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

The effect of social exclusion on the cognitive health of middle-aged and older adults: A systematic review

This systematic review aimed to evaluate the independent and joint effects of social exclusion in three specific domains-economic, social relations, and civic participation-on the cognitive health of middle-aged and older adults. Longitudinal studies from January 2000 to October 2023 were identified via Web of Science, Scopus, and PubMed, with sixty-five studies meeting inclusion criteria. The quality of the studies was assessed with Newcastle-Otawa Scale. Analysis revealed a strong association between economic exclusion and cognitive decline, with most studies indicating a significant negative impact. Ten studies found a positive link between volunteering and cognitive health for civic participation, while eight did not, showing mixed evidence. In social relations, most studies connected loneliness, social isolation, smaller social networks, reduced contact with family and friends, lower engagement in activities, and negative social interactions with cognitive decline. Notably, one study found that older adults experiencing social exclusion in multiple domains simultaneously face even greater cognitive decline. In summary, this review shows that social exclusion in economic, social relations, and civic participation and all together domains is associated with greater cognitive decline in older adults.

Clinically meaningful classes of financial toxicity for patients with diabetes

AIMS

This study aims to improve the interpretability and clinical utility of the COmprehensive Score for financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT) by identifying distinct financial toxicity classes in adults with diabetes.

METHODS

Data included a sample of 600 adults with Type 1 or Type 2 diabetes and high A1c. Latent Class Analysis was used to identify subgroups of patients based on COST-FACIT score patterns.

RESULTS

We identified 3 financial toxicity classes (high, medium and low) with strong indicators of membership classification. Multiple indicators of financial stress, maladaptive cost-coping behaviors, more comorbidities, more prescribed medications, more diabetes distress, more depressive symptoms, closer to the federal poverty level, female, having lower educational attainment and being single were all significant predictors of high financial toxicity class membership. A score of 26 on the COST-FACIT was the strongest threshold for sorting high vs. medium/low financial toxicity, with a positive predictive value (PPV) of 76% and negative predictive value (NPV) of 93%.

CONCLUSION

The COST-FACIT can be used to reliably identify people with diabetes that have high financial toxicity. Integrating this new cut-score into clinical practice may help clinical teams identify people in need of additional support due to financial toxicity.

Clinical Decision Support and Cardiometabolic Medication Adherence: A Randomized Clinical Trial

Importance

Medication adherence is important for managing blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), and hemoglobin A1c (HbA1c). Interventions to improve medication adherence are needed.

Objective

To examine the effectiveness of an intervention using algorithmic identification of low medication adherence, clinical decision support to physicians, and pharmacist outreach to patients to improve cardiometabolic medication adherence and BP, LDL-C, and HbA1c control.

Design, Setting, and Participants

A 2-arm, patient-randomized, parallel group clinical trial was conducted. Twenty-six primary care clinics using effective decision support to encourage timely adjustments of cardiometabolic medications were included. On the date of an index visit, participants were (1) aged 18 to 75 years, (2) receiving a statin or not at the goal level for HbA1c or BP, and (3) had proportion of days covered less than 80% for 1 or more BP or noninsulin glucose-lowering medications or a statin. The study was conducted from August 19, 2020, to September 30, 2023. Data analysis was performed from October 1, 2023, to August 30, 2024.

Intervention

Electronic health record-linked clinical decision support identified and encouraged discussion of medication adherence issues. For patients in the intervention cohort continuing to meet eligibility criteria 6 months after an index visit, pharmacist telephone outreach was attempted.

Main Outcomes and Measures

The main outcomes of the trial were (1) adherence to selected classes of cardiometabolic medications, (2) control of HbA1c, BP, or LDL-C levels at 12 months after the index visit, and (3) costs of care.

Results

Among 5421 participants (2990 [55%] male; mean [SD] age, 57 [11] years) 12 months after the index date, intervention patients had better adherence to BP medications (adjusted odds ratio [AOR], 1.29; 95% CI, 1.06-1.56), but no better adherence to statins (AOR, 1.18; 95% CI, 0.99-1.41) or noninsulin diabetes medications (AOR, 1.03; 95% CI, 0.82-1.30) compared with patients receiving usual care. The intervention did not improve mean HbA1c (-0.2%; 95% CI, -0.4 to 0.1), systolic BP (1.4 mm Hg; 95% CI, -0.8 to 3.5 mm Hg), or LDL-C (-1.8 mg/dL; 95% CI, -6.5 to 2.8 mg/dL). Compared with usual care, intervention patients eligible for pharmacist outreach had improved HbA1c (-0.4%; 95% CI, -0.8% to -0.1%) compared with those not eligible for outreach (-0.0; 95% CI, -0.3% to 0.3%). Health care use costs did not differ significantly between study arms.

Conclusions and Relevance

This cost-neutral intervention increased adherence to BP medications, but not to statins or glucose-lowering medications, with no overall improvement in BP, LDL-C, or HbA1c control. Modifications of this intervention strategy are needed to improve cardiometabolic risk factor control.

Trial Registration

ClinicalTrials.gov Identifier: NCT03748420.

Associations of serial negative income shock and all-cause mortality: a longitudinal study in China

Introduction

With a precarious economic outlook and increasing income volatility in current times, understanding the association between negative income shock and health is crucial. However, few studies have examined such associations in developing countries. Using data from China, this study aimed to examine associations of both serial absolute income drops and relative income trajectory and mortality.

Methods

We included 4757 participants from the China Health and Nutrition Survey, a large prospective cohort study. Data between 1989 and 1997 were used to define income drops and relative income trajectories. We defined income drop as a decrease of ≥50% between two consecutive interviews and defined relative income trajectory using a latent class model. All-cause mortality between 2000 and 2015 was ascertained by participants' family members.

Results

A total of 2066 (43.43%) experienced 1 income drop and 477 (10.03%) experienced ≥2 income drops. A total of 535 deaths occurred (incidence rate 8.88 per 1000 person-years). Income drops were associated with a greater risk of mortality after adjusting for baseline income, comorbidities, sociodemographic and behavioural factors (HR 1.42 (95% CI 1.04 to 1.93) for ≥2 income drops vs no income drop). The downshift in relative income was also associated with increased mortality risk (HR 3.61 (95% CI 1.45 to 8.96) for always low; HR 3.36 (95% CI 1.36 to 8.32) for decreasing; HR 2.92 (95% CI 1.14 to 7.51) for increasing vs always high relative income). The associations between income drops and mortality were observed only among individuals with low wealth and low household income.

Conclusion

In a large sample of the Chinese population with repeated income measurement and over 14 years of follow-up, both serial absolute income drops and a downward relative income trajectory were associated with higher risks of mortality in China. Priority should be given to policies aimed at enhancing resilience against serial income shocks and financial burdens.

Exploring patient perspectives on the impact of resuming cost sharing: a qualitative analysis

INTRODUCTION

The ACCESS trial showed that those who received a copayment elimination benefit had a modest improvement in their adherence to medications, but no improvement in clinical outcomes. This is consistent with other studies that have demonstrated that time-limited copayment elimination was welcomed by participants. However, the removal of such benefits can be problematic, as participants may have become accustomed to receiving the benefit, and made changes to their spending that would need to be reconsidered. We aimed to explore participants' experience with resuming cost sharing for their medications at the end of the ACCESS trial and if this experience influenced their willingness to participate in future trials like ACCESS.

METHODS

We conducted semi-structured interviews with 21 former participants of the ACCESS trial who were receiving the copayment elimination intervention, with discussions focused on the loss of the copayment elimination. The interviews were recorded, transcribed, and analyzed in duplicate using thematic analysis.

RESULTS

Four primary themes emerged from the analysis, including emotionality regarding loss of benefits; notification of benefit termination, describing tangible losses from coverage ending, but resistance to acknowledging negative impacts; and acceptability of receiving a temporary financial benefit. Many participants described negative emotions around the loss of coverage and concern about affording care for their chronic diseases. Despite negative emotions about the end of their study benefit, participants generally had a positive view of the study and would participate again in a future study of this nature.

CONCLUSION

The positive tangible and emotional benefits of the copayment elimination over 3 years outweighed the negative emotions and impacts associated with having to become reaccustomed to life without it.

PATIENT AND PUBLIC CONTRIBUTION

Within the ACCESS trial, participants were involved in the design, modification, and implementation of the program using multiple focus groups. The current study aimed to engage patients to provide input on their experience and engagement with the copayment elimination program.

Association of patient-reported financial barriers with healthcare utilization among Medicare beneficiaries with a history of cancer

PURPOSE

We examined characteristics associated with financial barriers to healthcare and the association of financial barriers with adverse healthcare events among US adult cancer survivors enrolled in Medicare.

METHODS

We used nationally representative Medicare Current Beneficiary Survey data (2011-2013, 2015-2017) to identify adults with a history of non-skin cancer. We defined financial barriers as cost-related trouble accessing and/or delayed care in the prior year. Using propensity-weighted multivariable logistic regression, we examined associations between financial barriers and adverse healthcare events (any ED visits, any inpatient hospitalizations).

RESULTS

Overall, 11.0% of adult Medicare beneficiaries with a history of cancer reported financial barriers in the prior year, with higher burden among beneficiaries < 65 years of age vs. ≥ 65 (32.5% vs. 8.2%, p < 0.0001) and with annual income < $25,000 vs. ≥ $25,000 (18.1% vs. 6.9%, p < 0.0001). In bivariate models, financial barriers were associated with a 7.8 percentage point (95% CI: 1.5-14.0) increase in the probability of ED visits. In propensity-weighted models, this association was not statistically significant. The association between financial barriers and hospitalizations was not significant in the overall population; however, financial barriers were associated with a decreased probability of hospitalization among Black/African American beneficiaries.

CONCLUSIONS

Despite Medicare coverage, beneficiaries with a history of cancer are at risk for experiencing financial barriers to healthcare. In the overall population, financial barriers were not associated with ED visits or hospitalizations.

IMPLICATIONS FOR CANCER SURVIVORS

Policies limiting Medicare patient out-of-pocket spending and care models addressing health-related social needs are needed to reduce financial barriers experienced.

A Randomized Controlled Trial to Improve Unmet Social Needs and Clinical Outcomes Among Adults with Diabetes

BACKGROUND

Adults with type 1 or type 2 diabetes often face financial challenges and other unmet social needs to effective diabetes self-management.

OBJECTIVE

Whether a digital intervention focused on addressing socioeconomic determinants of health improves diabetes clinical outcomes more than usual care.

DESIGN

Randomized trial from 2019 to 2023.

PARTICIPANTS

A total of 600 adults with diabetes, HbA1c ≥ 7.5%, and self-reported unmet social needs or financial burden from a health system and randomized to the intervention or standard care.

INTERVENTION

CareAvenue is an automated, e-health intervention with eight videos that address unmet social needs contributing to poor outcomes.

MEASURES

Primary outcome was HbA1c, measured at baseline, and 6 and 12 months after randomization. Secondary outcomes included systolic blood pressure and reported met social needs, cost-related non-adherence (CRN), and financial burden. We examined main effects and variation in effects across predefined subgroups.

RESULTS

Seventy-eight percent of CareAvenue participants completed one or more modules of the website. At 12-month follow-up, there were no significant differences in HbA1c changes between CareAvenue and control group (p = 0.24). There were also no significant between-group differences in systolic blood pressure (p = 0.29), met social needs (p = 0.25), CRN (p = 0.18), and perceived financial burden (p = 0.31). In subgroup analyses, participants with household incomes 100-400% FPL (1.93 (SE = 0.76), p < 0.01), 201-400% FPL (1.30 (SE = 0.62), p < 0.04), and > 400% FPL (1.27 (SE = 0.64), p < 0.05) had significantly less A1c decreases compared to the control group.

CONCLUSIONS

On average, CareAvenue participants did not achieve better A1c lowering, met needs, CRN, or perceived financial burden compared to control participants. CareAvenue participants with higher incomes achieved significantly less A1c reductions than control. Further research is needed on social needs interventions that consider tailored approaches to population subgroups.

CLINICAL TRIALS REGISTRY

ClinicalTrials.gov ID NCT03950973, May 2019.

Predicting Self-Reported Social Risk in Medically Complex Adults Using Electronic Health Data

BACKGROUND

Social barriers to health care, such as food insecurity, financial distress, and housing instability, may impede effective clinical management for individuals with chronic illness. Systematic strategies are needed to more efficiently identify at-risk individuals who may benefit from proactive outreach by health care systems for screening and referral to available social resources.

OBJECTIVE

To create a predictive model to identify a higher likelihood of food insecurity, financial distress, and/or housing instability among adults with multiple chronic medical conditions.

RESEARCH DESIGN AND SUBJECTS

We developed and validated a predictive model in adults with 2 or more chronic conditions who were receiving care within Kaiser Permanente Northern California (KPNC) between January 2017 and February 2020. The model was developed to predict the likelihood of a "yes" response to any of 3 validated self-reported survey questions related to current concerns about food insecurity, financial distress, and/or housing instability. External model validation was conducted in a separate cohort of adult non-Medicaid KPNC members aged 35-85 who completed a survey administered to a random sample of health plan members between April and June 2021 (n = 2820).

MEASURES

We examined the performance of multiple model iterations by comparing areas under the receiver operating characteristic curves (AUCs). We also assessed algorithmic bias related to race/ethnicity and calculated model performance at defined risk thresholds for screening implementation.

RESULTS

Patients in the primary modeling cohort (n = 11,999) had a mean age of 53.8 (±19.3) years, 64.7% were women, and 63.9% were of non-White race/ethnicity. The final, simplified model with 30 predictors (including utilization, diagnosis, behavior, insurance, neighborhood, and pharmacy-based variables) had an AUC of 0.68. The model remained robust within different race/ethnic strata.

CONCLUSIONS

Our results demonstrated that a predictive model developed using information gleaned from the medical record and from public census tract data can be used to identify patients who may benefit from proactive social needs assessment. Depending on the prevalence of social needs in the target population, different risk output thresholds could be set to optimize positive predictive value for successful outreach. This predictive model-based strategy provides a pathway for prioritizing more intensive social risk outreach and screening efforts to the patients who may be in greatest need.

Impact of cost on prescribing diabetes medications for older adults with type 2 diabetes in the outpatient setting

BACKGROUND

Newer diabetes medications have cardiorenal benefits beyond blood sugar lowering that make them a preferred treatment option in many patients. Despite this, studies have shown that prescribing of these medications remains suboptimal with medication costs being hypothesized as a reason for underutilization.

OBJECTIVE

To understand clinicians' decision-making processes for prescribing diabetes medications in older adults, focusing on higher cost medications.

METHODS

Observations of patient encounters and semi-structured interviews were conducted with clinicians from primary care, endocrinology, and geriatrics to elucidate themes into diabetes medication prescribing. A qualitative descriptive approach was used to analyze the data from interviews using an inductive coding scheme with themes derived from the data.

RESULTS

Twenty-one interviews were conducted. Five themes were identified: 1) out-of-pocket costs drive prescribing decisions 2) out-of-pocket costs can be variable due to changing insurance plans or changing coverage 3) clinicians have difficulty with determining patient-specific out-of-pocket costs 4) clinicians manage the tradeoffs existing between cost, efficacy, and safety and 5) clinicians can use cost-modifying strategies such as patient assistance.

CONCLUSION

Addressing the challenges that medication costs pose to prescribing evidence-based medications for type 2 diabetes is necessary to optimize diabetes care for older adults.

Global outlook on affordability of biotherapeutic drugs

Although biotherapeutic drugs have the potential of transforming the management of many life-threatening diseases, their affordability and accessibility remain an issue. This study offers an overview of the global affordability of biotherapeutic products. For this, prices for 10 representative biotherapeutic products were examined in 40 countries, including high-income countries (HICs), upper middle-income countries (UMICs), lower middle-income countries (LMICs), and low-income countries (LICs). The affordability of these biotherapeutics was calculated based on the World Health Organization/Health Action International (WHO/HAI) method. As expected, affordability was found to be better in HICs, followed by UMICs, LMICs, and finally, LICs. Furthermore, based on the trend of per capita income, we predict that in UMICs and LMICs, the affordability of high molecular weight biologics will worsen by 1.5× and 2× by 2030, respectively, and further by 4× and 6× by 2040. On the other hand, affordability will stay nearly the same for people living in HICs in the coming decades. Our analysis suggests that it is imperative that measures be taken to make this class of products more affordable and accessible. Governments can contribute by creating conducive policies. Global institutions like the WHO can play a significant role as well. Finally, manufacturers need to invest in and implement manufacturing innovations.

Challenges in Promoting Health Equity and Reducing Disparities in Access Across New and Established Technologies

Medical innovations and novel technologies stand to improve the return on high levels of health spending in developed countries, particularly in cardiovascular care. However, cardiac innovations also disrupt the landscape of accessing care, potentially creating disparities in who has access to novel and extant technologies. These disparities might disproportionately harm vulnerable groups, including those whose nonmedical conditions-including social determinants of health-inhibit timely access to diagnoses, referrals, and interventions. We first document the barriers to access novel and existing technologies in isolation, then proceed to document their interaction. Novel cardiac technologies might affect existing available services, and change the landscape of care for vulnerable patient groups who seek access to cardiology services. There is a clear need to identify and heed lessons learned from the dissemination of past innovations in the development, funding, and dissemination of future medical technologies to promote equitable access to cardiovascular care. We conclude by highlighting and synthesizing several policy implications from recent literature.

Cardiovascular consequences of financial stress: A systematic review and meta-analysis

BACKGROUND

Cardiovascular diseases (CVD), notably coronary artery disease (CAD) and coronary heart disease (CHD), are predominant contributors to global morbidity and mortality. Financial stress is recognized as a non-traditional risk factor for CVD. The objective of this study is to conduct a systematic review and meta-analysis on the association between financial stress and the incidence of major cardiac outcomes.

METHODS

A literature search was conducted across multiple databases up until September 20, 2023. Primary studies reporting the association between financial stress and the incidence of CAD, CHD, or major cardiovascular outcomes were included. The quality of the incorporated studies was evaluated using the Newcastle-Ottawa Scale. Statistical analysis was performed using R version 4.3, employing a random-effects model.

RESULTS

Out of 2,740 identified studies, seven satisfied the inclusion criteria, displaying a diverse range in design, settings, and participant demographics. A significant association was found between financial stress and major cardiac outcomes, with a combined hazard ratio (HR) of 1.191 (95% CI: 1.00 to 1.47), p<0.001 from five studies. Possible publication bias and variations in definitions and measurements of financial stress were noted among the studies.

CONCLUSION

The available literature substantiates an association between financial stress and the incidence of CAD/CHD or major cardiac outcomes, underscoring an urgent need for standardized definitions and measurements of financial stress. Our findings support the integration of financial stress assessments in patient care and the development of health policies emphasizing economic strains to enhance cardiovascular health outcomes and overall well-being.

Protocol of a patient randomized clinical trial to improve medication adherence in primary care

BACKGROUND

Enhanced awareness of poor medication adherence could improve patient care. This article describes the original and adapted protocols of a randomized trial to improve medication adherence for cardiometabolic conditions.

METHODS

The original protocol entailed a cluster randomized trial of 28 primary care clinics allocated to either (i) medication adherence enhanced chronic disease care clinical decision support (eCDC-CDS) integrated within the electronic health record (EHR) or (ii) usual care (non-enhanced CDC-CDS). Enhancements comprised (a) electronic interfaces printed for patients and clinicians at primary care encounters that encouraged discussion about specific medication adherence issues that were identified, and (b) pharmacist phone outreach. Study subjects were individuals who at an index visit were aged 18-74 years and not at evidence-based care goals for hypertension (HTN), diabetes mellitus (DM), or lipid management, along with low medication adherence (proportion of days covered [PDC] <80%) for a corresponding medication. The primary study outcomes were improved medication adherence and clinical outcomes (BP and A1C) at 12 months. Protocol adaptation became imperative in response to major implementation challenges: (a) the availability of EHR system-wide PDC calculations that superseded our ability to limit PDC adherence information solely to intervention clinics; (b) the unforeseen closure of pharmacies committed to conducting the pharmacist outreach; and (c) disruptions and clinic closures due to the Covid-19 pandemic.

CONCLUSION

This manuscript details the protocol of a study to assess whether enhanced awareness of medication adherence issues in primary care settings could improve patient outcomes. The need for protocol adaptation arose in response to multiple implementation challenges.

Medication Cost Concerns and Disparities in Patient-Reported Outcomes Among a Multiethnic Cohort of Patients With Systemic Lupus Erythematosus

OBJECTIVE

Concerns about the affordability of medications are common in systemic lupus erythematosus (SLE), but the relationship between medication cost concerns and health outcomes is poorly understood. We assessed the association of self-reported medication cost concerns and patient-reported outcomes (PROs) in a multiethnic SLE cohort.

METHODS

The California Lupus Epidemiology Study is a cohort of individuals with physician-confirmed SLE. Medication cost concerns were defined as having difficulties affording SLE medications, skipping doses, delaying refills, requesting lower-cost alternatives, purchasing medications outside the United States, or applying for patient assistance programs. Linear regression and mixed effects models assessed the cross-sectional and longitudinal association of medication cost concerns and PROs, respectively, adjusting for age, sex, race and ethnicity, income, principal insurance, immunomodulatory medications, and organ damage.

RESULTS

Of 334 participants, medication cost concerns were reported by 91 (27%). Medication cost concerns were associated with worse Systemic Lupus Activity Questionnaire (SLAQ; beta coefficient [β] 5.9, 95% CI 4.3-7.6; P < 0.001), 8-item Patient Health Questionnaire depression scale (PHQ-8; β 2.7, 95% CI 1.4-4.0; P < 0.001), and Patient-Reported Outcomes Measurement Information System (PROMIS; β for physical function -4.6, 95% CI -6.7 to -2.4; P < 0.001) scores after adjusting for covariates. Medication cost concerns were not associated with significant changes in PROs over 2-year follow-up.

CONCLUSION

More than a quarter of participants reported at least 1 medication cost concern, which was associated with worse PROs. Our results reveal a potentially modifiable risk factor for poor outcomes rooted in the unaffordability of SLE care.

Patients want to talk about their out-of-pocket costs-Can real-time benefit tools help?

This editorial comments on the article by Mattingly et al.

Out-of-Pocket Health Care Spending at Older Ages: Do Caregiving Arrangements Matter?

Identifying the correlates of out-of-pocket (OOP) health care spending is an important step for ensuring the financial security of older adults. Whether or not someone has a family member providing assistance is one such factor that could be associated with OOP spending. If family caregivers facilitate better health, health care spending could be reduced. On the other hand, costs would be higher if family members facilitate more (or more costly) care for loved ones. This paper explores the relationship between caregiving arrangements and OOP spending using data from 5045 individuals in the 2000-2016 Health and Retirement Study with Medicare coverage and caregiving needs. We do not find a relationship between family caregiving and OOP health care costs, overall. However, among those with Medicare HMO insurance, having a family caregiver is associated with more spending than having no helper. This is mainly due to differences in spending on prescription medications.

Treatment outcomes and associated factors among chronic ambulatory heart failure patients at Jimma Medical Center, South West Ethiopia: prospective observational study

BACKGROUND

Heart failure has been one of the major causes of hospitalization across the world. Focusing on the treatment outcomes of ambulatory heart failure patients will reduce the burden of heart failure such as hospitalization and improve patient quality of life. Even if research is conducted on acute heart failure patients, there is limited data about treatment outcomes of chronic ambulatory heart failure patients. Therefore, this study aimed to assess treatment outcomes and associated factors of chronic ambulatory heart failure patients at Jimma Medical Center, South West Ethiopia.

METHODS

A hospital-based prospective observational study was conducted on 242 chronic ambulatory heart failure patients at Jimma Medical Center from November 2020 to June 2021. The data were collected with pretested data collection format, and analyzed with Statistical Package for Social Sciences version 23. Both univariate and multivariate logistic regression model were used to identify factors associated with treatment outcomes of outpatient heart failure, and with a reported p value < 0.05, 95% confidence interval (CI) was considered statistical significance.

RESULT

From 242 patients, 126 (52.1%) were males and 121 (50.0%) patients were aged between 45 and 65 years. Regarding treatment outcomes, 51 (21.1%) of patients were hospitalized, and 58 (24.0%) and 28 (11.6%) of patients had worsened and improved clinical states respectively. Clinical inertia [AOR = 2.820; 95% CI (1.301, 6.110), p = 0.009], out-of-pocket payment [AOR = 2.790; 95% CI (1.261, 6.172), p = 0.011] and New York Heart Association class II [AOR = 2.534; 95% CI (1.170, 5.488), p = 0.018] were independent predictors of hospitalization.

CONCLUSION

Hospitalization of ambulatory heart failure patients was relatively high. More than half of the patients had clinical inertia. And also, this study showed most ambulatory HF patients had inadequate self-care. Clinical inertia, out-of-pocket payment, and New York Heart Association class II were independent predictors of hospitalization in ambulatory heart failure patients. Therefore, it is better to give more attention to ambulatory heart failure patients to prevent hospitalization and the burden of heart failure.

Addressing Financial Barriers to Health Care Among People Who are Low-Income and Insured in New York City, 2014–2017

While health care-associated financial burdens among uninsured individuals are well described, few studies have systematically characterized the array of financial and logistical complications faced by insured individuals with low household incomes. In this mixed methods paper, we conducted 6 focus groups with a total of 55 residents and analyzed programmatic administrative records to characterize the specific financial and logistic barriers faced by residents living in public housing in East and Central Harlem, New York City (NYC). Participants included individuals who enrolled in a municipal community health worker (CHW) program designed to close equity gaps in health and social outcomes. Dedicated health advocates (HAs) were explicitly paired with CHWs to provide health insurance and health care navigational assistance. We describe the needs of 150 residents with reported financial barriers to care, as well as the navigational and advocacy strategies taken by HAs to address them. Finally, we outline state-level policy recommendations to help ameliorate the problems experienced by participants. The model of paired CHW–HAs may be helpful in addressing financial barriers for insured populations with low household income and reducing health disparities in other communities.

Managing the onset of a new disease in older age: Housing wealth, mortgage borrowing, and medication adherence

The relationship between wealth and health is an important yet complex topic for health research. While prior studies document the importance of wealth for healthy aging, the understanding of the mechanisms through which wealth supports health consumption is limited. We investigate the wealth-to-health link by explicitly modeling the effect of liquidating home equity through borrowing on health expenditures, measured here as cost-related non-adherence to prescription medications (CRN), following the onset of one of six costly diseases on or after age 65. Using individual-level data from the 2002-2018 waves of the U.S. Health and Retirement Study (3,772 respondents; 13,708 observations), we exploit exogenous spatial and intertemporal variation in ZIP-code level house values to instrument for borrowing. Results indicate each additional $10,000 in new mortgage borrowing is associated with a 1.6 percentage point reduction in CRN. In subsample regressions, this relationship is strongest for older adults for whom home equity is their largest source of wealth. In a falsification test, we find no relationship between house value changes and CRN for older renters, and no effect of mortgage borrowing on prescription drug non-adherence for health or memory reasons. Our results contribute to the literature by documenting how housing wealth can be tapped by older adults through borrowing to smooth health-related consumption following disease diagnosis. However, not all older homeowners are willing or able to borrow from home equity. Our findings suggest that it is not simply the stock of housing wealth that leads to better health outcomes, but instead the liquidation of housing wealth. Housing wealth is thus not a uniform social determinate of health for older homeowners as it is moderated by the ability to borrow.

Measurement and Validation of the Comprehensive Score for Financial Toxicity (COST) in a Population With Diabetes

OBJECTIVE

The Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT) is a validated instrument measuring financial distress among people with cancer. The reliability and construct validity of the 11-item COST-FACIT were examined in adults with diabetes and high A1C.

RESEARCH DESIGN AND METHODS

We examined the factor structure (exploratory factor analysis), internal consistency reliability (Cronbach α), floor/ceiling effects, known-groups validity, and predictive validity among a sample of 600 adults with diabetes and high A1C.

RESULTS

COST-FACIT demonstrated a two-factor structure with high internal consistency: general financial situation (7-items, α = 0.86) and impact of illness on financial situation (4-items, α = 0.73). The measure demonstrated a ceiling effect for 2% of participants and floor effects for 7%. Worse financial toxicity scores were observed among adults who were women, were below the poverty line, had government-sponsored health insurance, were middle-aged, were not in the workforce, and had less educational attainment (P < 0.01). Worse financial toxicity was observed for those engaging in cost coping behaviors, such as taking less or skipping medicines, delaying care, borrowing money, "maxing out" the limit on credit cards, and not paying bills (P < 0.01). In regression models for the full measure and its two factors, worse financial toxicity was correlated with higher A1C (P < 0.01), higher levels of diabetes distress (P < 0.01), more chronic conditions (P < 0.01), and more depressive symptoms (P < 0.01).

CONCLUSIONS

Findings support both the reliability and validity of the COST-FACIT tool among adults with diabetes and high A1C levels. More research is needed to support the use of the COST-FACIT tool as a clinically relevant patient-centered instrument for diabetes care.

Cost Analysis on Total Cost Incurred (Including Out-of-pocket Expenditure and Social Cost) During Palliative Care in Cases of Head-and-Neck Cancer at a Government Regional Cancer Centre in North India

Objectives:

Palliative care involves providing symptomatic relief from the pain and stress of a severe illness to markedly improve the quality of life for both the patients and their families. It imposes high indirect costs on the patients. The study was conducted at SGPGIMS, which caters to 500 head-and-neck cancer patients annually. Out of these, 30–40% of cases require dedicated palliative care. Unfortunately, often, when patients reach the stage of palliative care, they have exhausted their all financial reserves. Therefore, a cost analysis of total cost incurred (including out-of-pocket expenditure and social cost) during palliative care in cases of head-and-neck cancer at a Government Regional Cancer Centre was undertaken.

Material and Methods:

The study is a descriptive study and the study sample consisted of (a) patients who had undergone surgery, chemotherapy, or radiotherapy and had recurred/relapsed and were now candidates for palliative care and (b) patients who presented de novo to the Regional Cancer Centre, SGPGIMS with advanced-stage disease, where the cure was not possible. The expenditure incurred was obtained retrospectively and prospectively from the study samples.

Results:

The out-of-pocket expenditure per patient per day was INR 2044.21. The social cost per patient per day was INR 518.21. Out of the total expenditure of INR 2562.42/patient/day, 80% of the cost was out-of-pocket expenditure and the remaining 20% was social cost borne by the patient.

Conclusion:

The study thus added to perspective on the average expenditure on out-of-pocket expenses and social costs being incurred as of date, while getting palliative care for head-and-neck cancer at a Regional Cancer Centre.

Racial Differences and Social Determinants of Health in Achieving Hypertension Control

OBJECTIVE

To investigate whether specific social determinants of health could be a "health barrier" toward achieving blood pressure (BP) control and to further evaluate any differences between Black patients and White patients.

PATIENTS AND METHODS

We conducted a retrospective cohort study of 3305 patients with elevated BP who were enrolled in a hypertension digital medicine program for at least 60 days and followed up for up to 1 year. Patients were managed virtually by a dedicated hypertension team who provided guideline-based medication management and lifestyle support to achieve goal BP.

RESULTS

Compared with individuals without any health barriers, the addition of 1 barrier was associated with lower probability of control at 1 year from 0.73 to 0.60 and to 0.55 in those with 2 or more barriers. Health barriers were more prevalent in Black patients than in those who were White (44.6% [482 of 1081] vs 31.3% [674 of 2150]; P<.001). There was no difference at all in BP control between Black individuals and those who were White if 2 or more barriers were present.

CONCLUSION

Patient-related health barriers are associated with BP control. Black patients with poorly controlled hypertension have a higher prevalence of health barriers than their White counterparts. When 2 or more health barriers were present, there was no differences in BP control between White and Black individuals.

Bridging Care Transition After Hospitalization for Atrial Fibrillation and Coronary Interventions

ABSTRACT

Treatment fragmentation between hospitals and the community can result in catastrophic outcomes; uninterrupted treatment with anticoagulant and platelet aggregation inhibitors is particularly important. We assessed the proportion and characteristics of patients who did not visit their primary community-based physician within 1 week of discharge from our department of cardiovascular medicine and the proportion that failed to procure essential drugs at the community pharmacy. We prospectively studied 423 patients who were discharged from our department. They were provided detailed explanations, tablets for 7 days, prescriptions, and a printed drug plan. We traced the time from discharge until a visit with a primary community-based physician, and the time until the procurement of medications, using our computerized community-hospital-integrated system. Complete data were available for 313 patients, of whom 220 were treated with anticoagulants or platelet aggregation inhibitors. For 175 patients, these drugs were initiated during index hospitalizations. Only 1 patient did not receive platelet aggregation inhibitors despite recommendations. Seventy-nine patients (25%) first visited their primary care physicians more than 1 week after discharge. Predictors for delayed visits were living alone (hazard ratio 1.91) and having an in-house caregiver (hazard ratio 2.01). In conclusion, all but 1 patient continued drug therapy after discharge from the hospital. The simple predischarge steps included patient education and provision of a 1-week supply of tablets and prescriptions. Treatment continuation was independent of visits to the community-based primary physician. Patients living alone or with an in-house caregiver more often delayed visits to primary physicians yet continued relevant drug therapy.

Prevalence and characterization of forgoing care: comparison of two prospective multicentre cohorts between pre-COVID-19 era and a lockdown period

BACKGROUND

Little is known about patients who forego healthcare, although it is an important provider of unfavorable health-related outcomes. Forgoing healthcare characterizes situations in which people do not initiate or interrupt a care process, even though they perceive the need for it, whether or not this need is medically proven. The aims of this study were to assess the prevalence and the determinants of patients who forego healthcare. The second aim was to compare the characteristics of patients who gave up healthcare during the French lockdown due to COVID-19.

METHODS

We conducted two multicenter cross-sectional studies in 2017 and 2020 carried out in French patients presenting to the emergency departments. Patients who gave their consent to participate were interviewed with a standardized questionnaire. It consisted of two parts: epidemiological characteristics and health care refusal. A third part concerning the renunciation of care during the COVID-19 period was added to the second study period.

RESULTS

A total of 1878 patients had completed the questionnaire during the interview with the physicians, 900 during the first period in 2017 (47.9%) and 978 (52.1%) during the second period. A total of 401/1878 patients reported not seeking care in the last 12 months (21.4% [95%CI: 19.5-23.3%]). In 2020, patients forewent care more during the confinement period than outside with different characteristics of the foregoing care populations.

CONCLUSION

Forgoing care is common in a universal health care system such as France's and increased during the pandemic. Key public health messages targeted at the reasons for not seeking care must now be disseminated in order to combat this.

The Price of Progress: Cost, Access, and Adoption of Novel Cardiovascular Drugs in Clinical Practice

Purpose of Review

The launch of new effective and safe cardiovascular drugs has produced large gains in health outcomes for several cardiovascular conditions. But this innovation comes at the cost of rapidly increasing pharmaceutical spending and high out-of-pocket costs.

Recent Findings

In the USA, manufacturers are able to set prices according to what the market will bear rather than value to patients or society, with a complicated system of discounts and rebates obscuring the final price borne by payors. Some of these costs are passed on to patients in the form of co-payments or co-insurance, making these effective but high-cost medications unaffordable for many patients. Orphan drugs developed to treat rare diseases—for which manufactures are presented substantial financial and regulatory benefits—are particularly problematic, as they typically enter the market at very high prices compared with drugs for other indications.

Summary

Systematic cost-effectiveness analyses from the healthcare sector or societal perspectives can help identify the value-based price of a medication at market entry as well as later in the lifecycle of the drug when more data on effectiveness and safety becomes available. Despite bipartisan support, legislative progress on drug pricing has been slow. Clinicians should know the cost of the drugs they prescribe frequently, use generics where feasible, and regularly discuss out-of-pocket costs with patients to pre-empt cost-related non-adherence.

Vulnerable patients forgo health care during the first wave of the Covid-19 pandemic

During the first wave of the Covid-19 pandemic, access to health care was limited, and patients encountered important delays for scheduled appointments and care. Empirical data relying on patients' reports of forgoing health care are scarce. This study investigated Covid-19-related self-reports of forgoing health care in a sample of vulnerable outpatients in Geneva, Switzerland. We collected data from 1167 adult outpatients, including clinically vulnerable patients (with chronic diseases), geriatric patients (involved in a health care network for people aged 60 or older), and socially vulnerable patients (involved in a migrant health program or a mobile outpatient community care center) in June 2020. Data on sociodemographic factors, forgoing health care, and anti-SARS-CoV-2 antibodies were collected. Of the patients, 38.5% reported forgoing health care. Forgoing health care was more frequent for younger patients, women, patients with a low level of education, and patients with a chronic disease (p < .001). There was no significant association between the presence of anti-SARS-CoV-2 antibodies and forgoing health care (p = .983). As the decrease in routine management of patients might have important and unpredictable adverse health consequences, avoiding delayed health care is crucial.

Financial burden, distress, and toxicity in cardiovascular disease

Cardiovascular disease (CVD) is a major source of financial burden and distress, which has 3 main domains: (1) psychological distress; (2) cost-related care non-adherence or medical care deferral, and (3) tradeoffs with basic non-medical needs. We propose 4 ways to reduce financial distress in CVD: (1) policymakers can expand insurance coverage and curtail underinsurance; (2) health systems can limit expenditure on low-benefit, high-cost treatments while developing services for high-risk individuals; (3) physicians can engage in shared-decision-making for high-cost interventions, and (4) community-based initiatives can support patients with system navigation and financial coping. Avenues for research include (1) analysis of how healthcare policies affect financial burden; (2) comparative effectiveness studies examining high and low-cost strategies for CVD management; and (3) studying interventions to reduce financial burden, financial coaching, and community health worker integration.

High Out-of-pocket Health Care Cost Burden Among Medicare Beneficiaries With Diabetes, 1999-2017

OBJECTIVE

We examined the magnitude of and trends in the burden of out-of-pocket (OOP) costs among Medicare beneficiaries age 65 years or older with diabetes overall, by income level, by race/ethnicity, and compared with beneficiaries without diabetes.

RESEARCH DESIGN AND METHODS

Using data from the 1999-2017 Medicare Current Beneficiary Survey, we estimated average annual per capita OOP costs and percentage of beneficiaries experiencing high OOP burden, defined as OOP costs >10% or >20% of household income. We used joinpoint regression to examine the trends and generalized linear model and logistic regression for comparisons between beneficiaries with and without diabetes. Cost and income estimates were adjusted to 2017 USD.

RESULTS

Total OOP costs were $3,609-$5,283, with significant increases until 2005 followed by a leveling off. The prevalence of high OOP burden was 57%-72% at the 10% income threshold and 29%-41% at the 20% threshold, with significant increasing trends until 2003 followed by decreases. Total OOP costs were the highest in the ≥75% income quartile, whereas prevalence of high OOP burden was highest in the <25% and 25-50% income quartiles. Non-Hispanic Whites had the highest OOP costs and prevalence of high OOP burden. Beneficiaries with diabetes had significantly higher OOP costs ($498, P < 0.01) and were more likely to have high OOP burden than those without diabetes (odds ratios 1.32 and 1.25 at >10% and >20% thresholds, respectively, P < 0.01).

CONCLUSIONS

Over the past two decades, Medicare beneficiaries age 65 years or older with diabetes have faced substantial OOP burden, with large income-related disparities.

Recruiting people facing social disadvantage: the experience of the Free Meds study

BACKGROUND

Researching access to health services, and ways to improve equity, frequently requires researchers to recruit people facing social disadvantage. Recruitment can be challenging, and there is limited high quality evidence to guide researchers. This paper describes experiences of recruiting 1068 participants facing social disadvantage for a randomised controlled trial of prescription charges, and provides evidence on the advantages and disadvantages of recruitment methods.

METHODS

Those living in areas of higher social deprivation, taking medicines for diabetes, taking anti-psychotic medicines, or with COPD were eligible to participate in the study. Several strategies were trialled to meet recruitment targets. We initially attempted to recruit participants in person, and then switched to a phone-based system, eventually utilising a market research company to deal with incoming calls. We used a range of strategies to publicise the study, including pamphlets in pharmacies and medical centres, media (especially local newspapers) and social media.

RESULTS

Enrolling people on the phone was cheaper on average than recruiting in person, but as we refined our approach over time, the cost of the latter dropped significantly. In person recruitment had many advantages, such as enhancing our understanding of potential participants' concerns. Forty-nine percent of our participants are Māori, which we attribute to having Māori researchers on the team, recruiting in areas of high Māori population, team members' existing links with Māori health providers, and engaging and working with Māori providers.

CONCLUSIONS

Recruiting people facing social disadvantage requires careful planning and flexible recruitment strategies. Support from organisations trusted by potential participants is essential.

REGISTRATION

The Free Meds study is registered with the Australian and New Zealand Clinical Trials Registry ( ACTRN12618001486213 ).

Association of Branded Prescription Drug Rebate Size and Patient Out-of-Pocket Costs in a Nationally Representative Sample, 2007-2018

IMPORTANCE

Over the past decade, branded prescription drug manufacturers have substantially increased list prices while offering larger rebate payments to health care insurers. Whereas larger rebates can partially offset increases in list prices for insurers, patient out-of-pocket costs may be directly associated with list prices for individuals without insurance and indirectly associated with list prices for individuals with insurance through deductibles or coinsurance.

OBJECTIVE

To investigate the association between rebates and patient out-of-pocket costs and whether this association differs by coverage type (ie, Medicare, commercial, or uninsured) and before and after 2014.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted using data from the Medical Expenditure Panel Survey (MEPS) combined with pricing data for single-source branded drugs from SSR Health from 2007 through 2018. The study was conducted among a nationally representative sample of the noninstitutionalized civilian US population. Included individuals were respondents to MEPS with at least 1 prescription for a single-source branded drug who were covered by Medicare or commercial insurance or were uninsured during an entire year. Data analyses were conducted from August 2019 through March 2021.

EXPOSURES

Estimated rebate size.

MAIN OUTCOMES AND MEASURES

Out-of-pocket costs per prescription were calculated, adjusting for year and drug.

RESULTS

Among 38 131 individuals with at least 1 prescription, the mean age was 54 years (95% CI, 54 to 55 years), with 22 044 women (57.8%) and 29 086 White individuals (76.3%). The sample included 444 unique drugs with a survey-weighted total of 4.7 billion prescriptions. Estimated mean (SE) rebates increased from $34 ($1) per prescription in 2007 to $374 ($9) per prescription in 2018. The rebate sizes were associated with statistically significant mean out-of-pocket increases per branded prescription of $4 (95% CI, $4 to $4) from 2007 to 2013 and $11 (95% CI, $10 to $12) from 2014 to 2018. From 2014 to 2018, rebate sizes were associated with statistically significant mean increases in out-of-pocket costs per prescription of $13 (95% CI, $12 to $13) for individuals with Medicare, $6 (95% CI, $6 to $7) for individuals with commercial insurance, and $39 (95% CI, $34 to $44) for individuals without insurance. After adjusting for list prices, there was no association between rebates and out-of-pocket costs, with a change from 2014 to 2018 of -$0.01 (95% CI, -$0.04 to $0.02).

CONCLUSIONS AND RELEVANCE

These findings suggest that drug manufacturers may have provided larger rebates to insurers primarily by increasing list prices and that individuals without insurance had greater cost increases. The results emphasize the need for policy solutions that decouple list prices and out-of-pocket costs.

Beyond price: the effects of non-financial barriers on access to drugs and health outcomes

OBJECTIVES

We study the impact of the pharmacy dispensing channel (as a proxy for access to drugs) on the drug purchases, health outcomes, and health care utilization (emergency room visits or hospitalizations) of chronically ill patients in Liguria, Italy, in 2017.

METHODS

We use the coarsened exact matching algorithm to compare the health outcomes for a treated group of patients living in a local health authority (LHA) where drug distribution through community pharmacies was restricted. These patients were matched to a control group of patients living in other LHAs, where drugs were also dispensed through a broad network of community pharmacies. We exploit a unique administrative dataset with information on the socio-demographic characteristics and health care services utilization of Ligurian patients with chronic cardiovascular and respiratory ailments. We restrict our analysis to patients 65 years of age or older who were admitted to hospitals from 2013 to 2016 with either a principal or secondary diagnosis connected to chronic cardiovascular and respiratory diseases.

RESULTS

Reduced access to drugs leads to lowered drug consumption, a higher probability of adverse health outcomes including mortality, and a higher consumption of medical services in terms of hospitalizations and emergency room visits. These effects increase with patients' age.

CONCLUSION

The pharmacy dispensing channel significantly affects drug consumption and acts as a proxy for adherence among chronically ill patients. Thus, health outcomes and health care utilization should be carefully evaluated when comparing the costs of alternative dispensing channels.

Characteristics of Copayment Offsets for Prescription Drugs in the United States

IMPORTANCE

Despite ongoing debate regarding the high prices that patients pay for prescription drugs, to our knowledge, little is known regarding the use of coupons, vouchers, and other types of copayment "offsets" that reduce patients' out-of-pocket drug spending. Although offsets reduce patients' immediate cost burden, they may encourage the use of higher-cost products and diminish health insurers' ability to optimize pharmaceutical value.

OBJECTIVE

To examine the drugs most commonly covered by offsets, the percentage of out-of-pocket costs covered by offsets, and the characteristics of patients using offsets for retail pharmacy transactions in the United States in 2017 through 2019.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort analysis was conducted of a 5% nationally random sample of anonymized pharmacy claims from IQVIA's Formulary Impact Analyzer, which captures more than 60% of all US pharmacy transactions. This analysis focused on 631 249 individuals who used at least 1 offset between October 1, 2017, and September 30, 2019.

MAIN OUTCOMES AND MEASURES

Offset source, types of drugs covered by offsets, offset dollar value and percentage of out-of-pocket payment covered, and county characteristics of offset recipients.

RESULTS

The 631 249 individuals in the study (361 855 female participants [57.3%]; mean [SD] age, 45.7 [18.6] years) had approximately 33 million prescription fills, of which 12.8% had an offset used. Of these, 50.2% originated from a pharmaceutical manufacturer, 47.2% originated from a pharmacy or pharmacy benefit manager (PBM), and 2.6% originated from a state assistance program. A total of 80.0% of manufacturer-sponsored offsets were concentrated among 6.2% of unique products, and 79.9% of pharmacy-PBM offsets were concentrated among 4.9% of unique products. Most manufacturer offsets (88.2%) were for branded products, while most pharmacy-PBM offsets were for generic products (90.5%). The median manufacturer offset was $51.00, covering 87.1% of out-of-pocket costs; the median pharmacy-PBM offset was $16.30, covering 39.3% of out-of-pocket costs. There was no meaningful association between offset magnitude and county-level income, health insurance coverage, or race/ethnicity.

CONCLUSIONS AND RELEVANCE

In this analysis of patient-level pharmacy claims from 2017 to 2019, approximately half of all offsets involved pharmacy-PBM contractual arrangements, and half were offered by manufacturers. All offsets were associated with a significant reduction in patients' out-of-pocket costs, were highly concentrated among a few drugs, and were generally not more generous among individuals in counties with lower income or larger Black or uninsured populations.

Cost-related Medication Nonadherence and Its Risk Factors Among Medicare Beneficiaries

BACKGROUND

Unaffordability of medications is a barrier to effective treatment. Cost-related nonadherence (CRN) is a crucial, widely used measure of medications access.

OBJECTIVES

Our study examines the current national prevalence of and risk factors for CRN (eg, not filling, skipping or reducing doses) and companion measures in the US Medicare population.

RESEARCH DESIGN

Survey-weighted analyses included logistic regression and trends 2006-2016.

SUBJECTS

Main analyses used the 2016 Medicare Current Beneficiary Survey. Our study sample of 12,625 represented 56 million community-dwelling beneficiaries.

MEASURES

Additional outcome measures were spending less on other necessities in order to pay for medicines and use of drug cost reduction strategies such as requesting generics.

RESULTS

In 2016, 34.5% of enrollees under 65 years with disability and 14.4% of those 65 years and older did not take their medications as prescribed due to high costs; 19.4% and 4.7%, respectively, experienced going without other essentials to pay for medicines. Near-poor older beneficiaries with incomes $15-25K had 50% higher odds of CRN (vs. >$50K), but beneficiaries with incomes <$15K, more likely to be eligible for the Part D Low-Income Subsidy, did not have significantly higher risk. Three indicators of worse health (general health status, functional limits, and count of conditions) were all independently associated with higher risk of CRN.

CONCLUSIONS

Changes in the risk profile for CRN since Part D reflect the effectiveness of targeted policies. The persistent prevalence of CRN and associated risks for sicker people in Medicare demonstrate the consequences of high cost-sharing for prescription fills.

The effect of increased cost-sharing on low-value service use

We examine the effect of a value-based insurance design (VBID) program implemented at a large public employer in the state of Oregon. The program substantially increased cost-sharing for several healthcare services likely to be of low value for most patients: diagnostic services (e.g., imaging services) and surgeries (e.g., spinal surgeries for pain). Using a difference-in-differences design coupled with granular, administrative health insurance claims data over the period 2008-2012, we estimate the change in low-value service use among beneficiaries before and after program implementation relative to a comparison group not exposed to the VBID. Our findings suggest that the VBID significantly reduced the use of targeted services, with an implied elasticity of demand of -0.22. We find no evidence that the VBID led to substitution to non-targeted services or increased overall healthcare costs. However, we also observe no evidence that the program led to cost-savings.

The Moral Distress of Nurses When Patients Forgo Treatment Because of Cost

Nursing must recognize an ethical obligation to respond on behalf of these patients.

Do financial barriers to access to primary health care increase the risk of poor health? Longitudinal evidence from New Zealand

Primary health care policies in New Zealand, as in many countries, have focused on reducing barriers to access. Financial barriers to obtaining timely health care, while not the only important barriers, are amongst the most important, and are amenable to policy reforms. There is little robust empirical evidence about the extent to which cost related barriers are associated with adverse health outcomes. Past evidence is limited to cross-sectional studies of selected groups, selected primary health care services, and to cross-sectional studies that are susceptible to unmeasured confounding bias. Using fixed effects regression modelling and data from 17,363 participants with at least two observations in three waves (2004-05, 2006-07, 2008-09) of the SoFIE-Health panel data, this study examines the impact of financial barriers to access to primary health care (general practitioner and dentist) on health status using a longitudinal national panel study of adult New Zealanders. Self-rated health (SRH), physical health (PCS) and mental health summary scores (MCS) were the health measures. The two exposures were: not seeing 1) the doctor and 2) the dentist because of cost at least once during the preceding 12 months. We also tested for interactions between the exposure (deferral of care) and age, gender, ethnicity and three health outcomes. For all outcomes, after adjusting for time-varying confounders, health deteriorated as the number of waves increased in which a non-visit was reported. Moreover, the effect size for any health deterioration was greater for deferring a dentist visit than for deferring a physician visit. Except gender and age (for MCS and doctor visits), and gender and ethnicity (for SRH and dentist visits) we did not find any evidence of interactions. These results support policy responses focussed on decreasing financial barriers to access. In the New Zealand context this finding is particularly important for dental care.

Forgoing health care under universal health insurance: the case of France

OBJECTIVES

We investigate the reliability of a survey question on forgone healthcare services for financial reasons, based on analysis of actual healthcare use over the 3-year period preceding response to the question. We compare the actual use of different health services by patients who report having forgone health care to those who do not.

METHODS

Based on a prospective cohort study (CONSTANCES), we link survey data from enrolled participants to the Universal Health Insurance (UHI) claims database and compare use of health services of those who report having forgone health care to controls. We present multivariable logistic regression models and assess the odds of using different health services.

RESULTS

Compared to controls, forgoing care participants had lower odds of consulting GPs (OR = 0.83; 95% CI 0.73, 0.93), especially specialists outside hospitals (gynecologists: 0.74 (0.69, 0.78); dermatologists: 0.81 (0.78-0.85); pneumologists 0.82 (0.71-0.94); dentists 0.71 (0.68, 0.75)); higher odds of ED visits (OR = 1.25; 95% CI 1.19, 1.31); and no difference in hospital admissions (OR = 1.02; 95% CI 0.97, 1.09). Participants with lower occupational status and income had higher odds of forgoing health care.

CONCLUSIONS

The perception of those who report having forgone health care for financial reasons is consistent with their lower actual use of community-based ambulatory care (CBAC). While UHI may be necessary to improve healthcare access, it does not address the social factors associated with the population forgoing health care for financial reasons.

The distributive fairness of out-of-pocket healthcare expenditure in the Russian Federation

This article examines the effects of socioeconomic position and urban-rural settlement on the distribution of out-of-pocket expenditure (OPE) for health in the Russian Federation. Data comes from 2005 to 2016 waves of the Russian Longitudinal Monitoring Survey. Concentration index reflects changes in the distribution of OPE between the worse-off and the better-off Russians over a 12-year period. Finally, unconditional quantile regression-a recentred influence function approach estimates differential impacts of covariates along the distribution of OPE. OPE is concentrated amongst the better-off Russians in 2016. Urban settlements contribute to top end OPE distribution for the richest and town settlements, at the median for the richest and the poorest. Our model for the analysis is unique in the context of study population, as it marginalises the effect over the distributions of other covariates used in the model.

Study protocol: CareAvenue program to improve unmet social risk factors and diabetes outcomes- A randomized controlled trial

Despite the burdens costs can place on adults with diabetes, few evidence-based, scalable interventions have been identified that address prevalent health-related financial burdens and unmet social risk factors that serve as major obstacles to effective diabetes management. In this study, we will test the effectiveness of CareAvenue - an automated e-health tool that screens for unmet social risk factors and informs and activates individuals to take steps to connect to resources and engage in self-care. We will determine the effectiveness of CareAvenue relative to standard care with respect to improving glycemic control and patient-centered outcomes such as cost-related non-adherence (CRN) behaviors and perceived financial burden. We will also examine the role of patient risk factors (moderators) and behavioral factors (mediators) on the effectiveness of CareAvenue in improving outcomes. We will recruit 720 patients in a large health system with uncontrolled Type 1 diabetes mellitus (T1DM) or Type 2 diabetes mellitus (T2DM) who engage in CRN or perceive financial burden. Participants will be randomized to one of two arms: 1) receipt of a 15-20 min web-based program with routine follow-up (CareAvenue); or 2) receipt of contact information for existing health system assistance services. Outcomes will be assessed at baseline and 6- and 12-month follow-up. Clinical Trial Registration: ClinicalTrials.gov ID NCT03950973, May 2019.

Cost-related medication nonadherence among over-indebted individuals enrolled in statutory health insurance in Germany: a cross-sectional population study

Background

Millions of citizens in high-income countries face over-indebtedness that implies being unable to cover payment obligations with available income and assets on an ongoing basis. Studies have shown an association between over-indebtedness and health outcomes, independent of standard socioeconomic status measures. Patterns of cost-related medication nonadherence (CRN) among over-indebted individuals are yet unclear. The aim of this study was to examine the frequency of nonadherence to prescribed medications due to cost, and to identify risk factors for CRN among over-indebted individuals in Germany.

Methods

In 2017, we conducted a cross-sectional survey among over-indebted individuals recruited in 70 debt advice agencies in North Rhine-Westphalia, Germany. Data on CRN in the last 12 months (i.e. not filling prescriptions, skipping or decreasing doses of prescribed medication due to financial problems) were collected by a survey using a self-administered written questionnaire that was returned by 699 individuals with a response rate of 50.2%. Prevalence of CRN was assessed using descriptive statistics. Multiple logistic regression analysis was performed to examine risk factors of CRN, including participants enrolled in statutory health insurance with complete data (n = 521).

Results

The prevalence of CRN was 33.6%. The chronically ill had significantly greater odds of cost-related medication nonadherence (aOR 1.96; 95% CI 1.27–3.03) than individuals without a chronic illness. CRN was more likely to occur in individuals who had discussed financial problems with their general practitioner (aOR 1.58; 95% CI 1.01–2.47). There was no association between CRN and other sociodemographic factors or socioeconomic status.

Conclusions

Medication nonadherence due to financial pressures is common among over-indebted citizens enrolled in statutory health insurance in Germany. Stakeholders in social policy, research and health care need to address over-indebtedness to develop strategies to safeguard access to relevant medications, especially among those with high morbidity.

Trial registration

Arzneimittelkonsum, insbesondere Selbstmedikation bei überschuldeten Bürgerinnen und Bürgern in Nordrhein-Westfalen (ArSemü), (engl. ‘Medication use, particularly self-medication among over-indebted citizens in North Rhine-Westphalia’), German Clinical Trials Register: DRKS00013100. Date of registration: 23.10.2017. Date of enrolment of the first participant: 18.07.2017, retrospectively registered.

Association of Previous Hospitalization for Heart Failure With Increased Mortality in Patients Hospitalized for Acute Decompensated Heart Failure

Background: We sought to explore the effects of previous heart failure (HF) hospitalization on mortality in patients hospitalized for acute decompensated HF (ADHF) in a large Japanese contemporary observational database. Methods and Results: We prospectively enrolled consecutive patients with ADHF in 19 participating hospitals between October 2014 and March 2016. Of 4,056 patients, 1,442 patients (35.4%) had at least 1 previous HF hospitalization (previous hospitalization group), while 2,614 patients (64.5%) did not have a history of HF hospitalization (de novo hospitalization group). Patients with previous hospitalization were older and more often had comorbidities such as anemia, and renal failure than those without. The cumulative 1-year incidence of all-cause death was significantly higher in the previous hospitalization group than in the de novo hospitalization group (28% vs. 19%, P<0.001). After adjusting confounders, the excess risk of the previous hospitalization group relative to the de novo hospitalization group for all-cause death remained significant (HR, 1.28; 95% CI: 1.10-1.50, P=0.001). The excess risk was significant in patients without advanced age, anemia, or renal failure, but not significant in patients with these comorbidities, with significant interaction. Increase in the number of hospitalizations was associated with an increased risk for mortality. Conclusions: In a contemporary ADHF cohort in Japan, repeated hospitalization was associated with an increasing, higher risk for 1-year mortality.

Association of Medication Nonadherence Among Adult Survivors of Stroke After Implementation of the US Affordable Care Act

Importance

Among adults with chronic disease, survivors of stroke have high out-of-pocket financial burdens. The US government enacted the Affordable Care Act (ACA) in 2010 and implemented the law in 2014 to provide more low-income adults with health insurance coverage.

Objective

To assess whether ACA implementation is associated with cost-related nonadherence (CRN) to medication among adult survivors of stroke.

Design, Setting, and Participants

This study analyzed data from the 2000 to 2016 National Health Interview Survey, an in-person household survey of the noninstitutionalized US population conducted annually by the National Center for Health Statistics. Conducted at the University of Michigan Medical School, Ann Arbor, from July 24, 2017, to February 28, 2018, the study had a sample of 13 930 survivors of stroke. Analyses were stratified by age (45-64 years vs ≥65 years). Time was treated as a continuous variable and as a categorical variable across 4 periods (2000-2005, historical control; 2006-2010, economic recession and peak unemployment; 2011-2013, before ACA implementation; and 2014-2016, after ACA implementation). Percentages are weighted to reflect US population estimates.

Main Outcomes and Measures

The primary outcome was the self-report of CRN, defined as the inability to afford prescribed medications within the past 12 months.

Results

Among the 13 930 total survivors of stroke, 38.1% were aged 45 to 64 years (50.5% were female and 49.5% were male, with a mean [SE] age of 56.0 [0.10] years), and 61.9% were aged 65 years or older (54.9% were female and 45.1% were male, with a mean [SE] age of 76.2 [0.09] years). From 2011 to 2013 through 2014 to 2016, Medicaid increased (from 24.0% [95% CI, 21.0%-27.2%] in 2011-2013 to 30.8% [95% CI, 27.3%-34.6%] in 2014-2016; P < .001) and uninsurance decreased (from 13.7% [95% CI, 11.3%-16.4%] to 6.8% [95% CI, 5.3%-8.8%]; P < .001) among survivors of stroke aged 45 to 64 years. Among survivors aged 45 to 64 years, CRN increased over time before ACA implementation (from 18.6% [95% CI, 16.5%-20.9%] in 2000-2005, to 22.6% [95% CI, 19.7%-25.9%] in 2006-2010, to 23.8% [95% CI, 20.7%-27.3%] in 2011-2013) and decreased after ACA implementation to 18.1% (95% CI, 15.4%-21.3%; P = .01) in 2014 to 2016. The period after ACA implementation was associated with lower odds of CRN after adjustment for sociodemographics, year, and clinical factors (odds ratio [OR], 0.63; 95% CI, 0.47-0.85). The difference was attenuated after further adjustment for health insurance coverage (OR, 0.76; 95% CI, 0.56-1.03).

Conclusions and Relevance

After the ACA implementation, health insurance coverage increased and CRN decreased among adult survivors of stroke, suggesting that further expansion of Medicaid coverage is likely to be advantageous for survivors.

Improving the Affordability of Prescription Medications for People with Chronic Respiratory Disease. An Official American Thoracic Society Policy Statement

BACKGROUND

Mounting evidence indicates that out-of-pocket costs for prescription medications, particularly among low- and middle-income patients with chronic diseases, are imposing financial burden, reducing medication adherence, and worsening health outcomes. This problem is exacerbated by a paucity of generic alternatives for prevalent lung diseases, such as asthma and chronic obstructive pulmonary disease, as well as high-cost medicines for rare diseases, such as cystic fibrosis. Affordability and access challenges are especially salient in the United States, as citizens of many other countries pay lower prices for and have greater access to prescription medications.

METHODS

The American Thoracic Society convened a multidisciplinary committee comprising experts in health policy pharmacoeconomics, behavioral sciences, and clinical care, along with individuals providing industry and patient perspectives. The report and its recommendation were iteratively developed over a year of in-person, telephonic, and electronic deliberation.

RESULTS

The committee unanimously recommended the establishment of a publicly funded, politically independent, impartial entity to systematically draft evidence-based pharmaceutical policy recommendations. The goal of this entity would be to generate evidence and action steps to ensure people have equitable and affordable access to prescription medications, to maximize the value of public and private pharmaceutical expenditures on health, to support novel drug development within a market-based economy, and to preserve clinician and patient choice regarding personalized treatment. An immediate priority is to examine the evidence and make recommendations regarding the need to have essential medicines with established clinical benefit from each drug class in all Tier 1 formularies and propose recommendations to reduce barriers to timely generic drug availability.

CONCLUSIONS

By making explicit, evidence-based recommendations, the entity can support the establishment of coherent national policies that expand access to affordable medications, improve the health of patients with chronic disease, and optimize the use of public and private resources.

Prevalence and Correlates of Medical Financial Hardship in the USA

BACKGROUND

High patient out-of-pocket (OOP) spending for medical care is associated with medical debt, distress about household finances, and forgoing medical care because of cost in the USA.

OBJECTIVE

To examine the national prevalence of medical financial hardship domains: (1) material conditions from increased OOP expenses (e.g., medical debt), (2) psychological responses (e.g., distress), and (3) coping behaviors (e.g., forgoing care); and factors associated with financial hardship.

DESIGN AND PARTICIPANTS

We identified adults aged 18-64 years (N = 68,828) and ≥ 65 years (N = 24,614) from the 2015-2017 National Health Interview Survey. Multivariable analyses of nationally representative cross-sectional survey data were stratified by age group, 18-64 years and ≥ 65 years.

MAIN MEASURES

Prevalence of material, psychological, and behavioral hardship and hardship intensity.

KEY RESULTS

Approximately 137.1 million (95% CI 132.7-141.5) adults reported any medical financial hardship in the past year. Hardship is more common for material, psychological and behavioral domains in adults aged 18-64 years (28.9%, 46.9%, and 21.2%, respectively) than in adults aged ≥ 65 years (15.3%, 28.4%, and 12.7%, respectively; all p < .001). Lower educational attainment and more health conditions were strongly associated with hardship intensity in multivariable analyses in both age groups (p < .001). In the younger group, the uninsured were more likely to report multiple domains of hardship (52.8%), compared to those with some public (26.5%) or private insurance (23.2%) (p < .001). In the older group, individuals with Medicare only were more likely to report hardship in multiple domains (17.1%) compared to those with Medicare and public (12.1%) or Medicare and private coverage (10.1%) (p < .001).

CONCLUSIONS

Medical financial hardship is common in the USA, especially in adults aged 18-64 years and those without health insurance coverage. With trends towards higher patient cost-sharing and increasing health care costs, risks of hardship may increase in the future.