Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis

Cancer History, Health Insurance Coverage, and Cost-Related Medication Nonadherence and Medication Cost-Coping Strategies in the United States

OBJECTIVES

To evaluate the relationship between cancer history and cost-related medication nonadherence (CRN) as well as cost-coping strategies, by health insurance coverage.

METHODS

We used the 2013 to 2016 National Health Interview Survey to identify adults aged 18 to 64 years with (n = 3599) and without (n = 56 909) a cancer history. Cost-related changes in medication use included (1) CRN, measured as skipping, taking less, or delaying medication because of cost, and (2) cost-coping strategies, measured as requesting lower cost medication or using alternative therapies to save money. Separate multivariable logistic regressions were used to calculate the adjusted odds ratios (AORs) of CRN and cost-coping strategies associated with cancer history, stratified by insurance.

RESULTS

Cancer survivors were more likely than adults without a cancer history to report CRN (AOR 1.26; 95% confidence interval [CI] 1.10-1.43) and cost-coping strategies (AOR 1.10; 95% CI 0.99-1.19). Among the privately insured, the difference in CRN by cancer history was the greatest among those enrolled in high-deductible health plans (HDHPs) without health savings accounts (HSAs) (AOR 1.78; 95% CI 1.30-2.44). Among adults with HDHP and HSA, cancer survivors were less likely to report cost-coping strategies (AOR 0.62; 95% CI 0.42-0.90). Regardless of cancer history, CRN and cost-coping strategies were the highest for those uninsured, enrolled in HDHP without HSA, and without prescription drug coverage under their health plan (all P<.001).

CONCLUSIONS

Cancer survivors are prone to CRN and more likely to use cost-coping strategies. Expanding options for health insurance coverage, use of HSAs for those with HDHP, and enhanced prescription drug coverage may effectively address CRN.

Treatment adherence as a mediator of blood pressure control in Chinese older adults with depression

OBJECTIVES

Both depression and hypertension (HTN) are prevalent, costly, and destructive, and frequently coexist among the aging population of China. This study aimed to examine the role that treatment adherence plays in blood pressure control in older adult Chinese with depression.

METHODS

Data for these analyses were taken from a randomized control trial of a collaborative depression care management intervention conducted in rural villages of Zhejiang Province, China with older adults who had comorbid depression and HTN. They included baseline assessments of 2362 subjects ages ≥60 years, whose blood pressure and depression were measured using a calibrated manual sphygmomanometer and the Chinese version of the 17-item Hamilton Depression Rating Scale (HDRS-17), respectively. Treatment adherence was identified by a single question asking whether patients on occasion did not take their medicine.

RESULTS

Uncontrolled HTN was associated with older age (t = 3.10, P<0.01), higher HDRS-17 score (t = 5.76, P<0.01), and higher rates of non-adherence to HTN treatment (χ2  = 21.34, P<0.01). Logistic regression models indicated that adherence accounted for 39.4% of the total effect between depression and HTN. Specifically, those with poor adherence were at 1.417 greater odds of having their HTN uncontrolled compared with those with good adherence.

CONCLUSIONS

Hypertension control in older adults with depression is complicated by nonadherence to treatment. In addition to diagnosing and treating depression in their older adult patients, primary care physicians can optimize blood pressure control by identifying and addressing their patients' adherence to recommendations for HTN management.

The Impact of Dual Health Care System Use for Obtaining Prescription Medications on Nonadherence in Veterans With Type 2 Diabetes

BACKGROUND

Dual health system use may provide increased access to physicians, medications, and other health care resources but may also increase the complexity and coordination of medication regimens. Thus, it is important to elucidate the impact of dual use on medication adherence.

OBJECTIVE

The objective of this study was to evaluate the impact on medication adherence for veterans with dual health care system use (VA and Medicare) when obtaining prescription antihyperglycemic medications to treat diabetes.

METHODS

This was a longitudinal cohort study using VA and Medicare data from 2006 to 2010. Medication adherence was estimated by calculating annualized drug class-level proportion of days covered (PDC), where PDC >80% was considered adherent. Generalized linear models were used for estimations, accounting for correlation over time.

RESULTS

In total, 254 267 veterans with diabetes were included, with 71 057 (27.9%) defined as pharmacy system dual users. Mean age was 77.5 years, and nearly all had multiple comorbidities (mean count 10.2). During follow-up, 75% of VA-only users were deemed adherent to diabetes prescriptions, compared with 63% of dual users. In adjusted models, dual prescription benefit use from VA/Medicare was associated with 39% lower odds of medication adherence (odds ratio [OR] = 0.61; 95% CI = 0.60-0.61). Medication adherence significantly worsened with each additional diabetes medication (OR = 0.65; 95% CI = 0.64-0.65) and significantly decreased over time (OR = 0.95 per year; 95% CI = 0.95-0.96). Conclusion and Relevance: These data suggest that veterans utilizing VA and Medicare to obtain diabetes prescriptions are significantly less likely to be adherent.

Senior PharmAssist: Less Hospital Use with Enrollment in an Innovative Community-Based Program

OBJECTIVES

To evaluate changes in acute health services use of Senior PharmAssist participants.

DESIGN

Retrospective analysis.

SETTING

Community-based, nonprofit program in Durham County, North Carolina.

PARTICIPANTS

Adults aged 60 and older with income of 200% of the federal poverty level or less who enrolled in the Senior PharmAssist program (N = 191) between August 1, 2011, and March 15, 2017.

INTERVENTION

Medication therapy management (MTM), customized community referrals, Medicare insurance counseling, and medication copayment assistance provided by Senior PharmAssist.

MEASUREMENTS

Primary outcomes were self-reported emergency department (ED) visits and hospital admissions in the previous year, assessed at baseline and every 6 months for up to 2 years.

RESULTS

Mean number of ED visits declined over time (0.83 visits per year at baseline to 0.53 visits per year at 24 months, P = .002), as did the percentage of participants reporting an ED visit in the past year (49% at baseline to 31% at 24 months, P = .003). Mean hospital admissions also decreased (0.56 admissions per year at baseline to 0.4 admissions per year at 24 months, P = .02). There was no significant change in percentage of participants reporting a hospital admission in the past year (33% at baseline to 25% at 24 months, P = .23).

CONCLUSION

Older adults who enrolled in a community-based program that helps them manage medications, connect with community resources, and overcome barriers to medication access experienced reductions in acute health services use. J Am Geriatr Soc 66:2394-2400, 2018.

Association of a Negative Wealth Shock With All-Cause Mortality in Middle-aged and Older Adults in the United States

Importance

A sudden loss of wealth-a negative wealth shock-may lead to a significant mental health toll and also leave fewer monetary resources for health-related expenses. With limited years remaining to regain lost wealth in older age, the health consequences of these negative wealth shocks may be long-lasting.

Objective

To determine whether a negative wealth shock was associated with all-cause mortality during 20 years of follow-up.

Design, Setting, and Participants

The Health and Retirement Study, a nationally representative prospective cohort study of US adults aged 51 through 61 years at study entry. The study population included 8714 adults, first assessed for a negative wealth shock in 1994 and followed biennially through 2014 (the most recent year of available data).

Exposures

Experiencing a negative wealth shock, defined as a loss of 75% or more of total net worth over a 2-year period, or asset poverty, defined as 0 or negative total net worth at study entry.

Main Outcomes and Measures

Mortality data were collected from the National Death Index and postmortem interviews with family members. Marginal structural survival methods were used to account for the potential bias due to changes in health status that may both trigger negative wealth shocks and act as the mechanism through which negative wealth shocks lead to increased mortality.

Results

There were 8714 participants in the study sample (mean [SD] age at study entry, 55 [3.2] years; 53% women), 2430 experienced a negative wealth shock during follow-up, 749 had asset poverty at baseline, and 5535 had continuously positive wealth without shock. A total of 2823 deaths occurred during 80 683 person-years of follow-up. There were 30.6 vs 64.9 deaths per 1000 person-years for those with continuously positive wealth vs negative wealth shock (adjusted hazard ratio [HR], 1.50; 95% CI, 1.36-1.67). There were 73.4 deaths per 1000 person-years for those with asset poverty at baseline (adjusted HR, 1.67; 95% CI, 1.44-1.94; compared with continuously positive wealth).

Conclusions and Relevance

Among US adults aged 51 years and older, loss of wealth over 2 years was associated with an increased risk of all-cause mortality. Further research is needed to better understand the possible mechanisms for this association and determine whether there is potential value for targeted interventions.

Financial strain is associated with medication nonadherence and worse self-rated health among cardiovascular patients

Non-traditional indicators of socioeconomic status (SES; e.g., home ownership) may be just as or even more predictive of health outcomes as traditional indicators of SES (e.g., income). This study tested whether financial strain (i.e., difficulty paying monthly bills) predicted medication non-adherence and worse self-rated health. Research assistants administered surveys to 1,527 patients with acute coronary syndromes or acute decom-pensated heart failure. In adjusted models, having a higher income was associated with being more adherent (p &lt; .001), but was non-significant when adjusted for financial strain. Education, income, less financial strain, and being employed were each associated with better self-rated health (p &lt; .001). Financial strain was associated with less adherence (β =-.17, p &lt; .001) and worse self-rated health (β = -.23, p &lt; .001), and mediated the effect of income on adherence (coeff = .078 [BCa 95% CI: .051 to .108]). Future research should further explore the nuanced link between SES and health behaviors and outcomes.

Analysis of hospitalization expenditures and influencing factors for inpatients with coronary heart disease in a tier-3 hospital in Xi'an, China: A retrospective study

BACKGROUND

The medical costs for inpatients with coronary heart disease (CHD) have risen to unprecedented levels, putting tremendous financial pressure on their families and the entire society. The objective of this study was to examine the actual direct medical costs of inpatients with CHD and to analyze the influencing factors of those costs, to provide advice on the prevention and control of high medical costs of patients with CHD.

METHODS

A retrospective descriptive analysis of hospitalization expenditures data examined 10,301 inpatients with coronary heart disease of a tier-3 hospital in Xi'an from January 1, 2015 to December 31, 2015. The data included demographic information, the average length of stay, and different types of expenses incurred during the hospitalization period. The difference between different groups was analyzed using a univariate analysis, and the influencing factors of hospitalization expenditures were explored by the multiple linear stepwise regression analysis.

RESULTS

The average age of these patients was 60.0 years old, the average length of stay was 4.0 days, and the majority were males (7172, 69.6%). The average hospitalization expenses were $6791.38 (3294.16-9, 732.59), and the top 3 expenses were medical consumables, operation fees, and drugs. The influencing factors of hospitalization expenditures included the length of stay, the number of times of admission, the type of medical insurance schemes, whether have a surgery or not, the gender, the age, and the marriage status.

CONCLUSION

The inpatients with CHD in this tier-3 hospital were mostly over 45 years old. The average medical cost of males was much higher than that of females. Our findings suggest that the solution for tremendous hospitalization expenditures should be that more attention is paid to controlling the high expense of medical consumables and that the traditional method of reducing medical expenses by shortening the length of stay is still important in nowadays. Furthermore, the type of medical insurance schemes has different impacts on medical expenses. Reducing or controlling high hospitalization expenditures is a complicated process that needs multifaceted cooperation.

Understanding the patient experience of cost-related non-adherence to prescription medications through typology development and application

Many patients report skipping doses, splitting pills, or not filling prescriptions due to out-of-pocket costs-a phenomenon known as cost-related non-adherence (CRNA). This study investigated CRNA from the patient's perspective, and, to our knowledge, is the first study to undertake a qualitative investigation of CRNA specifically. We report the results from 35 semi-structured interviews conducted in 2014-15 with adults in four Canadian cities across two provinces. We used framework analysis to develop a CRNA typology to characterize major factors in patients' CRNA decisions. Our typology identifies four major components: (1) the insurance reason driving the drug cost, (2) the individual's overall financial flexibility, (3) the burden of drug cost on the individual's budget, and (4) the importance of the drug from the individual's perspective. The first two components set the context for CRNA and the final two components are the drivers for the CRNA decision. We also found four major patterns in CRNA experiences: (1) CRNA in individuals with low financial flexibility occurred for all levels of drug importance and all but the lowest level of cost burden; (2) CRNA for high importance drugs only occurred when the drug cost had a high burden on an individual's budget; (3) CRNA in individuals with more financial flexibility primarily occurred in drugs with medium importance but high or very high cost burdens; and (4) CRNA for low importance drugs occurred at almost all levels of drug cost burden. Our study furthers the understanding of how numerous factors such as income, insurance, and individual preferences combine and interact to influence CRNA and suggests that policy interventions must be multi-faceted or encourage significant insurance redesign to reduce CRNA.

Solutions to Address Diabetes-Related Financial Burden and Cost-Related Nonadherence: Results From a Pilot Study

BACKGROUND

Cost-related nonadherence (CRN) to recommended self-management behaviors among adults with chronic conditions such as diabetes is prevalent. Few behavioral interventions to mitigate CRN have been tested and evaluated.

AIMS

We developed a financial burden resource tool and examined its acceptability and the preliminary effects on patient-centered outcomes among adults with diabetes or prediabetes seen in a clinical setting.

METHOD

We report a pre-post one-group design pilot study. From an endocrinology clinic, we recruited 104 adults with diabetes who reported financial burdens with their diabetes management or engaged in CRN behaviors. We offered participants the financial burden resource tool we developed, which provided tailored, low-cost resource options for diabetes management and other social needs. Acceptability and self-reported outcomes were assessed 2 months after use of the tool.

RESULTS

Mean age of participants was 50.5 years ( SD = 15.3). Participants found the tool highly acceptable across 15 indicators (e.g., 93% "learned a lot," 98% "topics relevant" 95% "applicable to their lives," 98% "liked the information"). Significant improvements between baseline and 2-month follow-up were observed for discussion of cost concerns with nurses (19% to 29%, p < .05) and pharmacists (13% to 25.5%, p < .01), not skipping doses of medicines due to cost (11% to 4%, p < .03), and financial management (33.83 to 39.62, p < .007). There were no significant changes in perception of financial burden.

CONCLUSION

A financial burden resource tool is highly acceptable to patients, is easy to administer, and can prompt behavior change. This pilot study supports the need for well-powered trials with longer follow-up to further evaluate the effectiveness of such tools in improving CRN and key outcomes.

Association between copayment, medication adherence and outcomes in the management of patients with diabetes and heart failure

OBJECTIVE

To determine the association between copayment, medication adherence and outcomes in patients with Heart failure (HF) and Diabetes Mellitus (DM).

METHODS

PubMed, Scopus and Cochrane databases were searched using combinations of four sets of key words for: drug cost sharing; resource use, health and economic outcomes; medication adherence; and chronic disease.

RESULTS

Thirty eight studies were included in the review. Concerning the direct effect of copayment changes on outcomes, the scarcity and diversity of data, does not allow us to reach a clear conclusion, although there is some evidence indicating that higher copayments may result in poorer health and economic outcomes. Seven and one studies evaluating the relationship between copayment and medication adherence in DM and HF population, respectively, demonstrated an inverse statistically significant association. All studies (29) examining the relationship between medication adherence and outcomes, revealed that increased adherence is associated with health benefits in both DM and HF patients. Finally, the majority of studies in both populations, showed that medication adherence was related to lower resource utilization which in turn may lead to lower total healthcare cost.

CONCLUSION

The results of our systematic review imply that lower copayments may result in higher medication adherence, which in turn may lead to better health outcomes and lower total healthcare expenses. Future studies are recommended to reinforce these findings.

Should co-payments for financially deprived patients be lowered? Primary care physicians' perspectives using a mixed-methods approach in a survey study in Tokyo

BACKGROUND

Japan's stagnant economy has produced increasing income disparities, and the effect of poverty on health and health-care utilization is a significant issue. Co-payments could be a trade-off for patients when seeking medical care and limit health-care utilization. We sought primary care physicians' experiences in dealing with financially deprived patients and their perspectives about reducing co-payments by low-income patients.

METHODS

We used a convergent mixed-methods approach in a mail survey; it was distributed to 1989 primary care physicians practicing in areas with the highest proportions of socially disadvantaged individuals in Tokyo. The survey items included an open-ended question, seeking the participants' perspectives about reducing co-payments by low-income patients from the current 30%, and closed questions, asking their experience of patient behavior related to financial burdens during the previous 6 months.

RESULTS

We analyzed the responses of 365 physicians. Sixty-two percent of the primary care physicians agreed with lowering co-payments for financially deprived patients; however, the remainder disagreed or were uncertain. Those who disagreed were less likely to have experienced patient behavior related to financial burdens. The participants suggested challenges and potential measures for reducing co-payments by low-income patients in light of tight governmental financial resources and rapidly increasing health-care expenditures in Japan. The physicians were also concerned about the moral hazard in health-care utilization among patients receiving social welfare who obtain care at no cost.

CONCLUSIONS

From their experience in having dealt with low-income patients, the majority of physicians were positive about lowering co-payments by such patients; the remainder were negative or uncertain. It may be necessary to raise awareness of patients' socioeconomic status among primary care physicians as a possible deterrent for seeking care. To maintain health-care equity, policy makers should consider balancing co-payments among individuals with differing financial levels and health-care needs.

Geriatric Care Issues: An American and an International Perspective

As the global population ages, there is an opportunity to benefit from the increased longevity of a healthy older adult population. Healthy older individuals often contribute financially to younger generations by offering financial assistance, paying more in taxes than benefits received, and providing unpaid childcare and voluntary work. Governments must address the challenges of income insecurity, access to health care, social isolation, and neglect that currently face elderly adults in many countries. A reduction in disparities in these areas can lead to better health outcomes and allow societies to benefit from longer, healthier lives of their citizens.

Designing and Testing an End-of-Life Discussion Intervention for African American Patients With Heart Failure and Their Families

There is an escalating prevalence of heart failure (HF) with high mortality. Compared with other races, African Americans face a higher incidence of HF at earlier age of onset, with more rapid progression, and with increased family care burden and greater care costs and disparity in health care services at the end of life (EOL). Concomitant out-of-pocket HF costs and care demands indicate the need for early discussion of palliative and EOL care needs. We therefore developed and pilot tested a culturally sensitive intervention specific to the needs of African American HF patients and their families at the EOL. Our pilot study findings encompass patient and caregiver perspectives and align with the state of EOL science. The ultimate long-term goal of this intervention strategy is to translate into practice the preferred, culturally sensitive, and most cost-efficient EOL care recommendations for HF patients and families.

Impact of prescription charges on people living in poverty: A qualitative study

BACKGROUND

Prescription charges or copayments have been shown to reduce consumption of medicines. For people living in poverty, prescription charges can prevent them from getting the medicines they need, and this can result in poorer health status. Prescription charges are low in New Zealand compared to many other countries, but those living in poverty are not exempt from fees.

OBJECTIVES

The aim of this study was to explore the lived experience of people who struggle to pay prescription charges and to propose a model for how being unable to afford prescription charges might affect health.

METHODS

Participants were recruited through organizations that provide services entirely or predominantly to low income persons. Semi-structured interviews were carried out with 29 people who had been identified as having problems paying for prescriptions. Approximately half of the sample population was Māori (indigenous New Zealanders). Ethical approval was obtained from the University of Otago.

RESULTS

Participants reported having to make difficult decisions when picking up their prescription medicines. These included choosing some medicines and leaving others, such as choosing medicines for mental health rather than physical health; cutting food consumption or eating less healthy food so as to pay for medicines; or picking up medicines for children while leaving those for adults. Participants also reported strategies like reducing doses to make prescriptions last longer; and delaying picking up medicines. These led to sub-optimal dosing or interrupted treatment.

CONCLUSIONS

Even low financial barriers can have a significant impact on low income people's access to medicines and reduce the effectiveness of treatment. Not being able to afford prescription medicines may impact negatively on people's health directly by preventing access to medicines, through reducing expenditure on other items need for health, and by potentiating stigma.

Recent trends in the probability of high out-of-pocket medical expenses in the United States

OBJECTIVE

This article measures the probability that out-of-pocket expenses in the United States exceed a threshold share of income. It calculates this probability separately by individuals' health condition, income, and elderly status and estimates changes occurring in these probabilities between 2010 and 2013.

DATA AND METHOD

This article uses nationally representative household survey data on 344,000 individuals. Logistic regressions estimate the probabilities that out-of-pocket expenses exceed 5% and alternatively 10% of income in the two study years. These probabilities are calculated for individuals based on their income, health status, and elderly status.

RESULTS

Despite favorable changes in both health policy and the economy, large numbers of Americans continue to be exposed to high out-of-pocket expenditures. For instance, the results indicate that in 2013 over a quarter of nonelderly low-income citizens in poor health spent 10% or more of their income on out-of-pocket expenses, and over 40% of this group spent more than 5%. Moreover, for Americans as a whole, the probability of spending in excess of 5% of income on out-of-pocket costs increased by 1.4 percentage points between 2010 and 2013, with the largest increases occurring among low-income Americans; the probability of Americans spending more than 10% of income grew from 9.3% to 9.6%, with the largest increases also occurring among the poor.

CONCLUSION

The magnitude of out-of-pocket's financial burden and the most recent upward trends in it underscore a need to develop good measures of the degree to which health care policy exposes individuals to financial risk, and to closely monitor the Affordable Care Act's success in reducing Americans' exposure to large medical bills.

High Out-of-Pocket Medical Spending among the Poor and Elderly in Nine Developed Countries

OBJECTIVE

The design of health insurance, and the role out-of-pocket (OOP) payments play in it, is a key policy issue as rising health costs have encouraged greater cost-sharing measures. This paper compares the percentage of Americans spending large amounts OOP to meet their health needs with percentages in eight other developed countries. By disaggregating by age and income, the paper focuses on the poor and elderly populations within each.

DATA SOURCE

The study uses nationally representative household survey data made available through the Luxembourg Income Study. It includes nations with high, medium, and low levels of OOP spending.

STUDY DESIGN

Households have high medical spending when their OOP expenditures exceed a threshold share of income. I calculate the share of each nation's population, as well as subpopulations within it, with high OOP expenditures.

PRINCIPAL FINDINGS

The United States is not alone in exposing large numbers of citizens to high OOP expenses. In six of the other eight countries, one-quarter or more of low-income citizens devoted at least 5 percent of their income to OOP expenses, and in all but two countries, more than 1 in 10 elderly citizens had high medical expenses.

CONCLUSIONS

For some populations in the sample nations, health insurance does not provide adequate financial protection and likely contributes to inequities in health care delivery and outcomes.

Clinical and demographic correlates of medication and visit adherence in a large randomized controlled trial

BACKGROUND

Patient characteristics are associated with adherence, which has implications for planning clinical research or designing payment systems that reward superior outcomes. It is unclear to what extent clinician efforts to improve adherence can attenuate these associations.

METHODS

To identify factors predicting visit and medication adherence in settings designed to optimize adherence, we did a retrospective analysis of participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). ALLHAT recruited participants at 632 sites in North America, Puerto Rico, and the U.S. Virgin Islands for random assignment to antihypertensive treatment with amlodipine, chlorthalidone, or lisinopril. Site investigators reported clinic characteristics at the time they applied to participate in the study and research coordinators used standardized methods to measure patient characteristics. We defined adequate visit adherence as attending at least 80 % of scheduled visits; adequate medication adherence was defined as taking 80 % or more of the randomly assigned medication at all study visits.

RESULTS

The 31,250 ALLHAT participants eligible for the visit adherence analysis attended 78.5 % of scheduled study visits; 68.9 % attended more than 80 % of scheduled visits. Clinic setting was predictive of both forms of adherence; adherence was worst at private clinics; clinics that enrolled more study participants had superior adherence. Adjusting for clinic characteristics and clinical factors, women, younger participants, Blacks and smokers were less likely to have adequate visit adherence. Among the 28,967 participants eligible for the medication adherence analysis, 21,261 (73.4 %) reported adequate medication adherence. In adjusted analyses, younger and less educated participants, Blacks, and smokers were less likely to report adequate adherence.

CONCLUSIONS

Participant demographics were associated with adherence despite strenuous efforts to optimize adherence. Our results could inform decisions by researchers planning trials and policymakers designing payment systems.

TRIAL REGISTRATION

NCT00000542 . Registered 27 October 1999.

Socioeconomic inequalities in access to treatment for coronary heart disease: A systematic review

Strong socioeconomic inequalities exist in cardiovascular mortality and morbidity. The current review aims to synthesize the current evidence on the association between socioeconomic status (SES) and access to treatment of coronary heart disease (CHD). We examined quantitative studies analyzing the relationship between SES and access to CHD treatment that were published between 1996 and 2015. Our data sources included Medline and Web of Science. Our search yielded a total of 2066 records, 57 of which met our inclusion criteria. Low SES was found to be associated with low access to coronary procedures and secondary prevention. Access to coronary procedures, especially coronary angiography, was mainly related to SES to the disadvantage of patients with low SES. However, access to drug treatment and cardiac rehabilitation was only associated with SES in about half of the studies. The association between SES and access to treatment for CHD was stronger when SES was measured based on individual-level compared to area level, and stronger for individuals living in countries without universal health coverage. Socioeconomic inequalities exist in access to CHD treatment, and universal health coverage shows only a minor effect on this relationship. Inequalities diminish along the treatment pathway for CHD from diagnostic procedures to secondary prevention. We therefore conclude that CHD might be underdiagnosed in patients with low SES. Our results indicate that there is an urgent need to improve access to CHD treatment, especially by increasing the supply of diagnostic angiographies, to reduce inequalities across different healthcare systems.

Age-Dependent Impact of Medication Underuse and Strategies for Improvement

Background: Medication underuse is common in aging populations and, because of the growing risk for competing deaths, the benefit of preventive medicines gradually vanishes with advancing age, thus limiting their success. Objective: To estimate the optimum time of initiation of the secondary prevention of cardiovascular events, we examined the impact of appropriate pharmacotherapy for different starting ages at which it is implemented. Methods: In the competing risk framework, we obtained the population's life course from life tables, combined it with effect estimates quantifying the real-world effectiveness of secondary prevention, and compared the outcome of patients not receiving appropriate treatment (underuse) with those receiving preventive medicines that have demonstrated a reduction in the transition to serious cardiovascular events (START criteria). Starting at the age of 55 years, the population proportions of the distinct states of the framework were calculated for each year of chronological age in subgroups of appropriate treatment and underuse. These proportions were used over a follow-up period to estimate measures of treatment effectiveness and risks of underuse. Results: Despite increasing relative effectiveness with advancing age, benefits measured by patient-relevant endpoints, such as life years gained (LYG) or gained quality-adjusted life years (QALYs), markedly dropped after the starting age of 75 years, but even at an initiation age of 85 years, QALYs gained exceeded 1 year. Conclusion: Interventions targeting medication underuse may achieve considerable benefits at any stage of later life, while the benefit is probably largest if appropriate treatment is started before 75 years.

The financial burden of out-of-pocket expenses in the United States and Canada: How different is the United States?

BACKGROUND

This article compares the burden that medical cost-sharing requirements place on households in the United States and Canada. It estimates the probability that individuals with similar demographic features in the two countries have large medical expenses relative to income.

METHOD

The study uses 2010 nationally representative household survey data harmonized for cross-national comparisons to identify individuals with high medical expenses relative to income. Using logistic regression, it estimates the probability of high expenses occurring among 10 different demographic groups in the two countries.

RESULTS

The results show the risk of large medical expenses in the United States is 1.5-4 times higher than it is in Canada, depending on the demographic group and spending threshold used. The United States compares least favorably when evaluating poorer citizens and when using a higher spending threshold.

CONCLUSION

Recent health care reforms can be expected to reduce Americans' catastrophic health expenses, but it will take very large reductions in out-of-pocket expenditures-larger than can be expected-if poorer and middle-class families are to have the financial protection from high health care costs that their counterparts in Canada have.

The Australasian Hepatology Association consensus guidelines for the provision of adherence support to patients with hepatitis C on direct acting antivirals

BACKGROUND

Hepatitis C is a blood-borne virus primarily spread through sharing of drug-injecting equipment. Approximately 150 million people worldwide and 230,000 Australians are living with chronic hepatitis C infection. In March 2016, the Australian government began subsidizing direct acting antivirals (DAAs) for the treatment of hepatitis C, which are highly effective (95% cure rate) and have few side effects. However, there is limited evidence to inform the provision of adherence support to people with hepatitis C on DAAs including the level of medication adherence required to achieve a cure.

METHODOLOGY

In February 2016, a steering committee comprising four authors convened an expert panel consisting of six hepatology nurses, a hepatologist, a pharmacist, a consumer with hepatitis C and treatment experience, and a consumer advocate. The expert panel focused on the following criteria: barriers and enablers to DAA adherence; assessment and monitoring of DAA adherence; components of a patient-centered approach to DAA adherence; patients that may require additional adherence support; and interventions to support DAA adherence. The resultant guidelines underwent three rounds of consultation with the expert panel, Australasian Hepatology Association (AHA) members (n=12), and key stakeholders (n=7) in June 2016. Feedback was considered by the steering committee and incorporated if consensus was achieved.

RESULTS

Twenty-four guidelines emerged from the evidence synthesis and expert panel discussion. The guidelines focus on the pretreatment assessment and education, assessment of treatment readiness, and monitoring of medication adherence. The guidelines are embedded in a patient-centered approach which highlights that all patients are at risk of nonadherence. The guidelines recommend implementing interventions focused on identifying patients' memory triggers and hooks; use of nonconfrontational and nonjudgmental language by health professionals; and objectively monitoring adherence.

CONCLUSION

These are the first guidelines to support patients and health professionals in the delivery of clinical care by identifying practical adherence support interventions for patients taking DAAs.

Facing Financial Hardship: Patients' Views on Clinical Trade-offs in Exchange for Cost Savings

As more patients enroll in health insurance with high out-of-pocket costs, provider-patient cost discussions are of growing importance. Little is known about how patients want providers to engage in cost conversations. We surveyed 842 chronically ill adults seeking financial help to examine preferences around treatment trade-offs in 3 areas-convenience, side effects, and efficacy and whether preferences changed with different savings. To save money, half of patients were willing to endure inconvenience (increased dosing), with no difference by magnitude of savings ($50 vs $150 per month). Few participants were willing to tolerate side effects or reduced efficacy.

Is cost-related non-collection of prescriptions associated with a reduction in health? Findings from a large-scale longitudinal study of New Zealand adults

OBJECTIVE

To investigate whether cost-related non-collection of prescription medication is associated with a decline in health.

SETTINGS

New Zealand Survey of Family, Income and Employment (SoFIE)-Health.

PARTICIPANTS

Data from 17 363 participants with at least two observations in three waves (2004-2005, 2006-2007, 2008-2009) of a panel study were analysed using fixed effects regression modelling.

PRIMARY OUTCOME MEASURES

Self-rated health (SRH), physical health (PCS) and mental health scores (MCS) were the health measures used in this study.

RESULTS

After adjusting for time-varying confounders, non-collection of prescription items was associated with a 0.11 (95% CI 0.07 to 0.15) unit worsening in SRH, a 1.00 (95% CI 0.61 to 1.40) unit decline in PCS and a 1.69 (95% CI 1.19 to 2.18) unit decline in MCS. The interaction of the main exposure with gender was significant for SRH and MCS. Non-collection of prescription items was associated with a decline in SRH of 0.18 (95% CI 0.11 to 0.25) units for males and 0.08 (95% CI 0.03 to 0.13) units for females, and a decrease in MCS of 2.55 (95% CI 1.67 to 3.42) and 1.29 (95% CI 0.70 to 1.89) units for males and females, respectively. The interaction of the main exposure with age was significant for SRH. For respondents aged 15-24 and 25-64 years, non-collection of prescription items was associated with a decline in SRH of 0.12 (95% CI 0.03 to 0.21) and 0.12 (95% CI 0.07 to 0.17) units, respectively, but for respondents aged 65 years and over, non-collection of prescription items had no significant effect on SRH.

CONCLUSION

Our results show that those who do not collect prescription medications because of cost have an increased risk of a subsequent decline in health.

Impacts of intensive follow-up on the long-term prognosis of percutaneous coronary intervention in acute coronary syndrome patients - a single center prospective randomized controlled study in a Chinese population

OBJECTIVES

To investigate the impact of cardiologist-coordinated intensive follow-up on the long-term prognosis of percutaneous coronary intervention in Chinese patients.

METHODS

We recruited 964 patients who had acute coronary syndrome and underwent successful percutaneous coronary intervention in the First Hospital Affiliated to Henan University of Science and Technology, China. Participants were randomly assigned into the intensive follow-up (n = 479) and usual follow-up group (control group, n = 485). They received secondary prevention education during hospitalization and telephone follow-ups after discharge. The control group received telephone calls from nurses, while the intensive follow-up group received telephone calls and medical consultations from cardiologists. Both groups were followed up for 36 months.

RESULTS

(1) At 36 months, the proportions of all-cause death, cardiac death and cumulative major adverse cardiovascular events (MACEs) were 5.3%, 4.4% and 18.6% in the intensive follow-up group. These events were significantly lower than in the control group (10.1%, 9.3 % and 28.8% (p = 0.004, p = 0.003 and p < 0.001). (2) Multivariable Cox regression analysis identified intensive follow-up as an independent predictor of survival, cardiac death-free survival and MACE-free survival. (hazard ratio (HR) = 0.487, 95% confidence interval (CI) 0.298-0.797, p = 0.004; HR = 0.466, 95% CI 0.274-0.793, p = 0.005; HR = 0.614, 95% CI 0.464-0.811, p = 0.001). Kaplan-Meier analysis revealed that patients in the intensive follow-up groups had longer survival (log rank = 8.565, p = 0.003), cardiac death-free survival (log rank = 8.769, p = 0.003) and MACE-free survival (log rank = 15.928, p < 0.001). (3) The average medical cost was significantly less in the intensive follow-up group, especially the cost for re-hospitalization (US$582.74 ± 1753.20 vs. US$999.32 ± 2434.57, p = 0.003). The bleeding events were similar. (4) Patients in the intensive follow-up group had significantly better controls of cardiovascular risk factors and medication adherence.

CONCLUSIONS

A cardiologist-coordinated intensive follow-up program markedly decreased cardiovascular risk factors, reduced medical costs, promoted medication adherence and improved the long-term prognosis of patients after percutaneous coronary intervention in the Chinese population.

Physician-patient communication on cost and affordability in asthma care. Who wants to talk about it and who is actually doing it

RATIONALE

Patient perceptions of financial burden and rates of cost-related nonadherence are high among individuals with asthma across the socioeconomic spectrum. Little is known about preferences and frequency of physician-patient discussions about cost/affordability among individuals managing respiratory conditions.

OBJECTIVES

To examine who has a preference to discuss the cost of their asthma care with their physician, how often physician-patient communication about cost/affordability actually is occurring, and what clinical and demographic characteristics of patients are predictive of communication.

METHODS

Data came from 422 African American adult women with asthma who were asked about communication preferences and practices around cost and affordability with their physician. Data were analyzed using descriptive statistics and multiple variable logistic regression models.

MEASUREMENTS AND MAIN RESULTS

Fifty-two percent (n = 219) of this sample perceived financial burden. Seventy-two percent (n = 300) reported a preference to discuss cost with their health-care provider. Thirty-nine percent (n = 163) reported actually having a conversation with their physician about cost. Among the 61% who reported no discussion, 40% (n = 103) reported financial burden, and 55% (n = 140) reported a preference for discussion. Lower household income (P < 0.001), perception of financial burden (P < 0.001), and higher out-of-pocket expenses for medicines (P < 0.05) were significantly predictive of greater preference to communicate about cost/affordability with the doctor when adjusted for clinical and demographic characteristics. Perception of financial burden (P < 0.001), preference to discuss affordability (P < 0.001), and greater number of chronic conditions (P < 0.001) were significantly predictive of greater likelihood of communication about cost/affordability with the doctor when adjusted for clinical and demographic characteristics. Bivariate analyses revealed that patients who reported a discussion of cost were more likely to report worse asthma control and lower asthma-related quality of life.

CONCLUSIONS

An imbalance is evident between patients who would like to discuss cost with their doctor and those who actually do. Patients are interested in low-cost options and a venue for addressing their concerns with a care provider; therefore, a greater understanding is needed in how to effectively and efficiently integrate these conversations and viable solutions into the delivery of health care. Additional research is necessary to determine whether communication about the cost of therapy is associated with health outcomes.

Financial Strain and Medication Adherence among Diabetes Patients in an Integrated Health Care Delivery System: The Diabetes Study of Northern California (DISTANCE)

OBJECTIVE

To examine self-reported financial strain in relation to pharmacy utilization adherence data.

DATA SOURCES/STUDY SETTING

Survey, administrative, and electronic medical data from Kaiser Permanente Northern California.

STUDY DESIGN

Retrospective cohort design (2006, n = 7,773).

DATA COLLECTION/EXTRACTION METHODS

We compared survey self-reports of general and medication-specific financial strain to three adherence outcomes from pharmacy records, specifying adjusted generalized linear regression models.

PRINCIPAL FINDINGS

Eight percent and 9 percent reported general and medication-specific financial strain. In adjusted models, general strain was significantly associated with primary nonadherence (RR = 1.37; 95 percent CI: 1.04-1.81) and refilling late (RR = 1.34; 95 percent CI: 1.07-1.66); and medication-specific strain was associated with primary nonadherence (RR = 1.42, 95 percent CI: 1.09-1.84).

CONCLUSIONS

Simple, minimally intrusive questions could be used to identify patients at risk of poor adherence due to financial barriers.

Design, implementation, and first-year outcomes of a value-based drug formulary

BACKGROUND

Value-based insurance design attempts to align drug copayment tier with value rather than cost. Previous implementations of value-based insurance design have lowered copayments for drugs indicated for select "high value" conditions and have found modest improvements in medication adherence. However, these implementations have generally not resulted in cost savings to the health plan, suggesting a need for increased copayments for "low value" drugs. Further, previous implementations have assigned equal copayment reductions to all drugs within a therapeutic area without assessing the value of individual drugs. Aligning the individual drug's copayment to its specific value may yield greater clinical and economic benefits. In 2010, Premera Blue Cross, a large not-for-profit health plan in the Pacific Northwest, implemented a value-based drug formulary (VBF) that explicitly uses cost-effectiveness analyses after safety and efficacy reviews to estimate the value of each individual drug. Concurrently, Premera increased copayments for existing tiers.

OBJECTIVE

To describe and evaluate the design, implementation, and first-year outcomes of the VBF.

METHODS

We compared observed pharmacy cost per member per month in the year following the VBF implementation with 2 comparator groups: (1) observed pharmacy costs in the year prior to implementation, and (2) expected costs if no changes were made to the pharmacy benefits. Expected costs were generated by applying autoregressive integrated moving averages to pharmacy costs over the previous 36 months. We used an interrupted time series analysis to assess drug use and adherence among individuals with diabetes, hypertension, or dyslipidemia compared with a group of members in plans that did not implement a VBF. 

RESULTS

Pharmacy costs decreased by 3% compared with the 12 months prior and 11% compared with expected costs. There was no significant decline in medication use or adherence to treatments for patients with diabetes, hypertension, or dyslipidemia.

CONCLUSIONS

The VBF and copayment changes enabled pharmacy plan cost savings without negatively affecting utilization in key disease states.

Material need support interventions for diabetes prevention and control: a systematic review

Unmet material needs, such as food insecurity and housing instability, are associated with increased risk of diabetes and worse outcomes among diabetes patients. Healthcare delivery organizations are increasingly held accountable for health outcomes that may be related to these "social determinants," which are outside the scope of traditional medical intervention. This review summarizes the current literature regarding interventions that provide material support for income, food, housing, and other basic needs. In addition, we propose a conceptual model of the relationship between unmet needs and diabetes outcomes and provide recommendations for future interventional research.

Material need insecurities, control of diabetes mellitus, and use of health care resources: results of the Measuring Economic Insecurity in Diabetes study

IMPORTANCE

Increasing access to care may be insufficient to improve the health of patients with diabetes mellitus and unmet basic needs (hereinafter referred to as material need insecurities). How specific material need insecurities relate to clinical outcomes and the use of health care resources in a setting of near-universal access to health care is unclear.

OBJECTIVE

To determine the association of food insecurity, cost-related medication underuse, housing instability, and energy insecurity with control of diabetes mellitus and the use of health care resources.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional data were collected from June 1, 2012, through October 31, 2013, at 1 academic primary care clinic, 2 community health centers, and 1 specialty center for the treatment of diabetes mellitus in Massachusetts. A random sample of 411 patients, stratified by clinic, consisted of adults (aged ≥21 years) with diabetes mellitus (response rate, 62.3%).

MAIN OUTCOMES AND MEASURES

The prespecified primary outcome was a composite indicator of poor diabetes control (hemoglobin A1c level, >9.0%; low-density lipoprotein cholesterol level, >100 mg/dL; or blood pressure, >140/90 mm Hg). Prespecified secondary outcomes included outpatient visits and a composite of emergency department (ED) visits and acute care hospitalizations (ED/inpatient visits).

RESULTS

Overall, 19.1% of respondents reported food insecurity; 27.6%, cost-related medication underuse; 10.7%, housing instability; 14.1%, energy insecurity; and 39.1%, at least 1 material need insecurity. Poor diabetes control was observed in 46.0% of respondents. In multivariable models, food insecurity was associated with a greater odds of poor diabetes control (adjusted odds ratio [OR], 1.97 [95% CI, 1.58-2.47]) and increased outpatient visits (adjusted incident rate ratio [IRR], 1.19 [95% CI, 1.05-1.36]) but not increased ED/inpatient visits (IRR, 1.00 [95% CI, 0.51-1.97]). Cost-related medication underuse was associated with poor diabetes control (OR, 1.91 [95% CI, 1.35-2.70]) and increased ED/inpatient visits (IRR, 1.68 [95% CI, 1.21-2.34]) but not outpatient visits (IRR, 1.07 [95% CI, 0.95-1.21]). Housing instability (IRR, 1.31 [95% CI, 1.14-1.51]) and energy insecurity (IRR, 1.12 [95% CI, 1.00-1.25]) were associated with increased outpatient visits but not with diabetes control (OR, 1.10 [95% CI, 0.60-2.02] and OR, 1.27 [95% CI, 0.96-1.69], respectively) or with ED/inpatient visits (IRR, 1.49 [95% CI, 0.81-2.73] and IRR, 1.31 [95% CI, 0.80-2.13], respectively). An increasing number of insecurities was associated with poor diabetes control (OR for each additional need, 1.39 [95% CI, 1.18-1.63]) and increased use of health care resources (IRR for outpatient visits, 1.09 [95% CI, 1.03-1.15]; IRR for ED/inpatient visits, 1.22 [95% CI, 0.99-1.51]).

CONCLUSIONS AND RELEVANCE

Material need insecurities were common among patients with diabetes mellitus and had varying but generally adverse associations with diabetes control and the use of health care resources. Material need insecurities may be important targets for improving care of diabetes mellitus.

Cost-sharing, physician utilization, and adverse selection among Medicare beneficiaries with chronic health conditions

Pooled data from the 2007, 2009, and 2011/2012 California Health Interview Surveys were used to compare the number of self-reported annual physician visits among 36,808 Medicare beneficiaries ≥65 in insurance groups with differential cost-sharing. Adjusted for adverse selection and a set of health covariates, Medicare fee-for-service (FFS) only beneficiaries had similar physician utilization compared with HMO enrollees but fewer visits compared with those with supplemental (1.04, p = .001) and Medicaid (1.55, p = .003) coverage. FFS only beneficiaries in very good or excellent health had fewer visits compared with those of similar health status with supplemental (1.30, p = .001) or Medicaid coverage (2.15, p = .002). For subpopulations with several chronic conditions, FFS only beneficiaries also had fewer visits compared with beneficiaries with supplemental or Medicaid coverage. Observed differences in utilization may reflect efficient and necessary physician utilization among those with chronic health needs.

Unintentional prescription drug non-compliance for financial reasons in families with a child with a limiting health condition

Area probability sampling via U.S. postal addresses was used to select households from seven high poverty U.S. metropolitan areas. In person and telephone interviews with one adult household member were used to determine the odds of delaying or failing to fill a needed prescription for families with a child member with a limiting health condition. Logistic models indicate families with a child with a limiting health condition are 1.57 times more likely to delay or fail to fill a needed prescription, and families with more than one child with a limiting condition are 1.85 times more likely. Implications are set forth.

Patient experience and attitudes toward addressing the cost of breast cancer care

BACKGROUND

The American Society of Clinical Oncology views patient-physician discussion of costs as a component of high-quality care. Few data exist on patients' views regarding how cost should be addressed in the clinic.

METHODS

We distributed a self-administered, anonymous, paper survey to consecutive patients with breast cancer presenting for a routine visit within 5 years of diagnosis at an academic cancer center. Survey questions addressed experience and preferences concerning discussions of cost and views on cost control. Results are primarily descriptive, with comparison among participants on the basis of disease stage, using chi-square and Fisher's exact tests. All p values are two-sided.

RESULTS

We surveyed 134 participants (response rate 86%). Median age was 61 years, and 28% had stage IV disease. Although 44% of participants reported at least a moderate level of financial distress, only 14% discussed costs with their doctor; 94% agreed doctors should talk to patients about costs of care. Regarding the impact of costs on decision making, 53% felt doctors should consider direct costs to the patient, but only 38% felt doctors should consider costs to society. Moreover, 88% reported concern about costs of care, but there was no consensus on how to control costs.

CONCLUSION

Most breast cancer patients want to discuss costs of care, but there is little consensus on the desired content or goal of these discussions. Further research is needed to define the role of cost discussions at the bedside and how they will contribute to the goal of high-quality and sustainable cancer care.

Patient experience and attitudes toward addressing the cost of breast cancer care

BACKGROUND

The American Society of Clinical Oncology views patient-physician discussion of costs as a component of high-quality care. Few data exist on patients' views regarding how cost should be addressed in the clinic.

METHODS

We distributed a self-administered, anonymous, paper survey to consecutive patients with breast cancer presenting for a routine visit within 5 years of diagnosis at an academic cancer center. Survey questions addressed experience and preferences concerning discussions of cost and views on cost control. Results are primarily descriptive, with comparison among participants on the basis of disease stage, using chi-square and Fisher's exact tests. All p values are two-sided.

RESULTS

We surveyed 134 participants (response rate 86%). Median age was 61 years, and 28% had stage IV disease. Although 44% of participants reported at least a moderate level of financial distress, only 14% discussed costs with their doctor; 94% agreed doctors should talk to patients about costs of care. Regarding the impact of costs on decision making, 53% felt doctors should consider direct costs to the patient, but only 38% felt doctors should consider costs to society. Moreover, 88% reported concern about costs of care, but there was no consensus on how to control costs.

CONCLUSION

Most breast cancer patients want to discuss costs of care, but there is little consensus on the desired content or goal of these discussions. Further research is needed to define the role of cost discussions at the bedside and how they will contribute to the goal of high-quality and sustainable cancer care.

Determinants of Cost-Related Nonadherence to Medications among Chronically Ill Patients in Maccabi Healthcare Services, Israel

BACKGROUND

The effectiveness of value-based insurance design is based on nonadherence, which derives solely from patients' economic constraints.

OBJECTIVE

Our objective was to examine the extent of cost-related nonadherence to chronic medications and to analyze its potential determinants.

METHODS

We conducted a telephone survey among a representative sample of Maccabi Healthcare Services chronically ill patients aged 55 years or older (n = 522). We developed a 12-month recall questionnaire that included demographic and socioeconomic characteristics, out-of-pocket expenditure on prescribed medication, physician's provision of explanation regarding prescribed therapy, adherence, and reasons for nonadherence. Respondents were defined as nonadherent if they reported that they did not purchase prescribed medications in the previous year because of their cost. We applied the multivariable logistic regression model to examine predictors of nonadherence.

RESULTS

Median (interquartile range) age of the study sample was 69 (13) years (53% males). One hundred sixty-five patients (31.6%) reported not purchasing prescribed medications mainly because of medications' adverse effects and/or cost. Fifty respondents (9.6%) reported cost-related nonadherence. The multivariable logistic regression model revealed that cost-related nonadherence was associated with respondent's income lower than 4600 New Israeli shekel (odds ratio [OR] = 10.86; 95% confidence interval [CI] 1.45-81.12), unemployment (OR = 4.32; 95% CI 1.47-12.66), lack of physician explanation about the prescribed medication (OR = 2.38; 95% CI 1.18-4.78), and age (OR = 0.95; 95% CI 0.91-0.99).

CONCLUSIONS

Cost-related nonadherence to chronic pharmaceuticals is self-reported among nearly 10% of the chronically ill patients and is strongly affected by low socioeconomic status, even under universal health insurance coverage and with relatively low co-payments as applied in Israel. Lack of information provided by physicians regarding the therapy is associated with a higher likelihood of cost-related nonadherence.

Patients' annual income adequacy, insurance premiums and out-of-pocket expenses related to heart failure care

OBJECTIVES

To (1) identify the amount patients spend for insurance premiums, co-payments, deductibles, and other out-of-pocket costs related to HF and chronic health care services and estimate their annual non-reimbursed and out-of-pocket costs; and (2) identify patients' concerns about nonreimbursed and out-of-pocket expenses.

BACKGROUND

HF is one of the most expensive illnesses for our society with multiple health services and financial burdens for families.

METHODS

Mixed methods with quantitative questionnaires and qualitative interviews.

RESULTS

Patients (N = 149) reported annual averages for non-reimbursed health services co-payments and out-of-pocket costs ranging from $3913 to $5829 depending on insurance coverage. Thirty one patients (21%) reported inadequate health coverage related to their non-reimbursed costs.

CONCLUSIONS

Non-reimbursed costs related to HF care are substantial and vary depending on their insurance, health services use, and out-of-pocket costs. Patient referral to social services to assist with expenses could provide some relief from the burden of high HF-related costs.

Enhancing aging services through evidence-based health promotion: a training for service providers

During the next several decades, increasing numbers of older Americans will suffer chronic illnesses and many will face challenges due to growing racial and economic health disparities. Agencies serving older adults need to respond by creating and promoting evidence-based health promotion (EBHP) practices to address the growing diversity among older adults in urban areas. One such agency, the Detroit Area Agency on Aging recently partnered with the Wayne State University School of Social Work to conduct an EBHP educational program for service providers. The educational program used information from the National Council on Aging Center for Healthy Aging, the reach, effectiveness/efficacy, adoption, implementation, and maintenance (RE-AIM) model, and the National Wellness Institute. Survey respondents found that the interaction with other participants was beneficial and helped them to conceptualize EBHP as a new way of thinking about service delivery. Participants learned practical lessons about implementing a training program on evidence-based practice and additional steps are offered to increase the uptake of EBHP practices by older adult service providers.

Cost-control mechanisms in Canadian private drug plans

Approximately 68% of Canadians receive prescription drug coverage through an employer-sponsored private plan. However, we have very limited data on the structure of these plans. This study aims to identify and describe the use of cost-control mechanisms in private drug plans in Canada and describe what private coverage looks like for the average Canadian. Using 2010 data from over 113,000 different private drug plans, provided by Applied Management Consultants, we determined the overall use of key cost-control measures, and the cost-control tools that appear to be gaining currency compared to a report on benefits coverage in 1998. We found that the use of common cost-control measures is relatively low among Canadian private benefits programs. Co-insurance is much more common in private coverage plans than co-payments. Deductibles are uncommon in Canada and, when in place, are very small. The use of annual and lifetime maximums is increasing. Canadian private benefits programs use few cost-control measures to respond to increasing costs, particularly in comparison to their public counterparts. These results suggest there are ample opportunities for greater efficiency in private sector drug coverage plans.

Early education and health outcomes of a 2001 U.S. birth cohort

This paper looks at health outcomes, health behaviors, and health screening with respect to participation in Early Childhood Care and Education. With information on health status at multiple periods in time, we are able to look at whether healthier children select into early childhood education (as measured by center-based preschool care and Head Start), as well as whether early childhood education has immediate and near-term effects on a range of health status measures. There is some evidence that child obesity is ameliorated by participation in center-based preschool or Head Start and this finding is supported by clear evidence of improved nutrition and increased levels of health screening. Effects on other health outcomes such as asthma, ear infections, and respiratory problems may be partially masked by unobserved heterogeneity.

The relationship between emergency department use and cost-related medication nonadherence among Medicare beneficiaries

STUDY OBJECTIVE

The objective of this study was to evaluate the relationship between self-reported cost-related nonadherence to prescription medications and emergency department (ED) utilization among Medicare beneficiaries. We hypothesized that persons who report cost-related medication nonadherence would have subsequent higher ED use.

METHODS

We conducted a retrospective cohort study of continuously enrolled Medicare beneficiaries in 2006 and 2007. We used multivariate logistic regression to evaluate the relationship between ED use and cost-related medication nonadherence. Our principal dependent variable was any ED visit within a 364-day period after an interview assessing cost-related medication nonadherence. Our principal independent variables both denoted cost-related medication nonadherence: mild cost-related medication nonadherence, defined as a reduction in dose or a delay in filling medications because of cost; and severe cost-related medication nonadherence, defined as not filling a medication at all because of cost.

RESULTS

Our sample consisted of 7,177 Medicare Current Beneficiary Survey respondents. Approximately 7.5% of respondents reported mild cost-related medication nonadherence only (n=541) and another 8.2% reported severe cost-related medication nonadherence (n=581). Disabled Medicare beneficiaries with severe cost-related medication nonadherence were more likely to have at least 1 ED visit (1.53; 95% confidence interval 1.03 to 2.26) compared with both disabled Medicare beneficiaries without cost-related medication nonadherence and elderly Medicare beneficiaries in all cost-related medication nonadherence categories.

CONCLUSION

Our results show an association between severe cost-related medication nonadherence and ED use. Disabled beneficiaries younger than 65 years who report severe cost-related medication nonadherence were more likely to have at least 1 ED visit, even when adjusting for other factors that affect utilization.