Patterns of prescription drug expenditures and medication adherence among medicare part D beneficiaries with and without the low-income supplement

The cost of influence: How gifts to physicians shape prescriptions and drug costs

This paper investigates the influence of gifts - monetary and in-kind payments - from drug firms to US physicians on prescription behavior and drug costs. Using causal models and machine learning, we estimate physicians' heterogeneous responses to payments on antidiabetic prescriptions. We find that payments lead to increased prescription of brand drugs, resulting in a cost rise of $23 per dollar value of transfer received. Paid physicians show higher responses when they treat higher proportions of patients receiving a government-funded low-income subsidy that lowers out-of-pocket drug costs. We estimate that introducing a national gift ban would reduce diabetes drug costs by 2%.

Bromocriptine and Colesevelam Hydrochloride: Novel Therapies for Type II Diabetes Mellitus

The increasing prevalence of type II diabetes mellitus (T2DM) is a worldwide healthcare concern. Over the years, our understanding of T2DM has grown considerably in uncovering the pathophysiology of the disease and, in turn, understanding how improved treatment methods can be used to slow disease progression. Some long-term complications that are responsible for most T2DM mortalities include cardiovascular disease, neurological decline, and renal failure. In treating T2DM, it is important that not only glycemic control be obtained but also control of associated complications. Bromocriptine and colesevelam hydrochloride have both been approved by the Food and Drug Administration (FDA) to treat T2DM but are not readily used in practice. These medications are known to treat glycemic dysregulation via unconventional mechanisms, which might contribute to their potential to provide protection against common diabetic complications such as cardiovascular disease. In order to ensure that these overlooked medications become more readily used, it is vital that more research be performed to further elucidate their efficacy in a clinical setting. Future studies should continue to provide clinicians a better understanding of the role these medications have on the treatment of T2DM such as their ability to be used in combination with other commonly used T2DM medications or as monotherapies.

Consequences of forgoing prescription drug subsidies among low-income Medicare beneficiaries with diabetes

OBJECTIVE

The objective is to estimate the take-up of the Medicare Part D Low-Income Subsidy (LIS) among Medicare beneficiaries with diabetes and examine differences in out-of-pocket costs and prescription drug use between LIS enrollees and LIS-eligible non-enrollees. The LIS reduces out-of-pocket drug costs for low-income beneficiaries; however, not all LIS-eligible individuals are enrolled. Take-up of the LIS, and consequences of forgoing this benefit among beneficiaries with diabetes, remains unknown.

DATA SOURCES

Health and Retirement Study linked to Medicare administrative data from 2008 to 2016.

STUDY DESIGN

We conducted two analyses among beneficiaries with diabetes. First, we estimated LIS take-up stratified by income (≤100% of the Federal Poverty Level [FPL] and >100% to ≤150% of FPL). Second, to assess the consequences of forgoing the LIS among near-poor beneficiaries (incomes >100% to ≤150% of FPL), we conducted propensity score-weighted regression analyses to compare out-of-pocket costs, the prescription drug use, and cost-related medication non-adherence among LIS enrollees and LIS-eligible non-enrollees.

DATA COLLECTION/DATA EXTRACTION

N/A.

PRINCIPAL FINDINGS

Among Medicare beneficiaries with diabetes, 68.1% of those with incomes >100% to ≤150% of FPL received the LIS, while 90.3% with incomes ≤100% of FPL received the LIS. Among near-poor beneficiaries, LIS-eligible non-enrollees incurred higher annual out-of-pocket drug spending ($518; 95 [in USD]% CI: $370 [in USD], $667 [in USD]; p < 0.001), filled 7.3 fewer prescriptions for diabetes, hypertension, and hyperlipidemia drugs (95% CI: -11.1, -3.5; p < 0.001), and were 8.9 percentage points more likely to report skipping drugs due to cost (95% CI: 0.3, 18.0; p = 0.04), all compared to LIS enrollees.

CONCLUSIONS

Despite providing substantial financial assistance with prescription drug costs, the LIS is under-utilized among beneficiaries with chronic conditions requiring routine medication use. As policy makers discuss Part D reforms to address rising out-of-pocket drug costs, they should consider strategies to increase participation in existing programs that alleviate cost burdens among low-income Medicare beneficiaries.

Cost-Related Medication Nonadherence in Adults With Diabetes in the United States: The National Health Interview Survey 2013-2018

OBJECTIVE

Health-related expenditures resulting from diabetes are rising in the U.S. Medication nonadherence is associated with worse health outcomes among adults with diabetes. We sought to examine the extent of reported cost-related medication nonadherence (CRN) in individuals with diabetes in the U.S.

RESEARCH DESIGN AND METHODS

We studied adults age ≥18 years with self-reported diabetes from the National Health Interview Survey (NHIS) (2013-2018), a U.S. nationally representative survey. Adults reporting skipping doses, taking less medication, or delaying filling a prescription to save money in the past year were considered to have experienced CRN. The weighted prevalence of CRN was estimated overall and by age subgroups (<65 and ≥65 years). Logistic regression was used to identify sociodemographic characteristics independently associated with CRN.

RESULTS

Of the 20,326 NHIS participants with diabetes, 17.6% (weighted 2.3 million) of those age <65 years reported CRN, compared with 6.9% (weighted 0.7 million) among those age ≥65 years. Financial hardship from medical bills, lack of insurance, low income, high comorbidity burden, and female sex were independently associated with CRN across age groups. Lack of insurance, duration of diabetes, current smoking, hypertension, and hypercholesterolemia were associated with higher odds of reporting CRN among the nonelderly but not among the elderly. Among the elderly, insulin use significantly increased the odds of reporting CRN (odds ratio 1.51; 95% CI 1.18, 1.92).

CONCLUSIONS

In the U.S., one in six nonelderly and one in 14 elderly adults with diabetes reported CRN. Removing financial barriers to accessing medications may improve medication adherence among these patients, with the potential to improve their outcomes.

Using group-based trajectory modeling to characterize the association of past ACEIs/ARBs adherence with subsequent statin adherence patterns among new statin users

BACKGROUND

Despite well-documented benefits, statin adherence remains suboptimal. Studies have suggested that previous adherence to other chronic medications is a strong predictor of future adherence to newly initiated statins. Group-based trajectory modeling (GBTM) has been applied as a method to longitudinally depict the dynamic nature of adherence.

OBJECTIVES

This study aimed to examine the association between patients' adherence patterns to newly initiated statins and previous adherence trajectories of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) using GBTM.

METHODS

This retrospective cohort study was conducted among continuously enrolled statin initiators using claims data. Patients were included if they had ACEI/ARB use within 1 year before statin initiation (preindex period). Monthly adherence to ACEIs/ARBs was calculated during the preindex period and monthly adherence to statins was assessed 1 year after statin initiation using proportion of days covered (PDC). The monthly PDCs were modeled as a longitudinal response in a logistic GBTM to provide distinct patterns of adherence for ACEIs/ARBs and statins, separately. A multinomial logistic regression was conducted to determine an association between ACEI/ARB adherence trajectories and future statin trajectories, controlling for patient characteristics.

RESULTS

A total of 1078 patients were categorized into 4 distinct statin adherence trajectories: adherent (40.8%), gradual decline (37.4%), gaps in adherence (13.9%), and rapid decline (7.9%). Patients were further categorized into 4 groups on the basis of their distinct past ACEIs/ARBs trajectories: adherent (43%), gaps in adherence (29%), delayed nonadherence (15.2%), and gradual decline (12.8%). In the multinomial logistic regression, patients in the gaps in adherence or gradual decline groups were more likely to follow similar trajectories for future statin use than the adherent trajectory.

CONCLUSION

Previous adherence trajectories of ACEIs/ARBs may predict future adherence patterns for newly initiated statins. Knowledge of past medication-taking behavior could provide valuable information for developing tailored interventions to improve adherence.

Factors associated with medication nonadherence among Medicare low-income subsidy beneficiaries with diabetes, hypertension, and/or heart failure

BACKGROUND: Previous studies have documented factors influencing medication nonadherence among the Medicare population, but few studies have examined medication nonadherence among the Medicare low-income subsidy (LIS) population. Furthermore, little is known about the factors associated with nonadherence among this population, especially those with prevalent chronic conditions such as type 2 diabetes, hypertension, or heart failure. OBJECTIVE: To examine factors associated with the likelihood of medication nonadherence among Medicare LIS recipients with type 2 diabetes, hypertension, or heart failure. METHODS: This was a retrospective analysis of 2012-2013 Medicare Parts A, B, and D claims (most recent available for this research) linked to the Area Health Resources Files. Beneficiaries aged 65 years or older with continuous Medicare coverage and receiving any LIS were included. Individuals were categorized into full LIS or partial LIS groups. Nonadherence was determined by the proportion of days covered less than 80% for specified oral type 2 diabetes, hypertension, and heart failure medications, as defined by the Pharmacy Quality Alliance. A multivariate logistic regression was used to determine and compare individual-level and community-level characteristics associated with nonadherence among the entire study sample, the full LIS group, and the partial LIS group. RESULTS: The study sample included 505,771 Medicare beneficiaries, with 448,509 (88.7%) receiving full LIS and 57,262 (11.3%) receiving partial LIS. The proportion of individuals nonadherent was higher among the full LIS population (33.2%) than that of the partial LIS population (30.8%). Among the entire population, younger age was associated with nonadherence (OR = 0.98; 95% CI = 0.98-0.99). Men were more likely to be nonadherent than women (OR = 1.12; 95% CI = 1.11-1.14). Compared with non-Hispanic Whites, racial/ethnic minorities had higher nonadherence. Compared with beneficiaries who were non-Hispanic White, the ORs for those who were Black, Hispanic, Asian, and other were 1.41 (95% CI = 1.38-1.43), 1.58 (95% CI = 1.55-1.61), 1.08 (95% CI = 1.05-1.11), and 1.63 (95% CI = 1.56-1.70), respectively. There were higher nonadherence rates among patients living in communities with lower socioeconomic characteristics, such as a metropolitan statistical area (MSA vs non-MSA; OR = 1.05, 95% CI = 1.04-1.07). A higher risk adjustment summary score, indicating worse health status, was associated with an increased likelihood of medication nonadherence (OR = 1.21; 95% CI = 1.20-1.22). These patterns were similar among the full and partial LIS groups. CONCLUSIONS: Individual- and community-level characteristics were associated with the likelihood of medication nonadherence among Medicare LIS recipients with type 2 diabetes, hypertension, or heart failure. These characteristics included younger age, male sex, racial/ethnic minorities, living in lower socioeconomic communities, and a higher risk adjustment summary score. This study provided insight into medication nonadherence within the Medicare LIS population and identified the need to consider these factors when developing future policies to improve medication adherence. DISCLOSURES: This study was funded by the Pharmaceutical Research & Manufacturers of America (PhRMA), which was involved in the preparation and revision of the manuscript. Dougherty is employed by PhRMA. Todor was a PQA-CVS Health Foundation Scholar who was funded to work on this study. Hines is employed by Pharmacy Quality Alliance. Wang reports grants from AbbVie, Curo, Bristol Myers Squibb, and Pfizer, during the time of this study, and fees from the PhRMA Foundation for work on its Heath Outcomes Research Advisor Committee. The other authors have nothing to disclose. This study was presented as a poster at the online 2020 PQA Annual Meeting, May 7, 2020.

Identifying adherent patients to newly initiated statins using previous adherence to chronic medications

BACKGROUND: Statins are one of the most frequently prescribed medications in the United States. Despite well-documented benefits in managing hyperlipidemia and reducing cardiovascular risks, statin adherence remains suboptimal. Several effective interventions have been implemented to improve adherence to statins. However, identifying patients who are at risk for developing poor medication adherence at the time of treatment initiation could assist in planning early targeted interventions. Studies have suggested that previous adherence to chronic medications is a strong predictor of future adherence to newly initiated medications. OBJECTIVE: To investigate patients' adherence to newly initiated statins by measuring previous adherence to angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), and oral antidiabetic drugs (OADs). METHODS: A retrospective cohort study was conducted using administrative claims data from January 2016 to May 2018. New statin initiators were identified and included in the study if they were continuously enrolled in the health plan and had at least 1 prescription for ACEIs, ARBs, or OADs 1 year before statin initiation (pre-index period). Baseline adherence to ACEIs/ARBs, OADs, or both was calculated during a 1-year pre-index period using proportion of days covered (PDC) and defined as PDC ≥ 0.80. Adherence to statins was assessed 1 year after statin initiation and was the primary outcome, with a PDC ≥ 0.80 considered as adherent. Patient demographics were measured during the pre-index period. Multivariable logistic regression was conducted for each cohort separately to determine an association between baseline adherence and future statin adherence controlling for various demographic and clinical characteristics. RESULTS: 1,223 ACEI/ARB users, 714 OAD users, and 452 concomitant ACEI/ARB and OAD users were identified. In the regression model, adherence to baseline medications was significantly associated with 1-year adherence to statins (ACEI/ARB users: OR = 1.75, 95% CI = 1.37-2.25; OAD users: OR = 2.02, 95% CI = 1.46-2.79; concomitant ACEI/ARB and OAD users: OR = 1.73, 95% CI = 1.16-2.58). CONCLUSIONS: Past adherence to baseline medications may predict future adherence to newly initiated statins. Identifying patients likely to become nonadherent during treatment initiation could enable health care providers in recognizing individuals at risk of nonadherence and intervene earlier to enhance future adherence. DISCLOSURES: No funding was received for this study. Abughosh reports grants from Regeneron-Sanofi, BMS-Pfizer, and Valeant, unrelated to this work. Majd, Mohan, and Paranjpe have nothing to disclose.

Association Between Medication Adherence and Healthcare Costs Among Patients Receiving the Low-Income Subsidy

OBJECTIVES

Significant literature exists on the effects of medication adherence on reducing healthcare costs, but less is known about the effect of medication adherence among Medicare low-income subsidy (LIS) recipients. This study examined the effects of medication adherence on healthcare costs among LIS recipients with diabetes, hypertension, and/or heart failure.

METHODS

This retrospective study analyzed Medicare claims data (2012-2013) linked to the Area Health Resources Files. Using measures developed by the Pharmacy Quality Alliance, adherence to 11 medication classes was studied among patients with 7 possible combinations of the diseases mentioned. Adherence was measured in 8 categories of proportion of days covered (PDC): ≥95%, 90% to <95%, 85% to <90%, 80% to <85%, 75% to <80%, 50% to <75%, 25% to <50%, and <25%. Annual Medicare costs were compared across adherence categories. A generalized linear model was used to control for patient/community characteristics.

RESULTS

Among patients with only one disease, such as diabetes, patients with the lowest adherence (PDC < 25%) had $3152/year higher Medicare costs than patients with the highest adherence (PDC ≥ 95%; $11 101 vs $7949; P < .05). The adjusted costs among patients with PDC < 25% was $1893 higher than patients with PDC ≥ 95% ($9919 vs $8026; P < .05). Among patients with multiple chronic conditions, patients' adherence to medications for fewer diseases had higher costs.

CONCLUSIONS

Greater medication adherence is associated with lower Medicare costs in the Medicare LIS population. Future policy affecting the LIS program should encourage better medication adherence among patients with chronic diseases.

Decomposing the effect of drug benefit program on antihypertensive medication adherence among the elderly in urban China

PURPOSE

Hypertension is a rapidly growing epidemic in People's Republic of China, yet it remains inadequately controlled. This study aimed to identify the relative contributions of program effects and patients' characteristics to the differences in antihypertensive medication nonadherence between drug benefit program enrollees and non-enrollees.

PATIENTS AND METHODS

Data were from a cross-sectional survey of 1,969 community-dwelling elderly adults with hypertension. Self-reported adherence was measured following previous studies in People's Republic of China. The Blinder-Oaxaca nonlinear decomposition method was used to identify the relative contributions of program effects and patients' individual characteristics.

RESULTS

Eleven percent of the drug benefit program enrollees were nonadherent to their medication, while 17% of non-enrollees were. Blinder-Oaxaca decomposition identified that over 60% of the gap between the two groups was due to the program effects (P=0.024). The rest could be explained by differences in observable characteristics (P<0.001), such as diabetic status, duration of hypertension, and blood pressure control.

CONCLUSION

The study confirmed that drug benefit program enrollees were more likely to be adherent to their antihypertensive medication than non-enrollees in the context of People's Republic of China.

Shopping on the Public and Private Health Insurance Marketplaces: Consumer Decision Aids and Plan Presentation

BACKGROUND

The design of the Affordable Care Act's (ACA) health insurance marketplaces influences complex health plan choices.

OBJECTIVE

To compare the choice environments of the public health insurance exchanges in the fourth (OEP4) versus third (OEP3) open enrollment period and to examine online marketplace run by private companies, including a total cost estimate comparison.

DESIGN

In November-December 2016, we examined the public and private online health insurance exchanges. We navigated each site for "real-shopping" (personal information required) and "window-shopping" (no required personal information).

PARTICIPANTS

Public (n = 13; 12 state-based marketplaces and HealthCare.gov ) and private (n = 23) online health insurance exchanges.

MAIN MEASURES

Features included consumer decision aids (e.g., total cost estimators, provider lookups) and plan display (e.g., order of plans). We examined private health insurance exchanges for notable features (i.e., those not found on public exchanges) and compared the total cost estimates on public versus private exchanges for a standardized consumer.

RESULTS

Nearly all studied consumer decision aids saw increased deployment in the public marketplaces in OEP4 compared to OEP3. Over half of the public exchanges (n = 7 of 13) had total cost estimators (versus 5 of 14 in OEP3) in window-shopping and integrated provider lookups (window-shopping: 7; real-shopping: 8). The most common default plan orders were by premium or total cost estimate. Notable features on private health insurance exchanges were unique data presentation (e.g., infographics) and further personalized shopping (e.g., recommended plan flags). Health plan total cost estimates varied substantially between the public and private exchanges (average difference $1526).

CONCLUSIONS

The ACA's public health insurance exchanges offered more tools in OEP4 to help consumers select a plan. While private health insurance exchanges presented notable features, the total cost estimates for a standardized consumer varied widely on public versus private exchanges.

The Effect of Opioid Use and Mental Illness on Chronic Disease Medication Adherence in Superutilizers

BACKGROUND

Nonadherence to essential chronic medications has been identified as a potential driver of high health care costs in superutilizers of inpatient services. Few studies, however, have documented the levels of nonadherence and factors associated with nonadherence in this high-cost, vulnerable population.

OBJECTIVE

To examine the factors associated with nonadherence to essential chronic medications, with special emphasis on mental illness and use of opioid medications.

METHODS

This study was a retrospective panel analysis of 2-year baseline data for Medicare Part D beneficiaries eligible for the SafeMed care transitions program in Memphis, Tennessee, from February 2013 to December 2014. The 2-year baseline data for each patient were divided into four, 6-month patient periods. The study included Medicare superutilizers (defined as patients with ≥ 3 hospitalizations or ≥ 2 hospitalizations with ≥ 2 emergency visits in 6 months) with continuous Part D coverage who had filled at least 1 drug class used to treat hypertension, diabetes mellitus, congestive heart failure, coronary artery disease, or chronic lung disease. The outcome included medication nonadherence assessed using proportion of days covered (PDC), with PDC < 80% defined as nonadherent, and the main exposure variables included mental illness (defined as a diagnosis of depression or anxiety or ≥ 1 anxiolytic or antidepressant fill) and opioid medication fills assessed in each 6-month period. Pooled observations from the four 6-month periods were used for multivariable analyses using the patient periods as the unit of analysis. A random effects model with robust standard errors and a binary distribution were used to examine associations between independent variables (time invariant and time variant factors) and medication nonadherence. The model included lagged effects of time variant factors measured in each period.

RESULTS

Overall nonadherence to essential chronic medications ranged from 39.3% to 58.4%, with the highest for chronic lung disease medications (49.1%-64.4%). Factors associated with nonadherence included ≥ 4 opioid medication fills in the previous 6-month period (adjusted odds ratio [OR] = 1.90, 95% CI = 1.32-2.73); age 22-44 and 45-64 years vs. ≥ 65 years (OR = 3.57, 95% CI = 2.07-6.16, and OR = 2.07, 95% CI = 1.49-2.88); and a higher number of unique prescribers (OR = 1.10, 95% CI = 1.04-1.17). Factors protecting against nonadherence included higher number of unique medications filled (OR = 0.95, 95% CI = 0.92-0.98) and ≥ 1 physician office visit in the previous 6-month period (OR = 0.66, 95% CI = 0.46-0.94).

CONCLUSIONS

This study demonstrated that high levels of opioid medication use are significantly associated with essential chronic disease medication nonadherence among superutilizers. Other risk factors for nonadherence were aged < 65 years, low-income status, and a higher number of unique prescribers. Factors protecting against nonadherence were physician office visits and filling higher number of medications. Medication management interventions targeting superutilizers should focus on supporting chronic disease medication adherence.

DISCLOSURES

This project was supported by Funding Opportunity Number 1C1CMS331067-01-00 from the Centers for Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation. Support was also provided by the Pharmaceutical Research and Manufacturers of America Foundation. The content of this study is solely the responsibility of the authors. The authors declare no relevant conflicts of interest or financial relationships. Study concept and design were contributed by Surbhi, Bailey, and Graetz. Surbhi and Wan collected the data, and data interpretation was performed primarily by Surbhi, along with Graetz, Bailey, and Gatwood. The manuscript was primarily written by Surbhi, with assistance from Bailey and Graetz, and revised by Bailey, Graetz, Gatwood, and Surbhi. This study was presented as a poster at the Academy Health Annual Research Meeting in Boston, Massachusetts, on June 26-28, 2016.

Adherence to tyrosine kinase inhibitors among Medicare Part D beneficiaries with chronic myeloid leukemia

BACKGROUND

Tyrosine kinase inhibitors (TKIs) improve the survival of patients with chronic myeloid leukemia (CML) dramatically; however, nonadherence to TKI therapy may lead to resistance to the therapy. TKIs are very expensive and are covered under Part D insurance for Medicare patients. To the authors' knowledge, the impact of low-income subsidy status and cost sharing on adherence among this group has not been well studied in the literature.

METHODS

Surveillance, Epidemiology, and End Results (SEER) registry data linked with Medicare Part D data from the years 2007 through 2012 were used in the current study. The authors identified 836 patients with CML with Medicare Part D insurance coverage who were new TKI users. Treatment nonadherence was defined as a binary variable indicating the percentage of days covered was <80% during the 180-day period after the initiation of TKI therapy. Logistic regression was used to examine the relationship between out-of-pocket costs per 30-day drug supply, Medicare Part D plan characteristics, and treatment adherence while controlling for other patient characteristics.

RESULTS

Overall, 244 of the 836 patients with CML (29%) were nonadherent to targeted oral therapy during the 180 days after the initiation of treatment with TKIs. The multivariable logistic regression demonstrated that patients with heavily subsidized (odds ratio, 6.7; 95% confidence interval, 2.8-15.9) and moderately subsidized (odds ratio, 3.0; 95% confidence interval, 1.4-6.5) Medicare Part D plans were much more likely to demonstrate nonadherence compared with patients without a subsidy.

CONCLUSIONS

The current population-based study found a significantly higher rate of nonadherence among heavily subsidized patients with substantially lower out-of-pocket costs, which suggests that future research is needed to help lower the nonadherence rate among these individuals. Cancer 2018;124:364-73. © 2017 American Cancer Society.

Assessing disruptions in adherence to antidepressant treatments after breast cancer diagnosis

PURPOSE

Long-term treatment with antidepressants can lessen the symptoms of depression, but health-related crises-such as a cancer diagnosis-may disrupt ongoing depression care. The study aims to estimate the effect of receiving a breast cancer diagnosis on antidepressant adherence among women with depression.

METHODS

Using SEER-Medicare administrative claims, we identified women aged 65+ with newly diagnosed breast cancer between 2008 and 2011, who were diagnosed with depression and used antidepressants during the year before pre-diagnosis year. We compared antidepressant adherence among women with breast cancer to similar women without cancer using generalized estimation equations. Antidepressant adherence was estimated using the proportion of days covered 1 year before and after the index date.

RESULTS

We included 1142 women with breast cancer and pre-existing depression and 1142 matched non-cancer patients with pre-existing depression. Mean antidepressant adherence was similar for both groups in the year before and after the index date (all around 0.71); adherence decreased by approximately 0.01 following breast cancer diagnosis in cancer group, with similar reductions among non-cancer group (p = 0.19). However, substantial proportion of patients had inadequate adherence to antidepressants in the post-diagnosis period, and almost 40% of patients in each group discontinued antidepressants over the study period.

CONCLUSIONS

Antidepressant adherence was not associated with receiving a breast cancer diagnosis beyond what would have been expected in a similar cohort of women without cancer; however, adherence was poor among both groups. Ensuring adequate ongoing depression care is important to improve cancer care and patient quality of life in the long term. Copyright © 2017 John Wiley & Sons, Ltd.

Medicare Part D's Effects on Drug Utilization and Out-of-Pocket Costs: A Systematic Review

OBJECTIVE

To update a past systematic review on whether Medicare Part D changed drug utilization and out-of-pocket (OOP) costs overall and within subpopulations, and to identify evidence gaps.

DATA SOURCES/STUDY SETTING

Published and gray literature from 2010 to 2015 meeting prespecified screening criteria, including having a comparison group, and utilization or OOP cost outcomes.

STUDY DESIGN

We conducted a systematic literature review with a quality assessment.

DATA COLLECTION/EXTRACTION METHODS

For each study, we extracted information on study design, data sources, analytic methods, outcomes, and limitations. Because outcome measures vary across studies, we did a qualitative synthesis rather than meta-analysis.

PRINCIPAL FINDINGS

Sixty-five studies met screening criteria. Overall, Medicare Part D enrollees have increased drug utilization and decreased OOP costs, but coverage gaps limit the program's impact. Beneficiaries whose insurance becomes more generous after enrollment had disproportionately increased drug utilization and decreased OOP costs. Outcomes among dual-eligibles were mixed.

CONCLUSIONS

There is strong evidence on how Medicare Part D and the donut hole coverage gap affect utilization and OOP costs, but weak evidence on how effects vary among dual-eligibles or across diseases. Findings suggest that the Affordable Care Act's provisions to expand coverage and reduce the donut hole should improve patient outcomes.

Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors

At least 45% of patients with type 2 diabetes (T2D) fail to achieve adequate glycemic control (HbA1c <7%). One of the major contributing factors is poor medication adherence. Poor medication adherence in T2D is well documented to be very common and is associated with inadequate glycemic control; increased morbidity and mortality; and increased costs of outpatient care, emergency room visits, hospitalization, and managing complications of diabetes. Poor medication adherence is linked to key nonpatient factors (eg, lack of integrated care in many health care systems and clinical inertia among health care professionals), patient demographic factors (eg, young age, low education level, and low income level), critical patient beliefs about their medications (eg, perceived treatment inefficacy), and perceived patient burden regarding obtaining and taking their medications (eg, treatment complexity, out-of-pocket costs, and hypoglycemia). Specific barriers to medication adherence in T2D, especially those that are potentially modifiable, need to be more clearly identified; strategies that target poor adherence should focus on reducing medication burden and addressing negative medication beliefs of patients. Solutions to these problems would require behavioral innovations as well as new methods and modes of drug delivery.