Effects of health insurance on racial disparity in osteoporosis medication adherence

Natural history, reasons for, and impact of low/non-adherence to medications for osteoporosis in a cohort of community-dwelling older women already established on medication: a 2-year follow-up study

Approximately 15 % of older women on oral medications for osteoporosis could be considered for alternatives including parenteral therapies. Collection of data on socio-demographic/clinical variables is unlikely to be helpful in predicting low/non-adherence. Alternative approaches are needed to identify individuals at risk of low/non-adherence.

INTRODUCTION

This study aims to identify individual patient reasons for stopping medications for osteoporosis, and to investigate whether this can be predicted from knowledge about socio-demographic/clinical data, or whether alternative approaches need to be used.

METHODS

The Cohort for Skeletal Health in Bristol and Avon (COSHIBA) recruited 3200 older women from South West UK, of whom a proportion were on medications for osteoporosis at baseline. Information on self-reported adherence and reasons for low/non-adherence were collected at 6-monthly intervals over a 2-year period. Data was also collected on potential predictors of and impact of low/non-adherence.

RESULTS

Two hundred thirty-three of 3200 (7.3 %) women were on medications for osteoporosis at baseline. Mean length of time on treatment prior to enrolment was 46 months. Of those on osteoporosis medications, 94.9 % were on bisphosphonates; 8.5 % reported low adherence and 21.6 % stopped their medication completely over the 2-year follow-up period. Length of time on medication at baseline did not influence rates of low/non-adherence. Reasons for low/non-adherence to bisphosphonates included side effects (53.9 %), practical reasons such as forgetting to take them (18.0 %) and beliefs about medications (20.5 %). No convincing predictors of low/non-adherence were identified.

CONCLUSIONS

Approximately 15 % of older women on oral medications for osteoporosis could be considered for alternatives including parenteral therapies. This has important implications for healthcare provision. Collection of data on socio-demographic/clinical variables is unlikely to be helpful in predicting low/non-adherence. Alternative approaches are needed to identify individuals at risk of low/non-adherence to osteoporosis medications.

Racial differences in clinical treatment and self-care behaviors of adults with chronic heart failure

BACKGROUND

In the United States, the highest prevalence of heart failure (HF) is in blacks followed by whites. Compared with whites, blacks have a higher risk of HF-related morbidity and mortality and HF-related hospitalization. Little research has focused on explaining the reasons for these disparities. The purpose of this study was to examine racial differences in demographic and clinical characteristics in blacks and whites with HF and to determine if these characteristics influenced treatment, or together with treatment, influenced self-care behaviors.

METHODS AND RESULTS

This was a secondary analysis of existing data collected from adults (n=272) with chronic HF enrolled from outpatient sites in the northeastern United States and followed for 6 months. After adjusting for sociodemographic and clinical characteristics within reduced (HFrEF) and preserved ejection fraction (HFpEF) groups, there were 2 significant racial differences in clinical treatment. Blacks with HFrEF were prescribed ACE inhibitors and hydralazine and isosorbide dinitrate (H-ISDN) more often than whites. In the HFpEF group, blacks were taking more medications and were prescribed digoxin and a diuretic when symptomatic. Deficits in HF knowledge and decreased medication adherence, objectively measured, were more prominent in blacks. These racial differences were not explained by sociodemographic or clinical characteristics or clinical treatment variables. Premorbid intellect and the quality of support received contributed to clinical treatment and self-care.

CONCLUSION

Although few differences in clinical treatment could be attributed solely to race, knowledge about HF and medication adherence is lower in blacks than whites. Further research is needed to explain these observations, which may be targets for future intervention research.

Racial and health insurance disparities of inpatient spine augmentation for osteoporotic vertebral fractures from 2005 to 2010

BACKGROUND AND PURPOSE

Vertebroplasty and kyphoplasty are frequently utilized in the treatment of symptomatic vertebral body fractures. While prior studies have demonstrated disparities in the treatment of back pain and care for osteoporotic patients, disparities in spine augmentation have not been investigated. We investigated racial and health insurance status differences in the use of spine augmentation for the treatment of osteoporotic vertebral fractures in the United States.

MATERIALS AND METHODS

Using the Nationwide Inpatient Sample from 2005 to 2010, we selected all discharges with a primary diagnosis of vertebral fracture (International Classification of Diseases-9 code 733.13). Patients who received spine augmentation were identified by using International Classification of Diseases-9 procedure code 81.65 for vertebroplasty and 81.66 for kyphoplasty. Patients with a diagnosis of cancer were excluded. We compared usage rates of spine augmentation by race/ethnicity (white, black, Hispanic, and Asian/Pacific Islander) and insurance status (Medicare, Medicaid, self-pay, and private). Comparisons among groups were made by using χ(2) tests. A multivariate logistic regression analysis was fit to determine variables associated with spine augmentation use.

RESULTS

A total of 228,329 patients were included in this analysis, of whom 129,206 (56.6%) received spine augmentation. Among patients with spine augmentation, 97,022 (75%) received kyphoplasty and 32,184 (25%) received vertebroplasty; 57.5% (92,779/161,281) of white patients received spine augmentation compared with 38.7% (1405/3631) of black patients (P < .001). Hispanic patients had significantly lower spine augmentation rates compared with white patients (52.3%, 3777/7222, P < .001) as did Asian/Pacific Islander patients (53.1%, 1784/3361, P < .001). The spine augmentation usage rate was 57.2% (114,768/200,662) among patients with Medicare, significantly higher than that of those with Medicaid (43.9%, 1907/4341, P < .001) and those who self-pay (40.2%, 488/1214, P < .001).

CONCLUSIONS

Our findings demonstrate substantial racial and health insurance-based disparities in the inpatient use of spinal augmentation for the treatment of osteoporotic vertebral fracture.