Exploring the impact of financial barriers on secondary prevention of heart disease

Unfavorable social determinants of health are associated with higher burden of financial toxicity among patients with atherosclerotic cardiovascular disease in the US: findings from the National Health Interview Survey

BACKGROUND

Atherosclerotic cardiovascular disease (ASCVD) is a major cause of financial toxicity, defined as excess financial strain from healthcare, in the US. Identifying factors that put patients at greatest risk can help inform more targeted and cost-effective interventions. Specific social determinants of health (SDOH) such as income are associated with a higher risk of experiencing financial toxicity from healthcare, however, the associations between more comprehensive measures of cumulative social disadvantage and financial toxicity from healthcare are poorly understood.

METHODS

Using the National Health Interview Survey (2013-17), we assessed patients with self-reported ASCVD. We identified 34 discrete SDOH items, across 6 domains: economic stability, education, food poverty, neighborhood conditions, social context, and health systems. To capture the cumulative effect of SDOH, an aggregate score was computed as their sum, and divided into quartiles, the highest (quartile 4) containing the most unfavorable scores. Financial toxicity included presence of: difficulty paying medical bills, and/or delayed/foregone care due to cost, and/or cost-related medication non-adherence.

RESULTS

Approximately 37% of study participants reported experiencing financial toxicity from healthcare, with a prevalence of 15% among those in SDOH Q1 vs 68% in SDOH Q4. In fully-adjusted regression analyses, individuals in the 2nd, 3rd and 4th quartiles of the aggregate SDOH score had 1.90 (95% CI 1.60, 2.26), 3.66 (95% CI 3.11, 4.35), and 8.18 (95% CI 6.83, 9.79) higher odds of reporting any financial toxicity from healthcare, when compared with participants in the 1st quartile. The associations were consistent in age-stratified analyses, and were also present in analyses restricted to non-economic SDOH domains and to 7 upstream SDOH features.

CONCLUSIONS

An unfavorable SDOH profile was strongly and independently associated with subjective financial toxicity from healthcare. This analysis provides further evidence to support policies and interventions aimed at screening for prevalent financial toxicity and for high financial toxicity risk among socially vulnerable groups.

Patient Perspectives on Home-Based Care and Remote Monitoring in Heart Failure: A Qualitative Study

INTRODUCTION

As individual interventions, home-based care and remote monitoring have been shown to help prevent hospitalizations for those with heart failure (HF) although both interventions have been limited by scalability and technical constraints, respectively. Few qualitative studies have explored patient perspectives, including acceptability, barriers, and facilitators of HF care inclusive of both interventions. The objective of this study is to explore patient perceptions on HF management at home, the use of home-based remote monitoring, and the value of home-based care.

METHODS

Qualitative interviews (N = 27) were conducted via phone (12/2020-3/2021) with adults with HF. A framework analysis was used to identify main themes along with verbatim transcription for coding and analyses. There were 5 key interview domains: general HF knowledge, perceptions of the value of home-based care, unmet needs related to the social determinants of health (SDOH), experience with healthcare technology and remote monitoring, and challenges in HF home management.

RESULTS

Five major themes emerged. Patients reported: (1) home-based care plan instructions are understood; (2) following medication, diet, and fluid management instructions are challenging due to difficult adherence to and implementation at home; (3) financial limitations serve as barriers to acquiring healthy food; (4) home-based support is a valuable component of managing medications, diet, and fluid; (5) despite limited use of technology, strong willingness to use remote monitoring is present amongst most.

CONCLUSIONS

Participants reported understanding of care plan instructions and challenges adhering to care plans at home. Barriers included needing more home-based support for medications, diet, and fluid management and requiring additional assistance with financial barriers related to unmet social needs. A combined intervention inclusive of remote monitoring and home-based support has potential to improve home-based strategies and clinical outcomes for HF patients.

Association of Neighborhood-Level Material Deprivation With Atrial Fibrillation Care in a Single-Payer Health Care System: A Population-Based Cohort Study

BACKGROUND

There are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care.

METHODS

This was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply.

RESULTS

Among 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13-1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07-1.27]), heart failure (HR, 1.14 [95% CI, 1.11-1.18]), or bleeding (HR, 1.16 [95% CI, 1.07-1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89-0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96-0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95-0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82-0.86]), cardioversion (HR, 0.80 [95% CI, 0.76-0.84]), and ablation (HR, 0.45 [95% CI, 0.30-0.67]).

CONCLUSIONS

Despite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes.

Medicare Coverage and Out-of-Pocket Costs of Quadruple Drug Therapy for Heart Failure

BACKGROUND

Beta-blockers, angiotensin receptor-neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors (SGLT2i), known as quadruple therapy, are recommended for patients with heart failure with reduced ejection fraction (HFrEF).

OBJECTIVES

This study sought to determine Medicare coverage and out-of-pocket (OOP) costs of quadruple therapy and regimens excluding ARNI or SGLT2i.

METHODS

This study assessed cost sharing, prior authorization, and step therapy in all 4,068 Medicare prescription drug plans in 2020. OOP costs were determined during the standard coverage period and annually based on the Medicare Part D standard benefit, inclusive of deductible, standard coverage, coverage gap, and catastrophic coverage.

RESULTS

Tier ≥3 cost sharing was required by 99.1% of plans for ARNI and 98.5% for at least 1 SGLT2i. Only ARNI required prior authorization (24.3% of plans), and step therapy was required only for SGLT2is (5.4%) and eplerenone (0.8%). The median 30-day standard coverage OOP cost of quadruple therapy was $94 (IQR: $84-$100), including $47 (IQR: $40-$47) for ARNI and $45 (IQR: $40-$47) for SGLT2i. The median annual OOP cost of quadruple therapy was $2,217 (IQR: $1,956-$2,579) compared with $1,319 (IQR: $1,067-$1,675) when excluding SGLT2i and $1,322 (IQR: $1,025-$1,588) when including SGLT2i and substituting an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for ARNI. The median 30-day OOP cost of generic regimens was $3 (IQR: $0-$9).

CONCLUSIONS

Medicare drug plans restrict coverage of quadruple therapy through cost sharing, with OOP costs that are substantially higher than generic regimens. Quadruple therapy may be unaffordable for many Medicare patients with HFrEF unless medication prices and cost sharing are reduced.

Impact of financial barriers on health status, healthcare utilisation and economic burden among individuals with cognitive impairment: a national cross-sectional survey

OBJECTIVE

To study the impact of financial barriers to healthcare on health status, healthcare utilisation and costs among patients with cognitive impairment.

DESIGN

Cross-sectional.

SETTING

National Health Interview Survey (NHIS), 2011-2017.

PARTICIPANTS

Patients with cognitive impairment aged 18 years or older.

INTERVENTIONS

Financial barriers to healthcare were identified using a series of NHIS prompts asking about the affordability of healthcare services.

PRIMARY OUTCOME MEASURES

Health status was based on a survey prompt about respondents' general health. Healthcare utilisation included office visits, home healthcare visits, hospital stays and emergency department (ED) visits. Economic burden was based on the family spending on medical care. Logistic regression models were used to examine the impact of financial barriers to healthcare access on health status, home healthcare visits, office visits, hospital stays and ED visits, respectively.

RESULTS

Compared with cognitively impaired respondents without financial barriers to healthcare access, those with financial barriers were more likely to be unhealthy (OR 0.64, 95% CI 0.57 to 0.72). Cognitively impaired respondents with financial barriers were less likely to have home healthcare (OR 0.69, 95% CI 0.48 to 0.99) and more likely to have hospital stays (OR 1.33, 95% CI 1.19 to 1.48) and ED visits (OR 1.50, 95% CI 1.35 to 1.67). In addition, compared with cognitively impaired respondents without financial barriers to healthcare access, those with the barriers were more likely to have an increased economic burden (OR=1.85, 95% CI 1.65 to 2.07).

CONCLUSION

Financial barriers to healthcare worsened health status and increased use of ED, hospitalisation and economic burden. Policy decision-makers, providers and individuals with cognitive impairment should be aware of the impact of financial barriers and take corresponding actions to reduce the impact.

Patient partnership in cardiovascular clinical trials

Patients are ultimately the end-users of medical therapies and need to be actively integrated as contributors and decision-makers in the process of product development throughout product lifecycles. This is increasingly being recognized by patients, investigators, regulators, payers, sponsors, and medical journals. However, cardiovascular research remains behind other fields in terms of the extent of patient involvement and awareness of clinical trials in cardiovascular research. True patient partnerships in cardiovascular therapeutic development may permit more rapid recognition of unmet needs, ensure alignment of product development priorities with patient priorities, improve efficiency of trials (e.g. recruitment), and ensure outcomes of value to patients are being measured in trials (e.g. quality of life). This paper reviews ongoing initiatives and remaining opportunities to accomplish contributive patient involvement in cardiovascular clinical research.

Medication adherence in cardiovascular medicine

Cardiovascular disease is the leading cause of death globally. While pharmacological advancements have improved the morbidity and mortality associated with cardiovascular disease, non-adherence to prescribed treatment remains a significant barrier to improved patient outcomes. A variety of strategies to improve medication adherence have been tested in clinical trials, and include the following categories: improving patient education, implementing medication reminders, testing cognitive behavioral interventions, reducing medication costs, utilizing healthcare team members, and streamlining medication dosing regimens. In this review, we describe specific trials within each of these categories and highlight the impact of each on medication adherence. We also examine ongoing trials and future lines of inquiry for improving medication adherence in patients with cardiovascular diseases.

Referral and access to heart function clinics: A realist review

RATIONALE, AIM, AND OBJECTIVES

Heart failure (HF) clinics are highly effective, yet not optimally utilized. A realist review was performed to identify contexts (eg, health system characteristics, clinic capacity, and siting) and underlying mechanisms (eg, referring provider knowledge of clinics and referral criteria, barriers in disadvantaged patients) that influence utilization (provider referral [ie, of all appropriate and no inappropriate patients] and access [ie, patient attends ≥1 visit]) of HF clinics.

METHODS

Following an initial scoping search and field observation in a HF clinic, we developed an initial program theory in conjunction with our expert panel, which included patient partners. Then, a literature search of seven databases was searched from inception to December 2019, including Medline; Grey literature was also searched. Studies of any design or editorials were included; studies regarding access to cardiac rehabilitation, or a single specialist for example, were excluded. Two independent reviewers screened the abstracts, and then full-texts. Relevant data from included articles were used to refine the program theory.

RESULTS

A total of 29 papers from five countries (three regions) were included. There was limited information to support or refute many elements of our initial program theory (eg, referring provider knowledge/beliefs, clinic inclusion/exclusion criteria), but refinements were made (eg, specialized care provided in each clinic, lack of patient encouragement). Lack of capacity, geography, and funding arrangements were identified as contextual factors, explaining a range of mechanistic processes, including patient clinical characteristics and social determinants of health as well as clinic characteristics that help to explain inappropriate and low use of HF clinics (outcome).

CONCLUSION

Given the burden of HF and benefit of HF clinics, more research is needed to understand, and hence overcome sub-optimal use of HF clinics. In particular, an understanding from the perspective of referring providers is needed.

Atherosclerotic Cardiovascular Disease, Cancer, and Financial Toxicity Among Adults in the United States

Background

Financial toxicity (FT) is a well-established side-effect of the high costs associated with cancer care. In recent years, studies have suggested that a significant proportion of those with atherosclerotic cardiovascular disease (ASCVD) experience FT and its consequences.

Objectives

This study aimed to compare FT for individuals with neither ASCVD nor cancer, ASCVD only, cancer only, and both ASCVD and cancer.

Methods

From the National Health Interview Survey, we identified adults with self-reported ASCVD and/or cancer between 2013 and 2018, stratifying results by nonelderly (age <65 years) and elderly (age ≥65 years). We defined FT if any of the following were present: any difficulty paying medical bills, high financial distress, cost-related medication nonadherence, food insecurity, and/or foregone/delayed care due to cost.

Results

The prevalence of FT was higher among those with ASCVD when compared with cancer (54% vs. 41%; p < 0.001). When studying the individual components of FT, in adjusted analyses, those with ASCVD had higher odds of any difficulty paying medical bills (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.09 to 1.36), inability to pay bills (OR: 1.25; 95% CI: 1.04 to 1.50), cost-related medication nonadherence (OR: 1.28; 95% CI: 1.08 to 1.51), food insecurity (OR: 1.39; 95% CI: 1.17 to 1.64), and foregone/delayed care due to cost (OR: 1.17; 95% CI: 1.01 to 1.36). The presence of ≥3 of these factors was significantly higher among those with ASCVD and those with both ASCVD and cancer when compared with those with cancer (23% vs. 30% vs. 13%, respectively; p < 0.001). These results remained similar in the elderly population.

Conclusions

Our study highlights that FT is greater among patients with ASCVD compared with those with cancer, with the highest burden among those with both conditions.

Barriers to Self-care Among Patients with Heart Failure: A Qualitative Study

Introduction: Heart failure is the most prevalent cardiovascular disease. It is the end stage of most cardiovascular diseases and is characterized by the reduced ability of the heart to pump enough blood to fulfill the metabolic needs of the body. Self-care is the basis of the management of chronic diseases such as heart failure. The aim of this study was to explore the barriers to self-care among patients with heart failure. Methods: This was a qualitative content analysis. Participants were fourteen patients with heart failure and three healthcare providers who were purposively recruited from cardiac care centers in Zanjan, Iran. Data were collected through in-depth semi-structured interviews and were analyzed through the conventional qualitative content analysis approach proposed by Elo and Kyngäs. Results: Self-care barriers -care among patients with HF were categorized into three main categories, namely personal factors, disease burden, and inefficient support system. Each category had three subcategories which were respectively lack of self-care knowledge, heart failure-related negative emotions, the difficulty of changing habits, progressive physical decline, comorbid conditions, financial strain, inadequate social support, healthcare providers' inattention to self-care, and limited access to healthcare providers. Conclusion: Patients with heart failure face different personal, disease-related, and support-related barriers to self-care. Based on these barriers, healthcare providers can develop interventions for promoting self-care among patients with heart failure.

Association Between Cost-Related Medication Nonadherence and Hypertension Management Among US Adults

BACKGROUND

Medication nonadherence is an important element of uncontrolled hypertension. Financial factors frequently contribute to nonadherence. The objective of this study was to examine the association between cost-related medication nonadherence (CRMN) and self-reported antihypertensive medication use and self-reported normal blood pressure among US adults with self-reported hypertension.

METHODS

Participants with self-reported hypertension from the 2017 National Health Interview Survey were included (n = 7,498). CRMN was defined using standard questions. Hypertension management included: (i) self-reported current antihypertensive medication use and (ii) self-reported normal blood pressure within the past 12 months. Adjusted prevalence and prevalence ratios of hypertension management indicators among those with and without CRMN were estimated.

RESULTS

Overall, 10.7% reported CRMN, 83.6% reported current antihypertensive medication use, and 67.4% reported normal blood pressure within past 12 months. Adjusted percentages of current antihypertensive medication use (88.6% vs. 82.9%, P < 0.001) and self-reported normal blood pressure (69.8% vs. 59.5%, P = 0.002) were higher among those without CRMN compared with those with CRMN. Adjusted prevalence ratios showed that, compared with those with CRMN, those without CRMN were more likely to report current antihypertensive medication use (odds ratio = 1.08, 95% confidence interval 1.04-1.12) and self-reported normal blood pressure (1.15 (1.07-1.23)).

CONCLUSIONS

Among US adults with self-reported hypertension, those without CRMN were more likely to report current antihypertensive medication use and normal blood pressure within the past 12 months. Financial barriers to medication adherence persist and impact hypertension management.

"The Financial Impact Is Depressing and Anxiety Inducing": A Qualitative Exploration of the Personal Financial Toll of Arthritis

OBJECTIVE

The financial experience faced by working-age people with arthritis includes living below the poverty line for many. Financial distress among people with arthritis is known to contribute to poorer health outcomes, including high psychological distress and more severe pain. Despite the demonstrated societal cost of arthritis care and management, the personal costs borne by the individual are not well understood. The aim of this study was to explore the perceived financial impacts of living with arthritis among younger adults (defined as those ages 18-50 years).

METHODS

A qualitative descriptive study design was used. Participants with inflammatory arthritis or osteoarthritis were recruited from the community, including urban and rural settings. An interview schedule was developed, informed by existing literature, which was piloted prior to data collection. Deductive and inductive coding techniques were used to identify financial-related themes arising from the data.

RESULTS

Semistructured interviews were conducted with 21 adults (90% female) with a mix of arthritis conditions, including rheumatoid arthritis, psoriatic arthritis, and osteoarthritis. Four themes were identified: direct arthritis-attributable medical costs, indirect arthritis-attributable costs, insurance and pension costs, and broader financial impacts on the family. Nonsubsidized costs were frequently referenced by participants as burdensome and existed even within the publicly funded Australian health care system.

CONCLUSION

Adults with arthritis experience significant arthritis-attributable financial burden and related distress. Financial concerns should be actively identified and considered within shared clinical decision-making to provide more patient-centered care for these individuals.

Education of Migrant and Nonmigrant Patients Is Associated With Initiation and Discontinuation of Preventive Medications for Acute Coronary Syndrome

Background The benefits of preventive medications after acute coronary syndrome are impeded by low medication persistence, in particular among marginalized patient groups. Patient education might increase medication persistence, but the effect is still uncertain, especially among migrant groups. We, therefore, assessed whether use of patient education was associated with medication persistence after acute coronary syndrome and whether migrant background modified the potential associations. Methods and Results A cohort of patients discharged with a diagnosis of acute coronary syndrome (N=33 199) was identified in national registers. We then assessed number of contacts for patient education during a period of 6 months after discharge and the initiation and discontinuation of preventive medications during a period of up to 5 years. Results were adjusted for comorbidity and sociodemographic factors. Three or more contacts for patient education was associated with a higher likelihood of initiating preventive medications, corresponding to adjusted relative risks ranging from 1.12 (95% CI , 1.06-1.18) for statins to 1.39 (95% CI , 1.28-1.51) for ADP inhibitors. Lower risks of subsequent discontinuation were also observed, with adjusted hazard ratios ranging from 0.86 (95% CI , 0.79-0.92) for statins to 0.92 (95% CI , 0.88-0.97) for β blockers. Stratification and test for effect modification by migrant status showed insignificant effect modification, except for initiation of ADP inhibitors and statins. Conclusions Patient education is associated with higher chance of initiating preventive medications after acute coronary syndrome and a lower long-term risk of subsequent discontinuation independently of migrant status.

Incorporating intervention fidelity components into randomized controlled trials promoting exercise adherence in heart failure patients

Intervention fidelity (IF) in behavioral interventions is complicated by their dynamic and interactive nature. Translation of the outcomes to practice may be diminished by lack of fidelity. The purpose of this paper is to describe a systematic, evidence-based IF approach in a complex, multicomponent behavioral change study. The National Institutes of Health-funded randomized controlled trial was designed to evaluate the effect of an adherence to exercise intervention. Two hundred forty-six heart failure patients from two sites were enrolled. This description of the study-specific standardized protocol, the data collection methods used, findings from the plan, and the discussion of the successes and challenges contributes to the advancement of IF implementation science.

Barriers to Healthcare Access and to Improvements in Health-Related Quality of Life After an Acute Coronary Syndrome (From TRACE-CORE)

Little is known about how barriers to healthcare access affect health-related quality of life (HRQOL) after an acute coronary syndrome (ACS). In a large cohort of ACS survivors from 6 medical centers in Massachusetts and Georgia enrolled from 2011 to 2013, patients were classified as having any financial barriers, no usual source of care (USOC), or transportation barriers to healthcare based on their questionnaire survey responses. The principal study outcomes included clinically meaningful declines in generic physical and mental HRQOL and in disease-specific HRQOL from 1 to 6 months posthospital discharge. Adjusted relative risks (aRRs) for declines in HRQOL were calculated using Poisson regression models, controlling for several sociodemographic and clinical factors of prognostic importance. In 1,053 ACS survivors, 29.0% had a financial barrier, 14.2% had no USOC, and 8.7% had a transportation barrier. Patients with a financial barrier had greater risks of experiencing a decline in generic physical (aRR 1.48, 95% confidence interval [CI] 1.17, 1.86) and mental (aRR 1.36, 95% CI 1.07, 1.75) HRQOL at 6 months. Patients with 2 or more access barriers had greater risks of decline in generic physical (aRR 1.53, 95% CI 1.20, 1.93) and mental (aRR 1.50, 95% CI 1.17, 1.93) HRQOL compared with those without any healthcare barriers. There was a modest association between lacking a USOC and experiencing a decline in disease-specific HRQOL (aRR 1.46, 95% CI 0.96, 2.22). Financial and other barriers to healthcare access may be associated with clinically meaningful declines in HRQOL after hospital discharge for an ACS.

Barriers to Healthcare Access and Long-Term Survival After an Acute Coronary Syndrome

BACKGROUND

Barriers to healthcare are common in the USA and may result in worse outcomes among hospital survivors of an acute coronary syndrome (ACS).

OBJECTIVE

To examine the relationship between barriers to healthcare and 2-year mortality after hospital discharge for an ACS.

DESIGN

Longitudinal study.

SETTING

Survivors of an ACS hospitalization were recruited from 6 medical centers in central Massachusetts and Georgia in 2011-2013.

PATIENTS

Study participants with a confirmed ACS reported whether they had a financial-related healthcare barrier, no usual source of care, or a transportation-related healthcare barrier around the time of hospital admission.

INTERVENTIONS

None.

MEASUREMENTS

Cox regression analyses calculated adjusted hazard ratios (aHRs) for 2-year all-cause mortality for the three healthcare barriers while controlling for several demographic, clinical, and psychosocial characteristics.

RESULTS

The mean age of study participants (n = 2008) was 62 years, 33% were women, and 77% were non-Hispanic white. One third of patients reported a financial barrier, 17% lacked a usual source of care, and 12% had a transportation barrier. Five percent (n = 100) died within 2 years after hospital discharge. Compared to patients without these barriers, those lacking a usual source of care and with barriers to transportation experienced significantly higher mortality (aHRs 1.40, 95% CI 1.30 to 1.51 and 1.46, 95% CI 1.13 to 1.89, respectively). Financial barriers were not associated with all-cause mortality (aHR 0.79, 95% CI 0.60 to 1.06).

LIMITATIONS

Observational study with other unmeasured potentially confounding prognostic factors.

CONCLUSIONS

Absence of an established usual source of care and inconsistent transportation availability were associated with a higher risk for dying after an ACS. Patients with these barriers to follow-up care may benefit from more intensive follow-up and support.

A perspective on nonadherence to drug therapy: psychological barriers and strategies to overcome nonadherence

Medication adherence represents an inefficiency and ongoing challenge within medical care. The problem has been long-recognized - indeed, the research literature contains thousands of articles on the topic. Nonetheless, because of the complex nature of the problem, it still cannot be considered to be solved. Reasons for nonadherence are myriad but psychological barriers to adherence are most difficult to mitigate and, thus, are the focus of this paper. The present narrative review sketches a summary of theoretical models commonly utilized to understand and help address medication nonadherence; uses a patient-centered care approach to contextualize the problem of nonadherence to drug therapies; and then outlines a set of best-practice recommendations based on the extant data and framed from the perspective of the Information-Motivation-Strategy model.

Access to routine care and risks for 30-day readmission in patients with cardiovascular disease

BACKGROUND

Studies have shown that access to routine medical care is associated with the prevention, diagnosis, and treatment of chronic diseases. However, studies have not examined whether patient-reported difficulties in access to care are associated with rehospitalization in patients with cardiovascular disease.

METHODS

Electronic medical records and a standardized survey were used to examine cardiovascular patients admitted to a large medical center from January 1, 2015 through January 10, 2017 (n=520). All-cause readmission within 30 days of discharge was the primary outcome for analysis. Logistic regression models were used to examine the association between access to care and 30-day readmission while adjusting for patient demographics, socioeconomic status, healthcare utilization, and health status.

RESULTS

Nearly 1-in-6 patients (15.7%) reported difficulty in accessing routine medical care; and those who were younger, male, non-white, uninsured, with heart failure, and had low social support were significantly more likely to report difficulty. Patients who reported difficulty in accessing care had significantly higher rates of 30-day readmission than patients who did not report difficulty (33.3% vs. 17.9%; P=.001); and the risks remained largely unchanged after accounting for nearly two dozen covariates (unadjusted odds ratio [OR]=2.29; 95% CI, 1.46-3.60 vs. adjusted OR=2.17; 95% CI, 1.29-3.66). Risks for readmission were especially high for patients who reported issues with transportation (OR=3.24; 95% CI, 1.28-8.16) and scheduling appointments (OR=3.56; 95% CI, 1.43-8.84), but not for other reasons (OR=1.47; 95% CI, 0.61-3.54).

CONCLUSIONS

Cardiovascular patients who reported difficulty in accessing routine care had substantial risks of readmission within 30 days after discharge. These findings have important implications for identifying high-risk patients and developing interventions to improve access to routine medical care.

Recent Approaches to Improve Medication Adherence in Patients with Coronary Heart Disease: Progress Towards a Learning Healthcare System

PURPOSE OF REVIEW

Non-adherence to medications for the secondary prevention of myocardial infarction (MI) is a major contributor to morbidity and mortality in these patients. This review describes recent advances in promoting adherence to therapies for coronary artery disease (CAD).

RECENT FINDINGS

Two large randomized controlled trials to "incentivize" adherence were somewhat disappointing; neither financial incentives nor "peer pressure" successfully increased rates of adherence in the post-MI population. Patient education and provider engagement appear to be critical aspects of improving adherence to CAD therapies, where the provider is a physician, pharmacist, or nurse and follow-up is performed in person or by telephone. Fixed-dose combinations of CAD medications, formulated as a so-called "polypill," have shown some early efficacy in increasing adherence. Technological advances that automate monitoring and/or encouragement of adherence are promising but seem universally dependent on patient engagement. For example, medication reminders via text message perform better if patients are required to respond. Multifaceted interventions, in which these and other interventions are combined together, appear to be most effective. There are several available types of proven interventions through which providers, and the health system at large, can advance patient adherence to CAD therapies. No single intervention to promote adherence will be successful in all patients. Further study of multifaceted interventions and the interactions between different interventions will be important to advancing the field. The goal is a learning healthcare system in which a network of interventions responds and adapts to patients' needs over time.

Cost-related nonadherence to prescription medications in Canada: a scoping review

PURPOSE

The evidence is emerging that prescription medications are the topmost drivers of increasing health care costs in Canada. The financial burden of medications may lead individuals to adopt various rationing or restrictive behaviors, such as cost-related nonadherence (CRNA) to medications. Therefore, the purpose of this study is to provide an overview of the type, extent, and quantity of research available on CRNA to prescription drugs in Canada, and evaluate existing gaps in the literature.

METHODS

The study was conducted using a scoping review methodology. Six databases were searched from inception till June 2017. Articles were considered for inclusion if they focused on extent, determinants, and consequences of CRNA to prescription medication use in the Canadian context. Variables extracted for data charting included author(s), year of publication, study design, the focus of the article, sample size, population characteristics, and key outcomes or results.

RESULTS

This review found 37 studies that offered evidence on the extent, determinants, and consequences of CRNA to prescription medications in Canada. Depending on the population characteristics and province, the prevalence of CRNA varies between 4% and 36% in Canada. Canadians who are young (between 18 and 64 years), without drug insurance, have lower income or precarious or irregular employment, and high out-of-pocket expenditure on drugs are most likely to face CRNA to their prescriptions. The evidence that CRNA has negative health and social outcomes for patients is insufficient. Literature regarding the influence of prescribing health care professionals on patients' decisions to stop taking medications is limited. There is also a dearth of literature that explores patients' decisions and strategies to manage their prescription cost burden.

CONCLUSION

More evidence is required to make a strong case for national Pharmacare which can ensure universal, timely, and burden-free access to prescription medications for all Canadians.

Financial burden of survivors of medically-managed myocardial infarction and its association with selected social determinants and quality of life in a lower middle income country

Background

Burden from ischemic heart disease is rising in Sri Lanka due to the demographic and epidemiological transitions. Documented literature is scarce on quality of life, financial burden and its determinants in relation to myocardial infarction (MI). This study was done to describe the financial burden among the survivors of MI managed only with drugs (i.e. those who did not undergo Percutaneous Coronary Intervention or Coronary Artery Bypass Graft) and its association with selected social determinants (SDHs) and quality of life (QOL).

Methods

A cross sectional study was done among MI survivors in 13 hospitals in the premier province of Sri Lanka. Out of 336 participants recruited at hospital stay, 270 responded through a self-administered questionnaire at 1 month post discharge. Questionnaire included sections on financial burden, selected SDHs and on QOL measured by the EQ-5D-3 L QOL tool. Presence of financial burden was determined using an operational definition. Associations were tested with Mann–Whitney-U test, Chi square test and Spearman-correlation-coefficient at 5% significant level.

Results

Around 40% (n = 116) had to seek financial support for out-of-pocket expenditure. Nearly 5% (n = 6) of previously employed participants had lost their job. Of the employed respondents (n = 139, 51.5%), 29% (n = 85) had limited physical activity and 40% (n = 115) had limitations of employment time. Of the respondents, 15.4% had to apply for a loan, 7.8% had to sell a property, 19.1% had an income loss and 33.8% had to restrict usual expenses. Financial burden was not significantly associated with gender (p = 0.146), ethnicity (p = 0.068), highest education (p = 0.184) and area of residence (p = 0.369). Influence of income (p = 0.001), social support (p = 0.002) and the health infrastructure (p < 0.001) were significantly associated with the occurrence of a financial burden. In the group with a financial burden, the index score (p = 0.002) and VAS score (p < 0.001) of EQ-5D-3 L were significantly lower.

Conclusions

Financial burden is common among survivors of medically-managed occurring irrespective of the gender, ethnicity, education and the area. It is influenced significantly by the income, level of social support and the level of health infrastructure. The financial burden is influencing the post-discharge-1-month QOL.