion for this study. Patients from Haiti or age <18 years old were excluded. Participation was voluntary.

Survey items were dichotomized for univariate analysis to identify factors associated with running out of medication. To explore predictors of running out of medicine, we performed multivariate logistic regression analysis by ENTER method. 

Results

Of 127 patients, over half (58.3% [74]) reported running out of medication. Inadequate access to healthcare, daily medication use, and rationing personal medications were all significantly associated with running out of medicine. Frequency of WOH visits was not associated with running out of medication. Multivariate regression showed that being on daily medication and rationing personal medications were statistically significant predictors of running out of medicines. Access to healthcare, frequency of WOH visits, and WOH medication supply were not predictors of running out of medication.

Conclusion 

Mission interventions to improve medication practices should be explored due to the high number of patients who reported improper utilization of medication. In order to improve health outcomes in primary care settings, patients must play an active role in their care and understand the importance of taking their medication as prescribed for optimal disease management. Primary care STMMs may relieve short-term health concerns, but without proper utilization of chronic disease medications, it is unclear if STMMs role is impactful in long-term health outcomes.

Patient adherence to pharmaceutical care amid the economic crisis in Greece: Underlying priority areas for policy makers

The purpose of the study was to investigate the degree to which chronic patients adhered to medication regimens during the economic crisis in Greece. It is a quantitative cross-sectional study, with a convenience sample of 1,009 residents of Western and Northern Greece, aged ≥ 18 years, with chronic health problems. The survey was conducted between February and June 2016. Data were collected via a structured questionnaire with closed-ended questions, filled out during face to face interviews with all participants. The vast majority of respondents (94.5 %) said that they were able to buy prescribed drugs but had to economise in other ways (for example, by cutting back on clothing and travel) to cope with essential household expenses, including medication. Only 71 % of participants said they remembered to take their prescribed medications every day, following all of their physicians' recommendations. Almost 70 % of participants said that using generic medications made it easier to adhere to their treatment regimens. The results of a correlation analysis showed that patients experiencing financial hardships as a result of health problems were less likely to adhere to pharmaceutical care regiments than those who were not experiencing financial difficulties (p = 0.026). Men had a higher level of adherence than women (p = 0.001).

Integrated care for the management of ageing-related non-communicable diseases: current gaps and future directions

Due to the increase in the older population in Europe and associated rise in the absolute number of persons with Non-Communicable Diseases (NCDs), it is becoming increasingly important to find ways to promote healthy ageing, which is defined as the process of developing and maintaining the functional ability that enables well-being in older age. Older persons with NCDs can have complex care needs due to the increased risk of frailty, multimorbidity, and polypharmacy. However, current health systems in Europe often provide fragmented care for older people with NCDs; many receive disjointed care from numerous specialists or via different levels of care. In the current article, we discuss barriers and challenges in implementing integrated care models in European settings for older NCD patients. Specifically, we discuss the need for greater use of case managers in the care and treatment persons with complex care needs as well as the lack of training and education in healthcare professionals on topics related to multimorbidity, frailty, and polypharmacy. We discuss the limitations that arise from the current focus on disease-specific guidelines and care models that do not take comorbid conditions into account, and the lack of good quality evidence that evaluates the effectiveness of integrated care interventions, especially in European health settings. We highlight the importance of evaluating and monitoring mental health in conjunction with somatic symptoms in NCD patients and discuss the integral role of information and communication technology in healthcare to streamline integrated care processes and help to achieve better outcomes for patients.

Availability, cost and affordability of essential cardiovascular disease medicines in the south west region of Cameroon: Preliminary findings from the Cameroon science for disease study

BACKGROUND

More than 80% of premature deaths due to cardiovascular disease (CVD) occur in low- and middle-income countries. However, access to, and affordability of medications remain a challenge in these countries.

OBJECTIVE

To assess the availability, cost and affordability of essential cardiovascular medicines in the South West region of Cameroon.

METHODS

In an audit of 63 medicine outlets, twenty-six essential medicines were surveyed using the World Health Organisation (WHO) /Health Action International methodology. Availability, costs and the ratio of the median price to the international reference price were evaluated in public, confessional, private facility medicine outlets, and community pharmacies. Affordability was assessed by calculating the number of days' wages it will cost the lowest-paid unskilled government worker to purchase a month worth of chronic treatment.

FINDINGS

Availability ranged from 25.3% (public facility outlets) to 49.2% (community pharmacies) for all medicines. This was higher in urban and semi-urban compared to rural outlets. Cost of medicines was highest in community pharmacies and lowest in public facility outlets. Aspirin, digoxin, furosemide, hydrochlorothiazide and nifedipine were affordable (cost a day's wage or less). Medicines for heart failure and dyslipidaemia (beta blockers, angiotensin converting enzyme inhibitors and statins) required 2-5 days and 6-13 days wages respectively for one month of chronic treatment.

CONCLUSION

Overall availability of CVD essential medicines was lower than WHO recommendations, and medicines were largely unaffordable. While primary prevention is pivotal, improving availability and affordability of medicines especially for public facilities would provide additional benefit in curbing the CVD burden.

Statistical Methods for Adjusting Estimates of Treatment Effectiveness for Patient Nonadherence in the Context of Time-to-Event Outcomes and Health Technology Assessment: A Systematic Review of Methodological Papers

Introduction. Medication nonadherence can have a significant negative impact on treatment effectiveness. Standard intention-to-treat analyses conducted alongside clinical trials do not make adjustments for nonadherence. Several methods have been developed that attempt to estimate what treatment effectiveness would have been in the absence of nonadherence. However, health technology assessment (HTA) needs to consider effectiveness under real-world conditions, where nonadherence levels typically differ from those observed in trials. With this analytical requirement in mind, we conducted a review to identify methods for adjusting estimates of treatment effectiveness in the presence of patient nonadherence to assess their suitability for use in HTA. Methods. A "Comprehensive Pearl Growing" technique, with citation searching and reference checking, was applied across 7 electronic databases to identify methodological papers for adjusting time-to-event outcomes for nonadherence using individual patient data. A narrative synthesis of identified methods was conducted. Methods were assessed in terms of their ability to reestimate effectiveness based on alternative, suboptimal adherence levels. Results. Twenty relevant methodological papers covering 12 methods and 8 extensions to those methods were identified. Methods are broadly classified into 4 groups: 1) simple methods, 2) principal stratification methods, 3) generalized methods (g-methods), and 4) pharmacometrics-based methods using pharmacokinetics and pharmacodynamics (PKPD) analysis. Each method makes specific assumptions and has associated limitations. Five of the 12 methods are capable of adjusting for real-world nonadherence, with only g-methods and PKPD considered appropriate for HTA. Conclusion. A range of statistical methods is available for adjusting estimates of treatment effectiveness for nonadherence, but most are not suitable for use in HTA. G-methods and PKPD appear to be more appropriate to estimate effectiveness in the presence of real-world adherence.

The Assessment of Serum Drug Levels to Diagnose Non-Adherence in Stable Chronic Heart Failure Patients

Background: The aim of our study was to evaluate the prevalence of drug non-adherence in stable chronic heart failure (CHF) patients using serum drug levels (SDL) assessment. Methods: CHF patients were prospectively enrolled during scheduled outpatient visit. Except standard procedures an unanticipated blood sampling for the SDL assessment was obtained. Analysis was focused on the prescribed heart failure and antihypertensive medication and was performed by liquid chromatography coupled with mass spectrometry. The patient was labelled as non-adherent if at least one of drugs assessed was not found in the serum. In the first half of patients multiple SDL have been evaluated during the follow-up. Results: Eighty one patients were enrolled. The non-adherence was proven in twenty of them (25%). In the subgroup of thirty eight patients with multiple SDL evaluation the non-adherence raised significantly with increasing number of visits assessed together (21% for single visit, 29% for two of three visits assessed together and 34% for all three visits evaluated together, all p < 0.001). Conclusion: The non-adherence was proven in significant part of stable CHF patients using SDL assessment. This method seems to be reliable and effective and should be a part of clinical assessment in selected patients with CHF.

Adherence to immunomodulatory drugs in patients with multiple myeloma

Background

Immunomodulatory drugs (thalidomide, lenalidomide and pomalidomide; IMID) are widely used in the treatment of multiple myeloma patients. To date, few data are available on IMID adherence in multiple myeloma patients. The aim of our study was to evaluate IMID adherence and to compare two indirect methods to measure IMID adherence in multiple myeloma patients: a specific questionnaire and the medication possession ratio (MPR). Another aim was to explore this specific questionnaire for the assessment of IMID adherence in multiple myeloma patients.

Methods

All consecutive multiple myeloma patients, with at least two consecutive dispensations of thalidomide, lenalidomide or pomalidomide in our hospital were included in this prospective study. IMID adherence was measured using a specific questionnaire and the medication possession ratio. Relationship between the questionnaire scores and variables of interest was evaluated by multiple linear regression with a robust variance estimator.

Findings

Sixty-three patients were included in our study. The mean questionnaire score was 8.2±1.2 and the mean medication possession ratio value was 0.97±0.06. A total of 76% of patients were considered adherent according to the questionnaire (i.e. score ≥ 8), 94% according to the medication possession ratio (i.e. MPR ≥ 0.90), and 70% according to the questionnaire and the medication possession ratio. No statistically significant linear association was observed between the questionnaire score and any variables of interest including medication possession ratio. All Cronbach’s alpha were relatively low (range 0.0342–0.2443), showing a low correlation of the different questions with the questionnaire score.

Conclusions

Our study is the first prospective study evaluating IMID adherence in multiple myeloma patients in real life. The high adherence to IMIDs reported here, regardless of the drug, is encouraging considering the efficacy, toxicity and elevated cost of IMIDs. The specific questionnaire should be used with caution to evaluate IMID adherence.

Prevalence and Management of Drug-Related Problems in Chronic Kidney Disease Patients by Severity Level: A Subanalysis of a Cluster Randomized Controlled Trial in Community Pharmacies

BACKGROUND

Drug-related problems (DRPs) are prevalent among chronic kidney disease (CKD) patients. However, little is known about their severity and management by community pharmacists.

OBJECTIVES

To (a) describe the prevalence of DRPs by severity level in CKD patients and (b) assess the effect of a training-and-communication network program in nephrology (ProFiL) on these DRPs.

METHODS

This is a secondary analysis of a cluster randomized controlled trial evaluating the effect of the ProFiL-program. In 6 CKD clinics, patients at CKD stage 3 or 4 and their community pharmacists were recruited and assigned to the ProFiL group or a usual care (UC) group. Using validated criteria, 2 pharmacists identified DRPs and assessed their severity at baseline and after 12 months. The mean annual change in the number of DRPs per patient by severity level was assessed using a 2-level multivariable linear mixed-effects model.

RESULTS

A total of 494 pharmacists and 442 patients participated. At baseline, the prevalence (mean number of DRPs per patient [SD]) of mild DRPs (e.g., requiring dosage adjustment) and moderate DRPs (e.g., drug adherence requiring a monitoring plan) were 0.55 (0.98) and 1.04 (1.51), respectively. After 12 months, an unadjusted incremental annual reduction of 0.34 moderate DRPs (95% CI = -0.66 to -0.01) was observed in the ProFiL group compared with the UC group. After adjustment, no between-group differences were observed.

CONCLUSIONS

Among patients followed in CKD clinics, most DRPs have a moderate severity requiring specific monitoring by pharmacists. The benefit of continuing education programs, such as ProFiL, to reduce moderate DRPs remains to be determined.

DISCLOSURES

This study was supported by the Canadian Institutes of Health Research (grant number: MOP-230207). Part of the study was also funded by Pfizer Canada, Leo Pharma, and Amgen. The authors declare that they have no relevant financial interests. Study concept and design were contributed by Quintana-Bárcena, Lord, and Lalonde. Quintana-Bárcena, Lord, and Lizotte were responsible for the data analysis, and Quintana-Bárcena and Berbiche performed the statistical analysis. The manuscript was written by Quintana-Bárcena and Lalonde and revised by Quintana-Bárcena and Lalonde, along with the other authors.

Prescribing and medication communication on the post-take ward round

Gaps in communication between medical officers and poor planning are associated with prescribing errors and may result in patient harm. This study describes medication communication on post-take ward rounds (PTWR). Over 6 weeks on 24 PTWR, 130 patients, prescribed 1244 medications, were observed. Of these, 811 (65%) medications were discussed, with 249 discussions (relating to 126 medications) being 'in-depth'. Of 191 planned medication-related actions, 38 (20%) were not implemented by the end of the PTWR and 21 (11%) by time of discharge from hospital. This study suggests that the level of medication communication and subsequent actions are suboptimal. Processes to improve this situation should be explored.

Treatment of Stable Angina with a New Fixed-Dose Combination of Ivabradine and Metoprolol: Effectiveness and Tolerability in Routine Clinical Practice

Introduction

In this prospective, multicenter, observational cohort study, the effectiveness and tolerability of the first fixed-dose combination (FDC) formulation of the selective heart rate reducing agent ivabradine and the beta-blocker metoprolol was evaluated in stable angina pectoris (AP) patients in a clinical practice setting.

Methods

Stable AP outpatients received a FDC of ivabradine and metoprolol (b.i.d.) for 4 months, in addition to cardiovascular standard therapy. Resting heart rate (HR), number of angina attacks, short-acting nitrate consumption, severity of symptoms (assessed by patient judgment and documented by CCS score) and tolerability were documented. Medication adherence was assessed by a modified four-item Morisky questionnaire. Descriptive statistics were performed on all data.

Results

A total of 747 stable AP patients (mean age, 66.4 years, 62% male, 50% and 31% with previous PCI and myocardial infarction, respectively) were included. Apart from ivabradine and beta-blockers as free combination, most frequently used concomitant standard medications at baseline were aspirin (68%), statins (71%), ACEI/AT1-blockers (76%), diuretics (35%), and calcium antagonists (15%). Highly prevalent comorbidities were hypertension (86%), hyperlipidemia (65%), and diabetes (35%). After 4 months, switch to treatment with the FDC was associated with a significant reduction in mean HR by 10 bpm. Proportion of patients with ≥ 1 angina attacks/week decreased from 38 to 7%. Patients in CCS class 1 increased (25 to 63%), while they decreased in CCS class 3 (19 to 5%). Medication adherence was also significantly improved (p < 0.001 for all changes from baseline). Mostly mild adverse events were documented in 5.4% of patients.

Conclusions

In these stable AP patients in a real-life setting, treatment with a FDC of ivabradine and metoprolol was associated with reduced HR and angina symptoms, while exercise capacity (CCS score) was improved. These effects may be mainly mediated by the increased medication adherence of patients observed with use of the FDC formulation.

Funding

Servier

Trial registration number

ISRCTN51906157

Improving Adherence to Treatment and Reducing Economic Costs of Hypertension: The Role of Olmesartan-Based Treatment

Poor adherence to antihypertensive treatment is the single most important factor of unsatisfactory blood pressure (BP) control. This review focuses on therapy-related factors affecting adherence and suggests how to improve it with a wise choice of treatment schedule. Complex drug treatment schemes, poor tolerability and drug substitutions are frequent causes of poor adherence which, in turn, causes insufficient BP control, greater incidence of cardiovascular events and, finally, higher global health costs. The effects of prescribing generic drugs and of drug substitutions on adherence is also discussed. In terms of adherence, generic drugs do not seem to be better than branded drugs, unless patients have to bear very high "out of pocket" expenses to buy original drugs, suggesting no advantages in switching drug with the mere goal of reducing the cost of therapy. An important role in improving adherence (and thus cardiovascular events and health expenditure) is also played by the availability of fixed-dose combinations; among antihypertensive drugs, angiotensin receptor blockers (ARBs) are those associated with higher levels of adherence and persistence. Among ARBs, olmesartan stands out for a wide choice of effective fixed-dose combinations.

An upper and lower bound of the Medication Possession Ratio

BACKGROUND

The Medication Possession Ratio (MPR) is a ubiquitous and central measurement for adherence in the health care industry. However, attempts to standardize its calculation have failed, possibly due to the opacity of a single, static MPR, incapability of directly lending itself to a variety of studies, and challenges of comparing the value across studies. This work shows that the MPR strictly depends on the length of the time interval over which it is measured as well as on the dominant dispense quantity for short time intervals. Furthermore, removing a proportion of the patient cohort based on the number of acquisitions may also have a severe impact on the MPR. Therefore, it is suggested that the MPR is represented as a trend over a range of time intervals. To this end, an upper and lower bound of the MPR trend is developed with an upper bound acknowledging patients who change their treatment and the lower bound acknowledging patients who discontinue their treatment.

PURPOSE

Introducing a representation of the MPR value as a trend rather than a static number by developing a quantitative description of an upper and lower bound of the MPR trend, while shedding light on the impacts on prefiltering the patient cohort.

PATIENTS AND METHODS

Anonymized patient-level data was utilized as an example for a suggested calculation of an upper and lower bound of the MPR.

RESULTS

Representation of the MPR for a predefined time interval precludes a reliable MPR assessment. A quantitative approach is suggested to generate an upper and lower trend of the MPR while emphasizing the impact on removing patients with a limited number of acquisitions.

CONCLUSION

An upper and lower trend makes the MPR more transparent and allows a better comparison across different studies. Removing patients with a limited number of acquisitions should be avoided.

Who really manages our patients' medications? A study of inner city adults over 40 years of age

OBJECTIVES

Primarily to determine how many of our adult patients receive significant assistance from another individual with medication management. Secondarily, to determine if the number of prescribed medications can be predictors of whether the patient receives significant assistance with medication management.

DESIGN

Cross-sectional survey study.

SETTING

A level 3 patient-centered medical home family practice clinic in an inner city university hospital in Brooklyn, New York.

PARTICIPANTS

Patients 40 years of age and older coming for a regular clinic visit to see the primary care physician.

INTERVENTION

Administering the survey to the patients was the intervention. MAIN OUTCOME MEASURES: The number of patients who receive significant assistance with any phase of medication management was the main outcome measure.

RESULTS

Out of 143 patients surveyed, 61 patients (42.7%) received assistance with 1 or more phases of medication management; 38.5% (n = 55) of patients received help with phase 1 (ensuring that patients have medications at home). Of those 55 patients, 28 (50.9%) received help from family members, 22 (40%) received help from pharmacies, and 5 (9.1%) received help from home health aides or visiting nurses. Thirteen patients (9%) received help with phase 2 (arranging medications to help take them properly); 11 (84.6%) of them received help from family members. Twenty-three patients (16.1%) received help with phase 3 (reminding patients to take medications or handing them to the patient); 17 (73.9%) out of 23 received help from family members. There was a statistically significant trend (Mann-Whitney 2-sided test: P <0.001) showing a direct relationship between the number of medications and the need for assistance with 1 or more phases of medication management.

CONCLUSION

Many adult patients receive help with 1 or more phases of medication management. Family members are the major source of assistance with medication management. Pharmacies also play an important role in making certain that patients have medications at home. Patients with a higher number of medications are more likely to receive assistance from others.

Understanding adherence-related beliefs about medicine amongst patients of South Asian origin with diabetes and cardiovascular disease patients: a qualitative synthesis

BACKGROUND

Prevalence of diabetes and cardiovascular (CVD) disease amongst UK South Asians is higher than in the general population. Non-adherence to medicines may lead to poor clinical outcomes for South Asian patients with diabetes and CVD. To understand the decision making processes associated with taking medicines, a qualitative systematic meta-synthesis exploring medicine taking behaviours, and beliefs was undertaken.

METHODS

Four databases (Medline, Embase, Science Citation Index and CINAHL) were searched to identify qualitative studies of South Asian patients taking diabetic medicines. Data were thematic coded and synthesised.

RESULTS

The following themes were identified: [1] beliefs about the need for and efficacy of medicines; [2] toxicity of medicines and polypharmacy; [3] the necessity of traditional remedies versus "western medicines"; [4] stigma and social support; and [5] communication.

CONCLUSIONS

South Asians described cultural social stigma associated with diabetes and reported fears about drug toxicity as barriers to taking medicines. Cultural beliefs about traditional remedies and interactions with healthcare professionals also appeared to play a role in the way people made decisions about medicines. Advice should be tailored provided to South Asian patients highlighting the long term consequences of diabetes and CVD.

Medication Adherence and the Occurrence of Complications in Patients with Newly Diagnosed Hypertension

BACKGROUND AND OBJECTIVES

In this retrospective cohort study, we sought to elucidate the relationship between medication adherence (MA) and the incidence of complications in patients with newly diagnosed hypertension.

SUBJECTS AND METHODS

Using claims data from the National Health Insurance Service, we measured health outcomes based on levels of MA, analyzed the incidence of complications in patients with a good MA, and clarified factors that may affect or predict MA.

RESULTS

In 2008, a total of 4294773 patients were diagnosed with hypertension and were subsequently prescribed anti-hypertensive medications. In the present study, we enrolled 564782 patients who met our inclusion/exclusion criteria. The 40-59% medication possession ratio (MPR) group had a 1.36 times higher risk of developing complications (95% confidence interval [CI]: 1.27-1.45) than did the MPR≥ 80% group, as revealed through Cox's proportional hazards analysis. Similarly, the <20% MPR group was 2.01 times more likely to develop complications than the good MA group (95% CI: 1.82-2.23). Overall, patients who had a lower level of MA had a higher risk of developing complications.

CONCLUSION

Our results demonstrate that MA is tightly correlated with hypertension health outcomes. Improving MA could be one strategy for reducing the risk of cerebrovascular disease complications and the loss of productivity in these patients.

Systematic review of adherence rates by medication class in type 2 diabetes: a study protocol

INTRODUCTION

Treatment options for type 2 diabetes are becoming increasingly complex with people often prescribed multiple medications, and may include both oral and injectable therapies. There is ongoing debate about which drug classes provide the optimum second-line and third-line treatment options. In the real world, patient adherence and persistence determines medication effectiveness. A better understanding of adherence may help inform the choice of second-line and third-line drug classes.

METHODS AND ANALYSIS

This systematic review will compare adherence and persistence rates across the different classes of medication available to people with type 2 diabetes. It will include all identified studies comparing medication adherence or persistence between two or more glucose-lowering medications in people with type 2 diabetes. Research databases (MEDLINE, EMBASE, The Cochrane Library, The Register of Controlled Trials, PsychINFO and CINAHL) will be searched for relevant articles, using a comprehensive search strategy. All identified medication trials and observational studies will be included which compare adherence or persistence across classes of diabetes medication. The characteristics and outcomes of all the included studies will be reported along with a study quality grade, assessed using the Cochrane Risk Assessment Tool. The quality of adjustment for confounders of adherence or persistence will be reported for each study. Where multiple (n ≥ 3) studies provide compare adherence or persistence across the same 2 medication classes, a meta-analysis will be performed.

ETHICS AND DISSEMINATION

No ethics approval is required. This review and meta-analysis (where possible) will provide important information on the relative patient adherence and persistence, with the different classes of diabetes therapies. Once complete, the results will be made available by peer-reviewed publication.

TRIAL REGISTRATION NUMBER

CRD42015027865.

Perindopril and β-blocker for the prevention of cardiac events and mortality in stable coronary artery disease patients: A EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease (EUROPA) subanalysis

BACKGROUND

β-Blockers relieve angina/ischemia in stable coronary artery disease (CAD), and angiotensin-converting enzyme inhibitors prevent CAD outcomes. In EUROPA, the angiotensin-converting enzyme inhibitor perindopril reduced cardiovascular outcomes in low-risk stable CAD patients over 4.2 years. This post hoc analysis examined whether the addition of perindopril to β-blocker in EUROPA had additional benefits on outcomes compared with standard therapy including β-blocker.

METHODS

EUROPA was a multicenter, double-blind, placebo-controlled, randomized trial in patients with documented stable CAD. Randomized EUROPA patients who received β-blocker at baseline were identified, and the effect on cardiovascular outcomes of adding perindopril or placebo was analyzed. Endpoints were the same as those in EUROPA.

RESULTS

At baseline, 62% (n = 7534 [3789 on perindopril and 3745 on placebo]) received β-blocker. Treatment with perindopril/β-blocker reduced the relative risk of the primary end point (cardiovascular death, nonfatal myocardial infarction, and resuscitated cardiac arrest) by 24% compared with placebo/β-blocker (HR, 0.76; 95% CI, 0.64-0.91; P = .002). Addition of perindopril also reduced fatal or nonfatal myocardial infarction by 28% (HR, 0.72; 95% CI, 0.59-0.88; P = .001) and hospitalization for heart failure by 45% (HR, 0.55; 95% CI, 0.33-0.93; P = .025). Serious adverse drug reactions were rare in both groups, and cardiovascular death and hospitalizations occurred less often with perindopril/β-blocker.

CONCLUSIONS

The addition of perindopril to β-blocker in stable CAD patients was safe and resulted in reductions in cardiovascular outcomes and mortality compared with standard therapy including β-blocker.

Ivabradine in Combination with Metoprolol Improves Symptoms and Quality of Life in Patients with Stable Angina Pectoris: A post hoc Analysis from the ADDITIONS Trial

OBJECTIVES

Elevated heart rate can increase myocardial oxygen demand and reduce myocardial perfusion, provoking myocardial ischemia and angina symptoms. We evaluated adding ivabradine to the therapy of patients on metoprolol.

METHODS

ADDITIONS (prActical Daily efficacy anD safety of Procoralan® In combinaTION with betablockerS) was a multicenter, 4-month, noninterventional, prospective, open-label trial that involved stable-angina patients. Along with metoprolol, patients received ivabradine (5 or 7.5 mg, b.i.d.). We investigated the effect of ivabradine on heart rate, angina attacks, nitrate consumption, quality of life (QoL) and tolerability as well as the influence of baseline heart rate.

RESULTS

Heart rate fell by 19.7 ± 11.2 bpm, with an 8-fold decrease in weekly angina attacks (1.7 ± 2.2 to 0.2 ± 0.7) and nitrate consumption (2.4 ± 3.4 to 0.3 ± 0.9). Patient numbers in Canadian Cardiovascular Society class I more than doubled (i.e. from 29 to 65%) and QoL improved (the EQ-5D index and visual analog scale scores rose from 0.68 ± 0.27 to 0.84 ± 0.20 and 58.1 ± 18.4 to 72.2 ± 15.5 mm, respectively). The effect of ivabradine was greater in patients with a baseline heart rate ≥70 bpm (mean reduction in heart rate -21.2 ± 10.4 bpm, with a relative reduction in angina attacks and short-acting nitrate consumption of 87.1 and 87.2%, respectively).

CONCLUSIONS

Ivabradine combined with metoprolol safely and effectively reduces heart rate, angina attacks and nitrate use, and improves QoL in stable-angina patients.

Economic benefits associated with beta blocker persistence in the treatment of hypertension: a retrospective database analysis

OBJECTIVES

To assess the association between medical costs and persistence with beta blockers among hypertensive patients, and to quantify persistence related medical cost differences with nebivolol, which is associated with improved tolerability, versus other beta blockers.

METHODS

Adults who initiated hypertension treatment with a beta blocker were identified from the MarketScan * claims database (2008-2012). Patients were classified based on their first beta blocker use: nebivolol, atenolol, carvedilol, metoprolol, and other beta blockers. Patients with compelling indications for atenolol, carvedilol or metoprolol (acute coronary syndrome and congestive heart failure) were excluded. Patients enrolled in health maintenance organization or capitated point of service insurance plans were also excluded. Persistence was defined as continuous use of the index drug (<60 day gap). The average effect of persistence on medical costs (2012 USD) was estimated using generalized linear models (GLMs). Regression estimates were used to predict medical cost differences associated with persistence between nebivolol and the other cohorts.

RESULTS

A total of 587,424 hypertensive patients met the inclusion criteria. Each additional month of persistence with any one beta blocker was associated with $152.51 in all-cause medical cost savings; continuous treatment for 1 year was associated with $1585.98 in all-cause medical cost savings. Patients treated with nebivolol had longer persistence during the 1 year study period (median: 315 days) than all other beta blockers (median: 156-292 days). Longer persistence with nebivolol translated into $305.74 all-cause medical cost savings relative to all other beta blockers.

LIMITATIONS

The results may not be generalizable to hypertensive patients with acute coronary syndrome or congestive heart failure.

CONCLUSIONS

Longer persistence with beta blockers for the treatment of hypertension was associated with lower medical costs. There may be greater cost savings due to better persistence with nebivolol than other beta blockers.

Coronary heart disease risk factors and outcomes in the twenty-first century: findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

REasons for Geographic and Racial Differences in Stroke (REGARDS) is a longitudinal study supported by the National Institutes of Health to determine the disparities in stroke-related mortality across USA. REGARDS has published a body of work designed to understand the disparities in prevalence, awareness, treatment, and control of coronary heart disease (CHD) and its risk factors in a biracial national cohort. REGARDS has focused on racial and geographical disparities in the quality and access to health care, the influence of lack of medical insurance, and has attempted to contrast current guidelines in lipid lowering for secondary prevention in a nationwide cohort. It has described CHD risk from nontraditional risk factors such as chronic kidney disease, atrial fibrillation, and inflammation (i.e., high-sensitivity C-reactive protein) and has also assessed the role of depression, psychosocial, environmental, and lifestyle factors in CHD risk with emphasis on risk factor modification and ideal lifestyle factors. REGARDS has examined the utility of various methodologies, e.g., the process of medical record adjudication, proxy-based cause of death, and use of claim-based algorithms to determine CHD risk. Some valuable insight into less well-studied concepts such as the reliability of current troponin assays to identify "microsize infarcts," caregiving stress, and CHD, heart failure, and cognitive decline have also emerged. In this review, we discuss some of the most important findings from REGARDS in the context of the existing literature in an effort to identify gaps and directions for further research.

Cost-effectiveness of nurse practitioner/community health worker care to reduce cardiovascular health disparities

BACKGROUND

Although evidence-based guidelines on the management of cardiovascular disease (CVD) and type 2 diabetes have been widely published, implementation of recommended therapies is suboptimal.

OBJECTIVE

The aim of this study was to evaluate the cost-effectiveness of a comprehensive program of CVD risk reduction delivered by nurse practitioner/community health worker (NP/CHW) teams versus enhanced usual care to improve lipids, blood pressure (BP), and hemoglobin (Hb) A1c levels in patients in urban community health centers.

METHODS

A total of 525 patients with documented CVD, type 2 diabetes, hypercholesterolemia, or hypertension and levels of low-density lipoprotein cholesterol, BP, or Hb A1c that exceeded goals established by national guidelines were randomized to NP/CHW (n = 261) or enhanced usual care (n = 264) groups. Cost-effectiveness ratios were calculated, determining costs per percent and unit change in the primary outcomes.

RESULTS

The mean incremental total cost per patient (NP/CHW and physician) was only $627 (confidence interval, 248-1015). The cost-effectiveness of the 1-year intervention was $157 for every 1% drop in systolic BP and $190 for every 1% drop in diastolic BP, $149 per 1% drop in Hb A1c, and $40 per 1% drop in low-density lipoprotein cholesterol.

CONCLUSIONS

The findings suggest that management by an NP/CHW team is a cost-effective approach for community health centers to consider in improving the care of patients with existing CVD or at high risk for the development of CVD.

Co-payments for health care: what is their real cost?

Based on the premise that current trends in healthcare spending are unsustainable, the Australian Government has proposed in the recent Budget the introduction of a compulsory $7 co-payment to visit a General Practitioner (GP), alongside increased medication copayments. This paper is based on a recent submission to the Senate Inquiry into the impact of out-of-pocket costs in Australia. It is based on a growing body of evidence highlighting the substantial economic burden faced by individuals and families as a result of out-of-pocket costs for health care and their flow-on effects on healthcare access, outcomes and long-term healthcare costs. It is argued that a compulsory minimum co-payment for GP consultations will exacerbate these burdens and significantly undermine the tenets of universal access in Medicare. Alternative recommendations are provided that may help harness unsustainable health spending while promoting an equitable and fair health system.

Adjuvant endocrine therapy for women with hormone receptor-positive breast cancer: american society of clinical oncology clinical practice guideline focused update

PURPOSE

To update the ASCO clinical practice guideline on adjuvant endocrine therapy on the basis of emerging data on the optimal duration of treatment, particularly adjuvant tamoxifen.

METHODS

ASCO convened the Update Committee and conducted a systematic review of randomized clinical trials from January 2009 to June 2013 and analyzed three historical trials. Guideline recommendations were based on the Update Committee's review of the evidence. Outcomes of interest included survival, disease recurrence, and adverse events.

RESULTS

This guideline update reflects emerging data on duration of tamoxifen treatment. There have been five studies of tamoxifen treatment beyond 5 years of therapy. The two largest studies with longest reported follow-up show a breast cancer survival advantage with 10-year durations of tamoxifen use. In addition to modest gains in survival, extended therapy with tamoxifen for 10 years compared with 5 years was associated with lower risks of breast cancer recurrence and contralateral breast cancer.

RECOMMENDATIONS

Previous ASCO guidelines recommended treatment of women who have hormone receptor-positive breast cancer and are premenopausal with 5 years of tamoxifen, and those who are postmenopausal a minimum of 5 years of adjuvant therapy with an aromatase inhibitor or tamoxifen followed by an aromatase inhibitor (in sequence). If women are pre- or perimenopausal and have received 5 years of adjuvant tamoxifen, they should be offered 10 years total duration of tamoxifen. If women are postmenopausal and have received 5 years of adjuvant tamoxifen, they should be offered the choice of continuing tamoxifen or switching to an aromatase inhibitor for 10 years total adjuvant endocrine therapy.

Impact of compliance to oral hypoglycemic agents on short-term disability costs in an employer population

This study evaluated the relationships between compliance with oral hypoglycemic agents and health care/short-term disability costs in a large manufacturing company. The retrospective analysis used an observational cohort drawn from active employees of Ford Motor Company. The study population consisted of 4978 individuals who were continuously eligible for 3 years (between 2001-2007) and who received a prescription for an oral hypoglycemic agent during that time. Medical, pharmacy, and short-term disability claims data were obtained from the University of Michigan Health Management Research Center data warehouse. Pharmacy claims/refill data were used to calculate the proportion of days covered (PDC); an individual was classified as compliant if his/her PDC was ≥80%. Model covariates included age, sex, work type, and Charlson comorbidity scores. The impact of compliance on disability and health care costs was measured by comparing the costs of the compliant with those of the noncompliant during a 1-year follow-up. Among these employees, compliant patients had lower medical, higher pharmacy, and lower short-term disability costs than did the noncompliant. After adjusting for demographics and comorbidity, noncompliance was associated with statistically higher short-term disability costs ($1840 vs. $1161, P<0.0001), longer short-term disability duration, and an increase in short-term disability incidence (21.5% of the noncompliant had a claim compared to 16.0% of the compliant, P<0.0001). These results suggest that medication compliance may be important in curtailing the rise of health care/disability costs in the workplace. Employers concerned with the total costs associated with diabetes should not overlook the impact of compliance on short-term disability.

Generic medications and blood pressure control in diabetic hypertensive subjects: results from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study

OBJECTIVE

To investigate temporal improvements in blood pressure (BP) control in subjects with diabetes and policy changes regarding generic antihypertensives.

RESEARCH DESIGN AND METHODS

In a cross-sectional study we used logistic regression models to investigate the temporal relationship between access to generic antihypertensive medications and BP control (<130/80 mmHg) in 5,375 subjects (mean age, 66 ± 9 years; 61% African American) with diabetes and hypertension (HTN) enrolled in the national Results from the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort study between 2003 and 2007. At enrollment, BP was measured and medications in the home determined by medication label review by a trained professional. Generic antihypertensive medication status was ascertained from the U.S. Food and Drug Administration.

RESULTS

The percentage of subjects accessing generically available antihypertensive medications increased significantly from 66% in 2003 to 81% in 2007 (P < 0.0001), and the odds of achieving a BP <130/80 mmHg in 2007 was 66% higher (odds ratio 1.66 [95% CI 1.30-2.10]) than in 2003. Nevertheless, <50% of participants achieved this goal. African American race, male sex, limited income, and medication nonadherence were significant predictors of inadequate BP control. There was no significant relationship between access to generic antihypertensives and BP control when other demographic factors were included in the model (0.98 [0.96-1.00]).

CONCLUSIONS

Among African American and white subjects with HTN and diabetes, BP control remained inadequate relative to published guidelines, and racial disparities persisted. Although access to generic antihypertensives increased, this was not independently associated with improved BP control, suggesting that poor BP control is multifactorial.

Full coverage for hypertension drugs in rural communities in China

BACKGROUND

The control rate for hypertension is unacceptably low worldwide, and poor adherence to medication is a primary reason.

OBJECTIVES

To evaluate the impact of full coverage for hypertension drugs on adherence to medication, medical costs, and hypertension control in Shandong Province, China.

METHODS

In November 2009, we interviewed 110 hypertensive patients who had been participating in a free medication program since May 2008 and 241 hypertensive patients who were not participating. We used a 1:1 propensity-score matching technique to obtain matched samples of 102 program participants (intervention) and 102 nonparticipants (control). We used univariate analysis to compare patient drug-taking behaviors, medical costs, and hypertension control between the 2 groups.

RESULTS

All intervention patients took > 1 drugs for hypertension control and 93% of them took > 3 such drugs, 15 control patients (15%) did not take any, and only 39% took 3 or more (P < .001). Three-fourths (75%) of the intervention patients took the prescribed drugs regularly, whereas 66% of the control group (P = .034) did so. Participation in the program was associated with lower annual out-of-pocket medical costs both overall and for outpatient services (P < .001 for both).

CONCLUSIONS

Low-income rural residents in China receiving free drugs had enhanced medication adherence and reduced total medical costs. Providing hypertension drugs at no charge may be a promising strategy for preventing costly cardiovascular events associated with hypertension in China and other parts of the world with growing rates of cardiovascular disease.

[Preservative-containing eye drops and adherence in ophthalmological practice]

Chronic eye diseases, such as glaucoma or dry eye syndrome, require long-term drug application to the eyes. Good adherence is required to achieve the therapeutic goal and patient needs and requirements have to be taken into account. This distinguishes adherence to drug therapy from the former compliance which implies only following medical instructions. Adherence is influenced by socioeconomic, health system-related, disease-related, treatment-related and patient-related factors. It can be measured by tedious procedures, such as electronic monitoring, self-assessment, drop counting and laboratory findings of systemic drug levels. Non-adherence is a growing medical problem worldwide. An increase in adherence means an increased degree of therapeutic safety for the patient and long-term cost savings for the individual as well as society. Non-adherence in chronic diseases, such as glaucoma and dry eye syndrome is increased by eye drops that cause side effects. Often these side effects are caused by agents such as the preservative benzalkonium chloride. To achieve a good adherence preservative-free eye drops are advised.

Severity of menopausal symptoms and cardiovascular and osteoporosis risk factors

OBJECTIVES

To assess whether the severity of menopausal symptoms is related to increased cardiovascular and osteoporosis risk factors, and to determine whether women with more severe menopausal symptoms present a greater percentage of osteoporosis disease.

METHODS

This was a cross-sectional, descriptive study encompassing women aged 45-65 years in the whole Spanish territory. The study population sample was collected through random sampling. A total of 10 514 women were included. Their sociodemographic, medical history and lifestyle data were assessed by means of a survey. The Kupperman Index was used to assess the severity of menopausal symptoms. Bone mineral density was measured by the dual X-ray absorptiometry method.

RESULTS

The prevalences of risk factors for osteoporosis and cardiovascular disease were 67.6% and 74.8%, respectively. Women with a higher intensity of symptoms also had a greater percentage of cardiovascular (p < 0.001) and osteoporosis (p < 0.001) risk factors and suffered more from osteoporosis disease (p < 0.001). In the logistic regression analysis, those variables that contributed to the severity of menopausal symptoms were: arterial hypertension (odds ratio (OR) 2.14; 95% confidence interval (CI) 1.49-2.79; p < 0.001), dyslipidemia (OR 1.94; 95% CI 1.48-2.4; p < 0.001), obesity (OR 2.23; 95% CI 1.55-2.91; p < 0.001), family history (OR 1.38; 95% CI 1.17-1.59; p < 0.01), medication use (OR 1.12; 95% CI 0.52-1.72; p < 0.01) and osteoporosis disease (OR 3.71; 95% CI 2.9-4.52; p < 0.001).

CONCLUSIONS

Women with more severe menopausal symptoms had a greater prevalence of cardiovascular and osteoporosis disease risk factors and suffered more from osteoporosis disease compared to those who had milder or no menopausal symptoms.

How Does Out-of-Pocket Payment Affect Choices When Accessing Health Care?-A Qualitative Study on Hypertensive Outpatients in Southern Taiwan

OBJECTIVES

The National Health Insurance in Taiwan provides the entire population with universal coverage and full freedom to access health care, and thus results in accelerating medical utilization and costs. A differential outpatient co-payment was introduced on July 15, 2005, to deter nonessential visits and encourage initial contact in primary care and a stepwise access to health care (referral system). A previous study, however, showed a limited impact of this co-payment policy on reducing medical utilization and improving the referral system. This qualitative study aimed to explore Taiwanese patients' decision-making process to access health care and how the cost issue impacts patients' access to health care and explore patients' cost-saving strategies.

METHODS

Hypertensive patients from different tiers of medical facilities (community, regional hospitals, and medical centers) in the Kao-Ping area of southern Taiwan were invited to participate in focus groups from October 2008 to January 2009.

RESULTS

Of all, 40 participants were recruited for nine focus groups. The physicians' reputation, tiers of hospitals, and the convenience of transport and registration are the three major reasons why participants accessed different medical facilities. Participants expressed that the current out-of-pocket payment is affordable and not as important as other reasons for their choices. Continuous prescription was considered a cost-saving strategy for patients visiting higher tiers of medical facilities. Most participants were not fully aware of current National Health Insurance regulations such as co-payment, continuous prescriptions, and the referral policy.

CONCLUSIONS

The current out-of-pocket payment is affordable for hypertensive patients receiving regular treatments, but it fails to reduce the demand of health care. To establish a proper evaluation of the co-payment policy, future study is suggested to consider the views from health care providers and financially vulnerable patients.

Single-pill vs free-equivalent combination therapies for hypertension: a meta-analysis of health care costs and adherence

This meta-analysis compares health care resource use costs, adherence, and persistence between groups of patients taking antihypertensives as single-pill combinations (SPCs) vs free-equivalent components (FEC) based on a structured review of published studies. The search yielded 12 retrospective database studies included in analyses. The mean difference in combined total annual all-cause and hypertension-related health care costs was $1357 (95% confidence interval [CI], $778-$1935) lower in favor of SPC than FEC groups. Adherence, measured as the mean difference in medication possession ratio, was estimated to be 8% higher for patients naive to prior antihypertensives and 14% higher for nonnaive SPC patients compared with corresponding FEC patients. Persistence in the SPC groups was twice as likely as the FEC groups (pooled risk ratio, 2.1; 95% CI, 1.1-4.1). Improved adherence and persistence may have contributed to the lower costs in the SPC groups via improved clinical outcomes.

Medication adherence leads to lower health care use and costs despite increased drug spending

Researchers have routinely found that improved medication adherence--getting people to take medicine prescribed for them--is associated with greatly reduced total health care use and costs. But previous studies do not provide strong evidence of a causal link. This article employs a more robust methodology to examine the relationship. Our results indicate that although improved medication adherence by people with four chronic vascular diseases increased pharmacy costs, it also produced substantial medical savings as a result of reductions in hospitalization and emergency department use. Our findings indicate that programs to improve medication adherence are worth consideration by insurers, government payers, and patients, as long as intervention costs do not exceed the estimated health care cost savings.