Determinants of Self-Management Strategies to Reduce Out-of-Pocket Prescription Medication Expense in Homebound Older people

Out-of-pocket expenses related to aging in place for frail older people: a scoping review

OBJECTIVE

The objective of this scoping review was to map and describe the available evidence reporting out-of-pocket expenses related to aging in place for older people with frailty and their caregivers.

INTRODUCTION

As the global population ages, there has been increasing attention on supporting older people to live at home in the community as they experience health and functional changes. Older people with frailty often require a variety of supports and services to live in the community, yet the out-of-pockets costs associated with these resources are often not accounted for in health and social care literature.

INCLUSION CRITERIA

Sources that reported on the financial expenses incurred by older people (60 years or older) with frailty living in the community, or on the expenses incurred by their family and friend caregivers, were eligible for inclusion in the review.

METHODS

We searched for published and unpublished (ie, policy papers, theses, and dissertations) studies written in English or French between 2001 and 2019. The following databases were searched: CINAHL, MEDLINE, Scopus, Embase, PsycINFO, Sociological Abstracts, and Public Affairs Index. We also searched for gray literature in a selection of websites and digital repositories. JBI scoping review methodology was used, and we consulted with a patient and family advisory group to support the relevance of the review.

RESULTS

A total of 42 sources were included in the review, including two policy papers and 40 research papers. The majority of the papers were from the United States (n = 18), with others from Canada (n = 6), the United Kingdom (n = 3), Japan (n = 2), and one each from Australia, Brazil, China, Denmark, Israel, Italy, The Netherlands, Poland, Portugal, Singapore, South Korea, Taiwan, and Turkey. The included research studies used various research designs, including cross-sectional (n = 18), qualitative (n = 15), randomized controlled trials (n = 2), longitudinal (n = 2), cost effectiveness (n = 1), quasi-experimental (n = 1), and mixed methods (n = 1). The included sources used the term "frailty" inconsistently and used various methods to demonstrate frailty. Categories of out-of-pocket expenses found in the literature included home care, medication, cleaning and laundry, food, transportation, medical equipment, respite, assistive devices, home modifications, and insurance. Five sources reported on out-of-pocket expenses associated with people who were frail and had dementia, and seven reported on the out-of-pocket expenses for caregivers of people with frailty. While seven articles reported on specific programs, there was very little consistency in how out-of-pocket expenses were used as outcome measures. Several studies used measures of combined out-of-pocket expenses, but there was no standard approach to reporting aggregate out-of-pocket expenses.

CONCLUSIONS

Contextual factors are important to the experiences of out-of-pocket spending for older people with frailty. There is a need to develop a standardized approach to measuring out-of-pocket expenses in order to support further synthesis of the literature. We suggest a measure of out-of-pocket spending as a percentage of family income. The review supports education for health care providers to assess the out-of-pocket spending of community-dwelling older people with frailty and their caregivers. Health care providers should also be aware of the local policies and resources that are available to help older people with frailty address their out-of-pocket spending.

A mixed methods thematic review: Health-related decision-making by the older person

AIMS AND OBJECTIVES

To undertake a mixed methods thematic literature review that explored how elderly adults approached decision-making in regard to their health care following discharge.

BACKGROUND

A critical time for appropriate health decisions occurs during hospital discharge planning with nursing staff. However, little is known how the 89% of elderly living at home make decisions regarding their health care. Research into older adults' management of chronic conditions emerges as an important step to potentially encourage symptom monitoring, prevent missed care and detect deterioration. All should reduce the risk of hospital re-admission.

DESIGN

A mixed methods thematic literature review was undertaken. The structure followed the PRISMA reporting guidelines for systematic reviews recommended by the EQUATOR network.

METHODS

PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus online databases were searched using keywords, inclusion and exclusion criteria. References drawn from relevant publications, identified by experts and published between 1995 and 2017 were also considered. Twenty-five qualitative, quantitative and mixed methods studies and reviews were critically appraised (CASP 2013) before inclusion in the review. Analysis of each study's findings was undertaken using Braun and Clarke's (2006) steps to identify major themes and sub-themes.

RESULTS

Four main themes associated with health-related decision-making in the elderly were identified: "the importance of maintaining independence," "decision making style," "management of conditions at home" and "discharge planning."

CONCLUSION

Health care decision preferences in the elderly emerged as highly complex and influenced by multiple factors. Development of a tool to assess these components has been recommended.

RELEVANCE TO CLINICAL PRACTICE

Nurses play a vital role in exploring and understanding the influence that maintaining independence has with each patient. This understanding provides an initial step toward development of a tool to assist collaboration between patients and healthcare professionals involved in their care.

Self-Management of Multiple Chronic Conditions by Community-Dwelling Older Adults: A Concept Analysis

The proportion of the aging population living with multiple chronic conditions (MCC) is increasing. Self-management is valuable in helping individuals manage MCC. The purpose of this study was to conduct a concept analysis of self-management in community-dwelling older adults with MCC using Walker and Avant's method. The review included 30 articles published between 2000 and 2017. The following attributes were identified: (a) using financial resources for chronic disease management, (b) acquiring health- and disease-related education, (c) making use of ongoing social supports, (d) responding positively to health changes, (e) ongoing engagement with the health system, and (f) actively participating in sustained disease management. Self-management is a complex process; the presence of these attributes increases the likelihood that an older adult will be successful in managing the symptoms of MCC.

Perceptions of generic drug discount programs among low-income women: a qualitative study

PURPOSE

Increasing the awareness and use of generic drug discount programs (GDDP) may improve access to essential prescription drugs. However, little is known about public perceptions of GDDPs. The purpose of this study is to understand the perceptions and utilization patterns of low-income women regarding GDDP.

METHODS

Using a purposive sampling strategy, we conducted seven focus groups with a total of 50 participants using a semistructured guide to assess awareness and utilization of GDDP. Transcripts of the focus groups were systematically analyzed across groups with a general inductive approach for qualitative data analysis.

RESULTS

Five major categorical themes emerged from the focus group content analysis: 1) Perceived differences between generic and brand-name prescription drugs, 2) barriers to utilizing GDDP, 3) lack of adequate communication between pharmacy, physician and patient about GDDP, 4) perceived health impact of utilizing GDDPs, and 5) perceived health care savings. Most participants indicated that they perceive no difference between generic and brand-name prescription drugs. Lack of awareness was indicated as a barrier to utilization. There was general agreement among participants that GDDP can help to maintain health while saving money.

CONCLUSION

Study participants demonstrated generally favorable perceptions regarding GDDPs. Our findings underscore the need for policies that encourage expansion of the GDDP formulary and increasing awareness and utilization of GDDP.

How end-stage renal disease patients manage the Medicare Part D coverage gap

Medicare Part D was enacted to help elderly and disabled individuals pay for prescription drugs, but it was structured with a gap providing no coverage in 2010 between $2,830 and $6,440. Patients with end-stage renal disease (ESRD) are especially likely to be affected due to high costs of dialysis-related drugs and the importance of adherence for overall health. Researchers from social work, pharmacy, and dietetics interviewed 12 patients with ESRD to learn about strategies and challenges during the coverage gap. Constant comparison generated the following themes: the experience of hitting the gap, management strategies, physical and emotional consequences, and advice for others. Results suggest that patients could benefit from greater involvement with professionals and peers to prepare for and manage their medications during the coverage gap and for support in dealing with emotional consequences and stress related to financial pressures and living with a serious health condition.

Rural food insecurity in the United States as an overlooked site of struggle in health communication

This article indicates the need for health communication scholars to attend to the growing national problem of rural food insecurity. A review of the health communication literature reveals that food insecurity and rural health overall are research issues that have been overlooked. Using the Culture-Centered Approach ( Dutta, 2008 ), while simultaneously searching for community assets as well as problems, we explore aspects of rural residents' food environments, culture, and institutional structures that empower and constrain their communities. Twelve focus groups (n = 86), segmented by race/ethnicity, were conducted in rural central Texas. Results were analyzed using grounded theory methodology. Our findings outline problems and personal obstacles described by participants, as well as creative solutions and coping mechanisms illustrative of individual agency and social capital inherent in their rural culture. We conclude by providing suggestions for future research that will aid health communication scholars to further the conversation on rural food insecurity.

Food insecurity is associated with cost-related medication non-adherence in community-dwelling, low-income older adults in Georgia

Low-income older adults are at increased risk of cutting back on basic needs, including food and medication. This study examined the relationship between food insecurity and cost-related medication non-adherence (CRN) in low-income Georgian older adults. The study sample includes new Older Americans Act Nutrition Program participants and waitlisted people assessed by a self-administered mail survey (N = 1000, mean age 75.0 + so - 9.1 years, 68.4% women, 25.8% African American). About 49.7% of participants were food insecure, while 44.4% reported practicing CRN. Those who were food insecure and/or who practiced CRN were more likely to be African American, low-income, younger, less educated, and to report poorer self-reported health status. Food insecure participants were 2.9 (95% CI 2.2, 4.0) times more likely to practice CRN behaviors than their counterparts after controlling for potential confounders. Improving food security is important inorder to promote adherence to recommended prescription regimens.

Perceptions of health care provider communication activity among American cancer survivors and Adults Without Cancer Histories: an analysis of the 2003 Health Information Trends Survey (HINTS) Data

Provider communication is an important determinant of health outcomes. We examined the frequency with which five important communication activities were perceived by cancer survivors and adults without a history of cancer to have been performed by their primary care providers. We analyzed data on more than 5,000 adults drawn from the 2003 Health Information National Trends Survey (HINTS), a public dataset of the National Cancer Institute. We analyzed the responses to a question that asked how frequently the respondent's primary care provider had performed the following communication activities in the past 12 months: (1) listening carefully, (2) explaining things, (3) showing respect, (4) spending enough time, and (5) involving the patient in joint decision making. In addition, we compared responses among demographic subgroups. Results showed that regardless of health status or demographic characteristics, the 2003 HINTS respondents reported less than optimal rates of their providers "always" listening carefully, explaining things, showing respect, spending enough time, and involving them in joint decision making. Being Hispanic and having no usual provider or health insurance were associated with a significantly lower frequency of reporting that providers "always" performed the five communication activities (p < .05).

Self-care and professionally guided care in osteoarthritis: racial differences in a population-based sample

OBJECTIVE

The aim of this study was to examine the prevalence of self-management practices among older White and African American persons with osteoarthritis. Self-management was defined broadly to include all behaviors adopted to reduce morbidity, whether recommended by physicians or not.

METHODS

A population-based sample of Medicare beneficiaries (N = 551) was recruited. An expanded set of self-management behaviors using structured and open-ended inquiry, along with use of arthritis-specific medications was elicited.

RESULTS

Few differences in self-care behaviors between race groups were found. However, older African American persons were significantly less likely to have prescriptions for nonsteroidal anti-inflammatory agents (NSAIDs) and more likely to use over-the-counter nonprescription analgesics.

DISCUSSION

Older White and African American persons made similar use of self-care strategies to reduce disease morbidity. African Americans without access to prescription pain relievers substituted nonprescription analgesics. A broader view of self-management is valuable for assessing the ways people may move between professionally guided care and self-care.

Overall quality of life and difficulty paying for ostomy supplies in the Veterans Affairs ostomy health-related quality of life study: an exploratory analysis

PURPOSE

To explore whether there was a significant relationship between difficulty paying for ostomy supplies and overall quality of life among a sample of ostomates receiving care from the Veterans Health Administration (VHA).

METHODS

The data were collected as part of the Veterans Affairs (VA) Ostomy Health-Related Quality of Life Study, in which 511 respondents (239 cases, 272 controls) completed a survey instrument that included the modified City of Hope Quality of Life (mCOH-QOL) Ostomy questionnaire, SF-36V, and sociodemographic items. Responses from the 239 cases (ie, patients with intestinal stomas) were used in this analysis. The modified City of Hope Quality of Life Ostomy questionnaire item, "How good is your overall quality of life?," was the dependent variable for this analysis. The primary independent variable was the response (yes/no) to the item, "If you pay for any of the (ostomy) costs, is it difficult for you?" A hierarchical regression model was used to examine whether difficulty paying was significantly related to overall quality of life after adjusting for age, income, race/ethnicity, and physical health.

RESULTS

After accounting for the proportion of variance explained by age, income, race/ethnicity, and physical health, the additional proportion of variance explained by difficulty paying was statistically significant. Individuals reporting difficulty paying had a roughly 1 point lower (ie, beta-coefficient = -1.052; SE = 0.481) overall quality of life score on the 11-point scale.

CONCLUSIONS

We found a significant association between difficulty paying for ostomy supplies and overall quality of life. Although the cross-sectional study design does not allow causal inference, the results suggest a relationship that merits further examination.

Burden of Common Multiple-Morbidity Constellations on Out-of-Pocket Medical Expenditures Among Older Adults

PURPOSE

On average, adults aged 60 years or older have 2.2 chronic diseases, contributing to the over 60 million Americans with multiple morbidities. We aimed to understand the financial implications of the most frequent multiple morbidities among older adults.

DESIGN AND METHODS

We analyzed Health and Retirement Study data, determining out-of-pocket medical expenses from 1998 and 2002 separately and examining differences in the impact of multiple-morbidity constellations on these expenses. We paid particular attention to the most common disease constellations - hypertension, arthritis, and heart disease.

RESULTS

An increasing prevalence of multiple morbidity (58% compared with 70% of adults had two or more chronic conditions in 1998 and 2002, respectively) was accompanied by escalating out-of-pocket expenditures (2,164 dollars in 1998, increasing by 104% to 3,748 dollars in 2002). Individuals with two, three, and four chronic conditions had health care expenditure increases of 41%, 85%, and 100%, respectively, over 4 years. Such patterns were particularly noticeable among the oldest old, those with higher educational attainment, and women, although having supplementary health insurance or Medicaid mitigated these expenses. Finally, there were significant differences in out-of-pocket expenditure levels among the multiple-morbidity combinations.

IMPLICATIONS

Increasing rates of multiple morbidities in conjunction with escalating health care costs and stable or declining incomes among elders warrant creative attention from providers, researchers, and policy makers. Further understanding how specific multiple-morbidity constellations impact out-of-pocket spending moves us closer to effective interventions to support vulnerable elders.

Patients at-risk for cost-related medication nonadherence: a review of the literature

OBJECTIVE

Up to 32% of older patients take less medication than prescribed to avoid costs, yet a comprehensive assessment of risk factors for cost-related nonadherence (CRN) is not available. This review examined the empirical literature to identify patient-, medication-, and provider-level factors that influence the relationship between medication adherence and medication costs.

DESIGN

We conducted searches of four databases (MEDLINE, CINAHL, Sciences Citations Index Expanded, and EconLit) from 2001 to 2006 for English-language original studies. Articles were selected if the study included an explicit measure of CRN and reported results on covarying characteristics.

MAIN RESULTS

We found 19 studies with empirical support for concluding that certain patients may be susceptible to CRN: research has established consistent links between medication nonadherence due to costs and financial burden, but also to symptoms of depression and heavy disease burden. Only a handful of studies with limited statistical methods provided evidence on whether patients understand the health risks of CRN or to what extent clinicians influence patients to keep taking medications when faced with cost pressures. No relationship emerged between CRN and polypharmacy.

CONCLUSION

Efforts to reduce cost-related medication nonadherence would benefit from greater study of factors besides the presence of prescription drug coverage. Older patients with chronic diseases and mood disorders are at-risk for CRN even if enrolled in Medicare's new drug benefit.

Medication costs: the role physicians play with their senior patients

OBJECTIVES

To determine how often primary care physicians discuss medication costs with their senior patients and what cost-reducing strategies they employ.

DESIGN

Cross-sectional, random-sample mail questionnaire.

SETTING

State of California.

PARTICIPANTS

Six hundred seventy-eight of 1,098 (62%) internal medicine and family practice physicians selected from the American Medical Association Masterfile.

MEASUREMENTS

Main outcomes included frequency of cost discussions with senior patients in the previous 30 days and choice of cost-reducing strategy when a senior expresses financial difficulty with medication costs.

RESULTS

Forty-three percent of physicians reported discussing medication cost with at least half of their senior patients in the previous 30 days. Patients initiated most of these discussions. Forty percent reported that, at least one time in the previous 30 days, they had not discussed cost but wished they had. The most common reason given was "I ran out of time" (36%). Physicians with high perceived knowledge of medication costs were more likely to discuss cost (odds ratio (OR)=3.49, 95% confidence interval (CI)=1.66-7.3) versus low perceived knowledge, but this trend was not seen in physicians who scored high on actual knowledge of medication costs (OR=0.78, 95% CI=0.43-1.43) versus low actual knowledge. The most common cost-reducing strategies were generic substitution (33%) and offering samples (25%).

CONCLUSION

The frequency of medication cost discussions between physicians and senior patients is low, and when it occurs, is often initiated by patients. Physicians' perception of their knowledge of medication costs may be an important factor in initiating cost discussions.

Medication utilization in an urban homebound population

BACKGROUND

The number of medically homebound adults has grown with the aging of the U.S. population, yet little is known about their health care utilization. We sought to characterize the health status and medication utilization of an urban cohort of homebound adults and to identify factors associated with medication use in this population.

METHODS

We performed a retrospective cross-sectional analysis of 415 patients enrolled in a primary care program for homebound adults in New York City during October 2002. Numbers of medications were obtained from formularies corroborated by home visits. For patients without prescription insurance, medication out-of-pocket costs were estimated according to average wholesale pricing. Sociodemographic and disease characteristics were obtained by chart abstraction.

RESULTS

The median age was 83 years (range 25-106 years). Seventy-seven percent of patients were female, 63% were non-white, and 28% spoke Spanish. Sixty-four percent of patients had Medicaid. The cohort had a mean of 8.2 (range 1-27, standard deviation 4.5) medications prescribed per month. Multivariate analysis showed that increasing age was associated with fewer medications (p <.001). Charlson comorbidity score was positively associated with number of medications (p <.001), whereas Activities of Daily Living score, a measure of functional dependence, was not. Twenty-seven percent of the cohort lacked prescription drug coverage. The total number of medications per month among the uninsured patients was 7.4 (standard deviation 4.4). Estimated median monthly out-of-pocket cost for the uninsured patients was dollar 223 (range dollar 1-dollar 1512).

CONCLUSIONS

For homebound patients without prescription drug coverage, medication use may represent substantial financial burden. Additional research is needed to determine whether out-of-pocket medication costs represent a barrier to care in this population.

Longitudinal Examination of Homebound Older Adults Who Experience Heightened Food Insufficiency: Effect of Diabetes Status and Implications for Service Provision

PURPOSE

Healthful eating is important for optimal diabetes self-care. However, the level of food sufficiency may influence the degree of adherence to dietary self-care behaviors through the affordability of nutritionally appropriate food. This study examines whether homebound older adults with diabetes were at greater risk for heightened food insufficiency over 1 year, despite regular receipt of home-delivered meals.

DESIGN AND METHODS

This was a longitudinal study of a randomly recruited sample of 268 homebound older adults in the Nutrition and Function Study (NAFS) who regularly received home-delivered meals and completed baseline and 1-year in-home assessments. Based on an economic context model, self-reported data were collected on fundamental and proximate factors, food-sufficiency status, and intervening events. Determinants of heightened food insufficiency were examined with multivariate logistic regression models.

RESULTS

Not only did food-sufficiency status diminish over time in this sample, but it became or remained worse for older adults with diabetes. In addition to diabetes status, heightened food insufficiency was associated with perceived inadequacy of economic resources.

IMPLICATIONS

Health care providers and nutrition programs should attempt to identify high-risk older adults - those who have diabetes and are at risk of food insufficiency - and develop community linkages and strategies that integrate nutrition with diabetes care plans, thus supporting a multidisciplinary, chronic care model to improve diabetes management and outcomes.