Effects of user charges on the use of prescription medicines in different socio-economic groups

Exploring the contexts, mechanisms and outcomes of a torture, abuse and dental anxiety service in Norway: a realist evaluation

Background

Torture, abuse and dental anxiety (TADA) are often precursors to developing a pathological relationship with dental care due to elevated anxiety. Consequently, patients who suffer from one or more of these tend to avoid dental services. This could leave them with severe tooth decay, which could affect their general and psychosocial health. Norwegian dental services have implemented the TADA service to specifically alleviate dental anxiety and restore oral health for the TADA patient group. However, the service has not been evaluated, and there is a need to understand how and why this service works, for whom, under what circumstances. Therefore, this study aimed to develop theories on how the service’s structure alleviates dental anxiety and restores these patients’ oral health. Although developed in a Norwegian context, these theories may be applicable to other national and international contexts.

Methods

This realist evaluation comprised multiple sequential methods of service and policy documents (n = 13), followed by interviews with service developers (n = 12).

Results

The analysis suggests that, by subsidising the TADA service, the Norwegian state has removed financial barriers for patients. This has improved their access to the service and, hence, their service uptake. National guidelines on service delivery are perceived as open to interpretation, and can hereby meet the needs of a heterogeneous patient group. The services have become tailored according to the available regional resources and heterogeneous needs of the patient population. A perceived lack of explicit national leadership and cooperative practices has resulted in regional service teams becoming self-reliant and insular. While this has led to cohesion within each regional service, it is not conducive to interservice collaborations. Lastly, the complexity of migration processes and poor dissemination practices is presumed to be the cause of the lack of recruitment of torture survivors to the service.

Conclusions

Policy documents and service developers described the TADA service as a hybrid bottom-up/top-down service that allows teams to practise discretion and tailor their approach to meet individual needs. Being free of charge has improved access to the service by vulnerable groups, but the service still struggles to reach torture survivors.

The Effect of Changes in Cost Sharing on the Consumption of Prescription and Over-the-Counter Medicines in Catalonia

Many universal health care systems have increased the share of the price of medicines paid by the patient to reduce the cost pressure faced after the Great Recession. This paper assesses the impact of cost-sharing changes on the propensity to consume prescription and over-the-counter medicines in Catalonia, a Spanish autonomous community, affected by three new cost-sharing policies implemented in 2012. We applied a quasi-experimental difference-in-difference method using data from 2010 to 2014. These reforms were heterogeneous across different groups of individuals, so we define three intervention groups: (i) middle-income working population—co-insurance rate changed from 40% to 50%; (ii) low/middle-income pensioners—from free full coverage to 10% co-insurance rate; (iii) unemployed individuals without benefits—from 40% co-insurance rate to free full coverage. Our control group was the low-income working population whose co-insurance rate remained unchanged. We estimated the effects on the overall population as well as on the group with long-term care needs. We evaluated the effect of these changes on the propensity to consume prescription or over-the-counter medicines, and explored the heterogeneity effects across seven therapeutic groups of prescription medicines. Our findings showed that, on average, these changes did not significantly change the propensity to consume prescription or over-the-counter medicines. Nonetheless, we observed that the propensity to consume prescription medicines for mental disorders significantly increased among unemployed without benefits, while the consumption of prescribed mental disorders medicines for low/middle-income pensioners with long-term care needs decreased after becoming no longer free. We conclude that the propensity to consume medicines was not affected by the new cost-sharing policies, except for mental disorders. However, our results do not preclude potential changes in the quantity of medicines individuals consume.

Assessing adherence and patient satisfaction with medication

Purpose

The study considers a four-construct model for validating the factors of overall patient satisfaction with medication. This paper aims to study the satisfaction of patients with their medication. Patient satisfaction with medication influences treatment-related behaviors, such as their possibility of continuing to use their medication, to take their medication correctly and to adhere with medication regimens.

Design/methodology/approach

treatment satisfaction questionnaire for medication (TSQM) version 1.4 patient satisfaction model has been tested for reliability and validity through confirmatory factor analysis. A structured questionnaire, incorporating variables identified from original TSQM version 1.4 (Atkinson et al., 2005), has been used as a survey instrument for the study. Final respondent sample size was 380 patients who were on medication for a minimum duration of 10 days.

Findings

In total, 75 per cent of the willingly participating patients were found to adhere to medication regimen as advised by their physician. Effectiveness, side effects, convenience and global satisfaction were found to be reliable and valid factors for assessing satisfaction with medication among patients in emerging market settings.

Originality/value

The existing studies on measuring patient satisfaction have been majorly confined to developed economies. There is lack of focused research on patient satisfaction and its underlying determinants in the emerging market settings. The present study is an attempt to fill the existing research gap.

The abolition of user charges and the demand for ambulatory visits: evidence from the Czech Republic

This paper estimates the effect of the abolition of user charges for children's outpatient care (30 CZK/1.2 EUR) in 2009 on the demand for ambulatory doctor visits in the Czech Republic. Because the reform applied only to children, we can employ the difference-in-differences approach, where children constitute a treatment group and adults serve as a control group. The dataset covers 1841 observations. Aside from the treatment effect, we control for a number of personal characteristics using micro-level data (European Union Statistics on Income and Living Conditions). Using the zero-inflated negative binomial model, we found no significant effect from the abolition of user charges on doctor visits, suggesting either that user charges are ineffective in the Czech environment or that their value was set too low. On the contrary, personal income, the number of household members and gender have a significant effect. A number of robustness checks using restricted samples confirm the results.

Switching between endocrine therapies for primary breast cancer: Frequency and timing in Australian clinical practice

AIMS

To determine the frequency, timing and patterns of endocrine therapy switching in Australian practice for postmenopausal women with primary breast cancer.

METHODS

We identified postmenopausal women in a population-based cohort commencing endocrine therapy for invasive primary breast cancer between December 2005 and December 2008 (n = 645). Individual-level administrative health records and self-report data were used to determine women's demographic and clinical characteristics, including preexisting and newly-treated comorbidities, and switches in endocrine therapy. Time to therapy switching was calculated. Chi-square tests compared the characteristics of women who did and did not switch, and those switching within 2 years or after 2 years of commencing therapy.

RESULTS

Twenty-eight percent of women switched from their initial endocrine therapy, most commonly from tamoxifen to anastrozole, or the converse. A small number of anastrozole-to-exemestane and letrozole-to-exemestane switches were observed (n = 19). Most women (>80%) who switched therapies did not have newly-treated comorbidities. Few women (<5%) switched before completing 2 years of therapy, but these women were significantly more likely to have preexisting antidepressant use than women switching later (43% vs 23%, P = 0.048) and remained on the subsequent therapy for less time (6 months vs 2.7 years, P < 0.001).

CONCLUSIONS

Approximately one-quarter of postmenopausal women with primary breast cancer switched endocrine therapies. The findings suggest that the majority of switching in Australian practice was planned; occurring after 2-3 years of, not precipitated by comorbidity, and in a sequence supported by trial evidence. Early switching, however, was associated with preexisting depression and appeared to be a marker of poor persistence.

"Doctor my eyes": A natural experiment on the demand for eye care services

Preventive health care is promoted by many organisations from the World Health Organisation (WHO) to regional and national governments. The degree of cost-sharing between individuals and the health care service affects preventive service use. For instance, out-of-pocket fees that are paid by individuals for curative services reduce preventive care demand. We examine the impact of subsidised preventive care on demand. We motivate our analysis with a theoretical model of inter-temporal substitution in which individuals decide whether to have a health examination in period one and consequently whether to be treated if required in period two. We derive four testable hypotheses. We test these using the subsidised eye care policy introduced in Scotland in 2006. This provides a natural experiment that allows us to identify the effect of the policy on the demand for eye examinations. We also explore socio-economic differences in the response to the policy. The analysis is based on a sample from the British Household Panel Survey of 52,613 observations of people, aged between 16 and 59 years, living in England and Scotland for the period 2001-2008. Using the difference-in-difference methodology, we find that on average the policy did not affect demand for eye examinations. We find that demand for eye examinations only increased among high income households, and consequently, inequalities in eye-care services demand have widened in Scotland since the introduction of the policy.

Recommended drug use after acute myocardial infarction by migration status and education level

PURPOSE

The purpose of this study is to investigate the association between migration status and education level and the use of recommended drugs after first acute myocardial infarction (MI).

METHODS

A nationwide cohort study performed in Sweden from January 1, 2006 to August 1, 2008. The cohort consisted of 49,037 incident cases of first acute MI. In total, 37,570 individuals survived 180 days after MI, of whom 4782 (12.7%) were foreign-born. We used logistic regression to estimate the odds ratio (OR) with 95% confidence interval (CI) of the association between migration status and education level and prescribed drugs after MI.

RESULTS

One third of the patients who were not on any recommended cardiovascular drugs before MI continued to be without recommended cardiovascular drugs after MI. Among those with no cardiovascular drugs before MI, we found no difference in recommended drug use after MI by migration status (OR 1.00, 95% CI 0.89-1.12). Among those with some but not all recommended cardiovascular drugs before MI, foreign-born cases had a slightly non-significant lower use of recommended drugs (OR 0.92, 95% CI 0.83-1.03). Foreign-born patients with low education had a slightly lower use of recommended drug compared to Sweden-born. Women with low education had a lower use of drugs after MI (Sweden born, OR 0.85; 95% CI 0.74-0.96 and foreign born OR 0.51; 95% CI 0.34-0.77).

CONCLUSION

There is no apparent difference between foreign-born and Sweden-born in recommended drug use after MI. However, our study reveals an inequity in secondary prevention therapy after myocardial infarction by education level.

How does copayment for health care services affect demand, health and redistribution? A systematic review of the empirical evidence from 1990 to 2011

This article reviews the quantitative evidence on the behavioural effects of copayment within the health area across a wide range of countries. The review distinguishes itself from previous similar reviews by having a high degree of transparency for the search strategy used to identify the studies included in the review as well as the criteria for inclusion and by including the most recent literature. Empirical studies were identified by performing searches in EconLit. The literature search identified a total of 47 studies of the behavioural effects of copayment. Considering the demand effects, the majority of the reviewed studies found that copayment reduces the use of prescription medicine, consultations with general practitioners and specialists, and ambulatory care, respectively. The literature found no significant effects of copayment on the prevalence of hospitalisations. The empirical evidence on whether copayment for some services, but not for others, causes substitution from the services that are subject to copayment to the 'free' services rather than lower total use is sparse and mixed. Likewise, the health effects of copayment have only been analysed empirically in a limited number of studies, of which half did not find any significant effects in the short term. Finally, the empirical evidence on the distributional consequences of copayment indicates that individuals with low income and in particular need of care generally reduce their use relatively more than the remaining population in consequence of copayment. Hence, it is clear that copayment involves some important economic and political trade-offs.

Social Inequalities and Pharmaceutical Cost Sharing in Italian Regions

In recent years, Italian citizens have increasingly been asked to share pharmaceutical costs, but at the same time, households' medicines expenditure has decreased. Cost-sharing policies have to be assessed not just in terms of limitation of moral hazard and revenue to the state, but also for equal opportunities for citizen users accessing health services. The aim of this article is to analyze how Italian co-payment policies (“ticket”) on medicines may affect pharmaceutical expenditure of households, considering territorial and social groups variation. We reviewed the per capita private spending on medicines of Italian regions, separating pharmaceutical outlay and “ticket.” Across the period 2001–2010 we found that the overall per capita private spending on medicines remained substantially stable, although medicine expenditure decreases while the “ticket” increases. When cost sharing rises, out-of-pocket spending on medicines by poorer families seems to remain unchanged; however, poorer families seem to reduce their pharmaceutical expenditure. Our analysis suggests that applying co-payment in Italy is partly successful, in terms of greater revenue to the health system, but in the last few years, cost-sharing increases would seem to have rebounded negatively on more vulnerable families, due to the economic crisis.

The impact of cost-sharing schemes on drug compliance in Italy: evidence based on quantile regression

OBJECTIVES

In this article we investigate the causal effect of cost-sharing schemes on compliance with statins in a quantile regression framework.

METHODS

We use the health search CSD-LPD data, a longitudinal observational dataset containing computer-based patient records collected by Italian general practitioners. We exploit a series of natural experiments referring to several introductions of co-payment schemes in some of the Italian regions between 2000 and 2009. We adopt an extended difference-in-differences approach to provide quantile estimates of the impact of co-payments on compliance.

RESULTS

We find that (i) introduction of co-payments hurts residents of regions with worse quality and provision of health care; (ii) within these regions, co-payments were particularly harmful for high compliers; (iii) gender, clinical history and geographic residence are important determinants of compliance among poor compliers; (iv) compliance decreases with the potency and dosage of statins, particularly for poor compliers.

CONCLUSIONS

In the presence of inefficient health-care provision, co-payments are harmful for drug compliance, and this is especially true for patients who are originally good compliers.

Impact of Part D low-income subsidies on medication patterns for Medicare beneficiaries with diabetes

BACKGROUND

It is not known whether low-income subsidies (LIS) under Medicare Part D help beneficiaries overcome impediments to medication use associated with poor socioeconomic status and high disease burden.

OBJECTIVES

To compare Medicare beneficiaries with LIS and Medicaid (duals), LIS without dual eligibility, and non-LIS recipients on use of medications recommended in diabetes treatment.

RESEARCH DESIGN

Fixed-effect comparisons among beneficiaries in the same Part D plans in 2006-2007.

SUBJECTS

Nationally representative sample of enrollees in Part D prescription drug plans. A total of 109,292 beneficiaries were in 204 prescription drug plans; 47.5% non-LIS, 44.4% duals, and 8.1% nondual LIS recipients.

MEASURES

Medications included antidiabetic agents, renin-angiotensin-aldosterone system inhibitors, and antihyperlipidemics. Drug use was measured by exposure, duration of therapy, and medication possession ratio.

RESULTS

The LIS dual cohort had significantly higher comorbidity compared with non-LIS comparisons, LIS nonduals were significantly more likely to take medications in all 3 drug classes compared with non-LIS recipients, but differences were small (between 2% and 4%; P<0.05). Non-LIS recipients and duals had equivalent exposure to any antidiabetic drug and antihyperlipidemics, but duals were 3% less likely to receive renin-angiotensin-aldosterone system inhibitors compared with non-LIS recipients (P<0.05). Small differences in adjusted values for duration of therapy and medication possession ratio among the 3 cohorts were also observed, none of which were clinically meaningful.

CONCLUSIONS

Similarities in medication utilization among Part D enrollees with and without LIS coverage supports the program objective of providing enhanced access to needed medications for diverse groups of Medicare beneficiaries.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Use of medication among hospital workers]

Although medication is acknowledged as a key element in treating health problems, there is little information available on the use of medication by hospital workers. To estimate the prevalence and describe the patterns of medication consumption by hospital workers and to identify the factors associated with such consumption in this population, data from the "PROSEC" baseline cohort were analyzed (n=417). The prevalence of overall medication consumption was 72.4%, most of which was for nervous complaints (25.4%), especially analgesics (17.8%). Use of any amount of medication was independently associated with gender, number of medically diagnosed conditions and health problem in the two weeks prior to the interview. Use of a drug was significantly associated with income whereas self-diagnosed health problems were independently related with the use of two or more pharmaceutical products. The high prevalence of medication usage in this population, with analgesics being the most consumed medication, should be seen as a cause for concern, since many consumers are unaware that these products are not exempt from risk. Women and individuals in poor health are the main candidates for intervention programs in order to promote adequate and proper use of these pharmaceutical products.

[Differences in self-medication in the adult population in Spain according to country of origin]

OBJECTIVES

To explore the factors determining self-medication among the Spanish adult population, paying special attention to differences in pharmaceutical consumption patterns between the immigrant and autochthonous populations in Spain.

METHODS

Logistic regression models were used to evaluate the effect of several demographic, socioeconomic, lifestyle, and health-related variables on self-medication. Data were drawn from the adult sample of the 2006 Spanish National Health Survey, which included 29,478 individuals over 15 years old.

RESULTS

The results show that individuals at higher risk of self-medication were young, with a positive perception of health and no chronic diseases, frequent consumers of alcohol, widowers, holders of a private medical insurance policy not contracted through the civil servants' mutual funds, residents in the Autonomous Communities of Madrid or Valencia, and individuals born in Central or Eastern Europe.

CONCLUSIONS

Identifying the profile of self-medicated drug users in Spain may help health authorities to target high risk individuals in order to comply with European Union public health goals.

Generic substitution: additional challenge for adherence in hypertensive patients?

OBJECTIVE

This study aims to investigate whether, and in what way, generic substitution affects drug adherence in hypertensive patients.

METHODS

Personal interviews with 174 Norwegian patients (50-80 years) who had had their brand-name antihypertensive drug generically substituted were conducted using a semi-structured questionnaire.

RESULTS

On average, 4.4 (1-14) prescription drugs were used by the participants. Of these, 2.0 (1-4) drugs were antihypertensives. More than 50% of the patients had been using antihypertensive drugs for more than 10 years. One in four found it difficult to remember to take their medication every day. One in three said generic substitution made keeping track of their medications more demanding. Twenty-nine percent were anxious when they started to use a generically substituted drug. Eight percent felt that the effect of the drug had changed, and 15% reported having new or more side-effects. A negative attitude towards generics was significantly associated with low educational attainment, increasing number of drugs, having general concerns about medicine use, and having received insufficient information regarding generic substitution. Five percent of the patients had been using more than one equivalent generic drug at the same time. These were among those who used several different drugs and also among those who got their medications from more than one pharmacy. Five percent is a too small number to draw general conclusions; however, there is no reason to suspect that these mistakes do not occur from time to time.

CONCLUSIONS

This study shows that generic substitution can be an additional factor in poor drug adherence in hypertensive patients and contributes to concerns and confusion among the patients. Although generic substitution is an important measure of cost containment, health personnel should approach each patient individually. Clearly, many patients feel insecure about substituting their medication and demand more information.

Comparison of nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 (COX-2) inhibitors use in Australia and Nova Scotia (Canada)

AIMS

Cyclooxygenase-2 (COX-2) inhibitors were marketed aggressively and their rapid uptake caused safety concerns and budgetary challenges in Canada and Australia. The objectives of this study were to compare and contrast COX-2 inhibitors and nonselective nonsteroidal anti-inflammatory drug (ns-NSAID) use in Nova Scotia (Canada) and Australia and to identify lessons learned from the two jurisdictions.

METHODS

Ns-NSAID and COX-2 inhibitor Australian prescription data (concession beneficiaries) were downloaded from the Medicare Australia website (2001-2006). Similar Pharmacare data were obtained for Nova Scotia (seniors and those receiving Community services). Defined daily doses per 1000 beneficiaries day(-1) were calculated. COX-2 inhibitors/all NSAIDs ratios were calculated for Australia and Nova Scotia. Ns-NSAIDs were divided into low, moderate and high risk for gastrointestinal side-effects and the proportions of use in each group were determined. Which drugs accounted for 90% of use was also calculated.

RESULTS

Overall NSAID use was different in Australia and Nova Scotia. However, ns-NSAID use was similar. COX-2 inhibitor dispensing was higher in Australia. The percentage of COX-2 inhibitor prescriptions over the total NSAID use was different in the two countries. High-risk NSAID use was much higher in Australia. Low-risk NSAID prescribing increased in Nova Scotia over time. The low-risk/high-risk ratio was constant throughout over the period in Australia and increased in Nova Scotia.

CONCLUSIONS

There are significant differences in Australia and Nova Scotia in use of NSAIDs, mainly due to COX-2 prescribing. Nova Scotia has a higher proportion of low-risk NSAID use. Interventions to provide physicians with information on relative benefits and risks of prescribing specific NSAIDs are needed, including determining their impact.

Medication use and patient satisfaction: a population-based survey

BACKGROUND

In recent years, there is a growing interest to assess patients' satisfaction which further triggers the existing debate on the severe methodological issues regarding the interpretation of comparative surveys results.

OBJECTIVE

This cross-sectional national survey aimed to examine satisfaction of Greek households with specific aspects of medication use and their correlates.

METHODS

Between November 2004 and February 2005, telephone interviews were used for collecting information about socio-demographic and health-related characteristics in a systematic sample of 1000 Greek households. Respondents were classified into three categories: chronic or short-term prescribed medication use, occasional medication use and no medication use during the 3 months preceding the survey. Satisfaction was assessed through various aspects of medication use like physician's consultation, physician's response to adverse events, consultation and advice by pharmacists, symptoms' resolution, route of drug administration, drug tolerability and drug cost.

RESULTS

The prescribed drugs' use in the 3 months preceding the survey interview was 36.9%; 28.6% for subjects under chronic treatment and 8.3% under short-term treatment. During the same time period, 52.8% of the respondents reported the occasional self-use of over the counter drugs for minor symptoms. A high prevalence of hypertension, cardiovascular, musculoskeletal and endocrine disorders has been observed. In general, respondents expressed a high degree of satisfaction with all aspects of medication use examined, the only exception being costs. Age, area of residence, social insurance scheme and self-reported health status were associated with specific aspects of patient satisfaction.

CONCLUSIONS

Patient satisfaction with the aspects of medication use examined seems to be influenced by demographic and social factors; this points out to the necessity of taking into account socio-cultural variations and the structure of the health-care system in policymaking.

Understanding medication compliance and persistence from an economics perspective

OBJECTIVES

An increased understanding of the reasons for noncompliance and lack of persistence with prescribed medication is an important step to improve treatment effectiveness, and thus patient health. Explanations have been attempted from epidemiological, sociological, and psychological perspectives. Economic models (utility maximization, time preferences, health capital, bilateral bargaining, stated preference, and prospect theory) may contribute to the understanding of medication-taking behavior.

METHODS

Economic models are applied to medication noncompliance. Traditional consumer choice models under a budget constraint do apply to medication-taking behavior in that increased prices cause decreased utilization. Nevertheless, empiric evidence suggests that budget constraints are not the only factor affecting consumer choice around medicines. Examination of time preference models suggests that the intuitive association between time preference and medication compliance has not been investigated extensively, and has not been proven empirically. The health capital model has theoretical relevance, but has not been applied to compliance. Bilateral bargaining may present an alternative model to concordance of the patient-prescriber relationship, taking account of game-playing by either party. Nevertheless, there is limited empiric evidence to test its usefulness. Stated preference methods have been applied most extensively to medicines use.

RESULTS

Evidence suggests that patients' preferences are consistently affected by side effects, and that preferences change over time, with age and experience. Prospect theory attempts to explain how new information changes risk perceptions and associated behavior but has not been applied empirically to medication use.

CONCLUSIONS

Economic models of behavior may contribute to the understanding of medication use, but more empiric work is needed to assess their applicability.

What impact do prescription drug charges have on efficiency and equity? Evidence from high-income countries

As pharmaceutical expenditure continues to rise, third-party payers in most high-income countries have increasingly shifted the burden of payment for prescription drugs to patients. A large body of literature has examined the relationship between prescription charges and outcomes such as expenditure, use, and health, but few reviews explicitly link cost sharing for prescription drugs to efficiency and equity. This article reviews 173 studies from 15 high-income countries and discusses their implications for important issues sometimes ignored in the literature; in particular, the extent to which prescription charges contain health care costs and enhance efficiency without lowering equity of access to care.

Differences in pharmaceutical consumption and expenses between immigrant and Spanish-born populations in Lleida, (Spain): a 6-months prospective observational study

Background

There are few studies comparing pharmaceutical costs and the use of medications between immigrants and the autochthonous population in Spain. The objective of this study is to evaluate whether there are differences in pharmaceutical consumption and expenses between immigrant and Spanish-born populations.

Methods

Prospective observational study in 1,630 immigrants and 4,154 Spanish-born individuals visited by fifteen primary care physicians at five public Primary Care Clinics (PCC) during 2005 in the city of Lleida, Catalonia (Spain). Data on pharmaceutical consumption and expenses was obtained from a comprehensive computerized data-collection system. Multinomial regression models were used to estimate relative risks and confidence intervals of pharmaceutical expenditure, adjusting for age and sex.

Results

The percentage of individuals that purchased medications during a six-month period was 53.7% in the immigrant group and 79.2% in the autochthonous group. Pharmaceutical expenses and consumption were lower in immigrants than in autochthonous patients in all age groups and both genders. The relative risks of being in the highest quartile of expenditure, for Spanish-born versus immigrants, were 6.9, 95% CI = (4.2, 11.5) in men and 5.3, 95% CI = (3.5, 8.0) in women, with the reference category being not having any pharmaceutical expenditure.

Conclusion

Pharmaceutical expenses are much lower for immigrants with respect to autochthonous patients, both in the percentage of prescriptions filled at pharmacies and the number of containers of medication obtained, as well as the prices of the medications used. Future studies should explore which factors explain the observed differences in pharmaceutical expenses and if these disparities produce health inequalities.

Equal access to treatment? Population-based follow-up of drugs dispensed to patients after acute myocardial infarction in Sweden

BACKGROUND AND OBJECTIVE

The establishment of national guidelines is one approach to creating equity in terms of access to care, and both internationally and in Sweden, guidelines have been developed for coronary heart disease. We have analysed drug treatment in Sweden according to national guidelines after acute myocardial infarction (AMI). The aim was to investigate whether there are differences between population groups according to sex, education, country of birth and diabetes.

METHODS

Information was obtained from the Swedish Prescribed Drug Register on drugs dispensed between July and October 2005 for incident cases of AMI during the period 2003-2004 (n=28,168). Data on socio-economic and demographic conditions were included. Dispensed drugs after AMI were compared to the recommended drug treatment according to Swedish and European guidelines--acetylsalicylic acid (ASA), beta-blockers, lipid-lowering drugs and angiotensin-converting enzyme inhibitors (ACE inhibitors).

RESULTS

We found that, in general, there were only small differences between the sexes and between educational groups. The greatest differences were found in comparisons between regions of birth. In particular, foreign-born patients resident in Sweden but originally from outside the EU25 countries used fewer drugs than Swedish-born patients. The OR (odds ratio) for ASA was 0.73 [95% confidence interval (CI) 0.63-0.85], for beta-blockers, 0.72 (0.63-0.83), for lipid-lowering drugs, 0.75 (0.65-0.86) and for ACE inhibitors, 0.76 (0.67-0.86).

CONCLUSIONS

In general, we found only slight differences--or none at all--between population groups in terms of drug treatment after AMI. Only among immigrants from outside the EU25 countries was there a tendency towards a lesser use of the recommended drugs according to the national guidelines.

The influence of prescription drug insurance on psychotropic and non-psychotropic drug utilization in Canada

Using 2002 Canadian Community Health Survey data, this paper examines the effect of public and private prescription drug insurance on the utilization of psychotropic and non-psychotropic drugs. It is found that prescription drug utilization is characterized by two stochastic regimes requiring use of latent class modelling framework. In many instances, results differ for the classes of high and low users of prescription drugs. After accounting for the unobserved individual heterogeneity and a number of socio-demographic factors, health status, and province fixed effects, we find that having prescription drug insurance (public or private) increases the expected number of non-psychotropic medications for both low and high users. Public insurance affects psychotropic drug utilization positively for the low-user group only. The statistical insignificance of insurance for the high-user psychotropic drugs or lower magnitude of insurance coefficients on high-user non-psychotropic drugs seems to stem from high inelastic demand for prescription drugs in the concerned groups. In addition, we find that age, self-reported health status, and long-term mental and physical health problem diagnosed by a health professional are important determinants of prescription drug utilization for both classes of users.

Refill non-adherence to repeat prescriptions leads to treatment gaps or to high extra costs

OBJECTIVE

To determine the nature and extent of undersupply and the economic consequences of oversupply of medication among non-adherent patients.

METHODS

This study used copies of repeat prescriptions (= multiple dispensations), collected during 1 week in 2002 at 16 Swedish community pharmacies. For patients with a refill adherence below 80%, treatment gaps were defined as the number of days they had no drug available. The cost of drug oversupply (i.e., refill adherence > 120%) was calculated from the prices of the drug packages dispensed.

RESULTS

The number of collected repeat prescriptions was 3,636. The median of treatment gaps among patients with a refill adherence below 80% was 53 days per 90-100 days treatment period and the corresponding median for oversupply was 40 days. The cost of oversupply for exempt patients (i.e., patients who have paid 1,800 SEK (Euro 196; US$ 243) per year for medicines) was 32,000 SEK (Euro 3,500; US$ 4,300) higher than for non-exempt patients. An extrapolation to all Sweden indicates that exemption from charges leads to an additional oversupply of about 142 million SEK (Euro 15 million; US$ 19 million) per year above that of non-exempt patients.

CONCLUSION

Both undersupply and oversupply of prescribed medicines are common in Sweden. Patients with a refill adherence below 80% seem to have less than half of the prescribed treatment available. Oversupply or drug stockpiling occurs more frequently among exempt than among non-exempt patients, and this oversupply leads to high unnecessary costs.

Study on Variations in Price of Prescription Medicines in Thailand

There are evidences describing that the prices of prescription medicines can affect users, suppliers, and, in particular, payers in the health care system. Despite the significant effects of prices, the information regarding their characteristics is scarce. The objective of this study was to examine the prices and price variations of prescription medicines in an actual setting. A cross-sectional study on the prices of prescription medicines listed in a hospital formulary was undertaken. The medicines (n=1531) listed in the formulary were recorded according to the category of the medicine (essential or non-essential medicines), manufacturer types (local or foreign), dosage forms, therapeutic classifications (classes), and prices per unit in Baht. This study used coefficients of relative variations (CRVs) to determine the extent of price variations. Results revealed that the mean prices of non-essential and foreign medicines were significantly greater than those of its counterparts by 1.7 and 21.2 times, respectively. On an average, the classes with the highest prices were blood-related, antineoplastic, and endocrinological agents, while those with the lowest prices were the psychotherapeutic, CNS, and cardiovascular agents. The majority of the medicines (37%) were in the price range of >10-100 Baht. The price variations of different classes of medicines varied from about 100% to 600%. The mean price and CRV levels (low and high) formed four groups of medicines with different risks of high prices and variations to payers. In conclusion, the prices are associated with the category and manufacturer type. The prices and their variations could be used to distinguish the classes of medicines that possess different risks of high prices and variations to payers. Identifying the classes with high prices and high variations, high prices and low variations, and low prices and high variations is necessary for careful intervention to reduce the effect of prices and their variations on payers.

Drug compliance, co-payment and health outcomes: evidence from a panel of Italian patients

This paper studies the relationship between medical compliance and health outcomes - hospitalization and mortality rates - using a large panel of patients residing in a local health authority in Italy. These data allow us to follow individual patients through all their accesses to public health care services until they either die or leave the local health authority. We adopt a disease specific approach, concentrating on hypertensive patients treated with ACE-inhibitors. Our results show that medical compliance has a clear effect on both hospitalization and mortality rates: health outcomes clearly improve when patients become more compliant to drug therapy. At the same time, we are able to infer valuable information on the role that drug co-payment can have on compliance, and as a consequence on health outcomes, by exploiting the presence of two natural experiments during the period of analysis. Our results show that drug co-payment has a strong effect on compliance, and that this effect is immediate.

Prescription drug benefits and Canada's uninsured

The Canada Health Act provides a framework for the Canadian health system and a mechanism for federal healthcare funds to flow to the provinces. Presently, the Canada Health Act covers medically necessary hospital, physician and surgical-dental as well as limited long-term care services, but not prescription medication. Though not mandated, each province has chosen to also develop a prescription drug benefit plan. These plans differ with respect to the groups that are covered and the type of coverage provided. In this paper, we describe the key structural elements of the various provincial plans. In addition, using a population-based national health and mental healthcare survey of 33,000 Canadians, we explore the characteristics of the population currently not covered by prescription drug benefits. Finally, we look at a sub-population of Canadians with mental illness with regard to their insurance coverage and use of prescription drugs. Our findings suggest that drug coverage within provinces is working for individuals with chronic physical conditions only. The findings herein reaffirm the need for a national strategy, support the notion that prescription drug coverage is important, and raise questions about the role of employers in providing these benefits.

Affordability of medicines and patients' cost-reducing behaviour: empirical evidence based on SUR estimates from Italy and the UK

INTRODUCTION

Studies have demonstrated that co-payments on medication reduce the consumption of both non-essential and essential drugs, and that the latter can lead to worse health outcomes. Far less is known about how patients cope with the cost of medication, particularly if affordability is an issue, and how this compares across two countries with different prescription charge policies. Therefore, the aim of this article is to explore empirically how, and to what extent, costs incurred by patients influence their decision-making behaviour in accessing medicines.

METHODS

Based on the findings from focus groups, a questionnaire was designed that addressed medication cost issues relevant to patients in both the UK and Italy. Using an econometric model, several hypotheses are tested regarding patients' decision-making behaviour and how it is influenced by health status, sociodemographic characteristics and the novel concept of a self-rated affordability measure.

RESULTS

Quite a large percentage of patients (70.3% in the UK and 66.5% in Italy) stated they have to think about the cost of medicines at least sometimes. Respondents adopted numerous cost-reducing strategies, subdivided into (i) those initiated by patients and (ii) those involving self-medication. Their use was strongly influenced by income and drug affordability problems, but the self-rated affordability measure was a stronger predictor. Commonly used strategies were not to get prescribed drugs dispensed at all, prioritizing by not getting all prescribed items dispensed or delaying until the respondent got paid. Furthermore, respondents with affordability issues were also cost-conscious when self-medicating with over-the-counter (OTC) products for minor conditions such as dyspepsia. Despite patients in both countries using cost-reducing strategies, their use was more pronounced in the UK, where the prescription charge was significantly higher than in Italy.

DISCUSSION/CONCLUSION

The results from this study provide detail on the kinds of strategies patients use to reduce the cost burden of prescription charges, and support previous research showing they may be foregoing essential medication. Because the same questionnaire was applied in two European countries, where the national health systems aim to provide healthcare services that are accessible to all citizens in need, it offers interesting insights for policy makers in other countries, where patients may have to pay a larger share of their drugs out-of-pocket, such as the US.

Satisfaction with and access to community care of the chronically ill in Israel's health system

One goal of Israel's National Health Insurance Law was to improve services for vulnerable populations. However, it was feared that this goal would not be reached for the chronically ill, due to the regulations governing health plan reimbursement and to amendments to the law that authorize additional co-payments for services.

OBJECTIVE

To examine the satisfaction with and organizational and financial access to services of chronically ill patients, and compare them to those of healthy consumers.

METHODS

In autumn 2001, telephone interviews were conducted with a random sample of 1790 permanent residents of Israel over age 22, 512 (28%) of whom reported having a chronic illness.

RESULTS

No significant differences were found between chronically ill and healthy respondents in satisfaction with services, and few differences were found in organizational access to services. However, differences were found in financial access to services. Specifically, chronic illness had an independent positive effect on the burden of co-payments for health services and the likelihood of forfeiting care or medication due to cost.

CONCLUSIONS

Increased co-payments for services may restrict access to care. To lighten the burden on vulnerable populations, it is necessary to consider discounts and lower ceilings on co-payments.

Diabetes-related inequalities in health status and financial barriers to health care access in a population-based study

AIMS

We evaluated the relationship between diabetes, health status, household income and expenditure on health care in the general population in Trinidad.

METHODS

Multistage sampling of 300 households was used to select a sample of 548 adults aged > or = 25 years. There were 64 (12%) who reported a diagnosis of diabetes. Comparison was made with 128 non-diabetic controls who were frequency matched for age and sex.

RESULTS

Subjects with diabetes had lower income levels than non-diabetic controls [income < or = US dollars 533 per month for 66% diabetes cases and 48% controls, test for trend P = 0.007]. Compared with controls, subjects with diabetes were less likely to have good or very good self-rated health (diabetes 32%, controls 67%; P < 0.001), and more frequently reported long-standing illness, limitation of activities, visual impairment, or self-reported history of high blood pressure, angina or heart attack. Subjects with diabetes (11%) were less likely than controls (30%) to have private health insurance (P = 0.005). Diabetic subjects (35%) were more likely than controls (16%) to have incurred expenditure on doctors' services in the last 4 weeks (P = 0.021).

CONCLUSIONS

Diabetes is associated with worse health status and more frequent expenditure on medical services but greater financial barriers to access in terms of low income and lack of health insurance. Policies for diabetes should specifically address the problem of income-related variations in risk of diabetes, health care needs and barriers to uptake of preventive and treatment services, otherwise inequalities in health from this condition may increase.

Composition and cost of drugs stored at home by elderly patients

BACKGROUND

Elderly people often have multiple chronic diseases, are frequently treated by several physicians, and also use over-the-counter medications. Excessive prescribing, imperfect therapeutic adherence, treatment modifications after hospitalization, and oversized drug packages result in home storage of leftover drugs, resulting in a waste of healthcare resources.

PATIENTS AND METHODS

All patients aged >/=75 years hospitalized for >24 hours during a 6-month period in an urban teaching hospital in Switzerland were eligible for inclusion in a study collecting sociodemographics, medical, functional, and psychosocial characteristics. Six months later, a research nurse visited the patients at home and recorded the names, number of tablets, and expiration dates of all open or intact drug packages, and the doses actually taken. Acquisition costs of these drugs were computed.

RESULTS

One hundred ninety-five patients were included (127 women; mean age 82.2 +/- 4.8 y, range 75-96). They had a total of 2059 drugs (mean per patient 10.3 +/- 6.7, range per patient 1-42), corresponding to a total cost of (US) $62 826 (mean per patient 322 +/- 275, range per patient 10-1571). Self-reported drug intake was regular for 36% of the drugs (46.5% of total costs) and occasional for 11% (6.1%), whereas 35.7% (30.1%) had been stopped during the last month. Cardiovascular drugs amounted to 36.6% of the drugs and 55.5% of the costs. None of the patients' characteristics was significantly associated with a greater number of drugs and higher costs.

CONCLUSIONS

Drugs stored at home by elderly patients were worth about $320 per patient. Only about one-third of these drugs were regularly taken. In the context of resources shortage, innovative solutions should be found to reduce the waste linked with drugs stopped in previous months.

The cost of prescription medicines to patients

The study compares the cost-sharing (co-payment) arrangements for prescribed medicines in a sample of EU countries. Through a set of typical prescription scenarios, the cost burden to individual patients of prescriptions are examined, in the context of drug price, and from the perspective of therapeutic need. The cost to patients of medicines is consistently lower in some, and higher in other, countries, regardless of the type of prescription charge system. Fixed charge systems, as opposed to graduated co-payment systems, are obviously more likely to lead to similar charges for the treatment of comparable clinical conditions, but depending on the level of the charge, can result in the patient paying a higher charge than the price of the drug to the health organisation. Exemption from charges for prescription medicines, commonly relate to clinical condition and level of income. Some systems also have age-related criteria and apply ceilings to the total prescription cost burden borne by the patient. The impact on patient costs of specific policy formulations is discussed and a proposal is made for cost convergence for comparable therapies. The method used in this study may also provide a route for investigating model systems prior to implementation.

Priority setting in health policy in Sweden and a comparison with Norway

The development of priority setting policies has been an important part of the national agenda for health services in Sweden and Norway during the past 10 years. Both countries have health systems with a pronounced public character and a declared emphasis on equity and solidarity. Both countries have also had National Priority Commissions that have developed general documents providing advice, but not very detailed guidelines, on how to set priorities. Resource constraints and the rapid restructuring of the health care system were important characteristics forming the background for the National Priority Commission in Sweden (1995). In Norway, the starting point for the first-ever Priority Commission in the world (1987) was how to set limits for health care in a society with rapidly increasing wealth. The second Norwegian Commission (1997) critically reviewed the effects of the general principles for priority setting that have been put forward, and demonstrated the importance to link them to steering tools within health care services.