Cost-related non-adherence to prescribed medicines among older adults: a cross-sectional analysis of a survey in 11 developed countries

Medication regimen complexity and its impact on medication adherence in patients with multimorbidity at a comprehensive specialized hospital in Ethiopia

Background

Medication regimen complexity (MRC) is suspected to hinder medication adherence in patients with multiple illnesses. Despite this, the specific impact on Ethiopian patients with multimorbidity is unclear. This study assessed MRC and its impact on medication adherence in patients with multimorbidity.

Methods

A hospital-based cross-sectional study was conducted on patients with multimorbidity who had been followed at the University of Gondar Comprehensive and Specialized Hospital (UoGCSH), Ethiopia, from May to July 2021. Medication complexity was measured using the validated Medication Regimen Complexity Index (MRCI) tool, and the Adherence in Chronic Diseases Scale (ACDS) was used to measure medication adherence. Pearson's chi-square test was used to examine associations between MRCI levels and medication adherence. Ordinal logistic regression analysis was used to determine the impact of MRC and other associated variables on medication adherence. Statistical significance was determined using the adjusted odds ratio (AOR) at p-value <0.05 and its 95% confidence range.

Results

Out of 422 eligible patients, 416 (98.6%) were included in the study. The majority of participants (57.2%) were classified as having a high MRCI score with a mean (±SD) score of 9.7 (±3.4). Nearly half of the patients (49.3%) had low medication adherence. Patients with medium (AOR = 0.43, 95% CI: 0.04, 0.72) and higher (AOR = 0.31, 95% CI: 0.07, 0.79) MRCI levels had lower odds of medication adherence. In addition, monthly income (AOR = 4.59, 95% CI: 2.14, 9.83), follow-up durations (AOR = 2.31, 95% CI: 1.09, 4.86), number of medications (AOR = 0.63, 95% CI: 0.41, 0.97), and Charlson comorbidity index (CCI) (AOR = 0.36, 95% CI: 0.16, 0.83) were significantly associated with medication adherence.

Conclusion

Medication regimen complexity in patients with multimorbidity was found to be high and negatively impacted the levels of medication adherence. Healthcare providers and other stakeholders should seek interventions aimed at simplifying drug regimen complexity and improving adherence.

Association between self-perceived consultation time and understanding of the prescribed treatment: An analysis of a national survey in Peru

OBJECTIVE

To assess the relationship between the self-perceived consultation time and the knowledge of the proposed treatment.

METHODS

Secondary data from a 2015 national survey of health services in Peru were analyzed. The self-perceived consultation time was calculated by asking how long it took from when you entered the consultation until you departed. It was then categorized as low, medium, and high. Five self-reported questions were used to construct a knowledge of the prescribed treatment. Adjusted regression models from the Poisson family models were used to evaluate the relationship. We report adjusted prevalence ratios (aPR) with their 95% confidence intervals (95%CI).

RESULTS

A total of 9939 outpatients were analyzed, with 58% women; the average age was 44 years; and 45.4% had higher education. Using low self-perceived consultation time as references, medium and high consultation times were associated with understanding the prescribed treatment (aPR=1.17; 95%CI, 1.04-1.33 and aPR=1.30; 95%CI, 1.20-1.40, respectively).

CONCLUSION

Patients who reported a medium and high self-perceived consultation time better understood the prescribed treatment.

IMPLICATIONS FOR PRACTICE

Healthcare professionals should strive to maximize consultation time to ensure effective communication and improve patient knowledge of treatments, improving overall patient satisfaction and health outcomes.

Barriers to Medication Adherence Among Patients with Non-Communicable Disease in North Wollo Zone Public Hospitals: Socio-Ecologic Perspective, 2023

Background

The practice of taking medication as directed by a healthcare provider is known as medication adherence. Therefore, the application of a socio-ecological model to this study identifies multilevel factors on barriers of medication adherence on chronic non-communicable disease and provides information to develop scientific health communication interventional strategies to improve medication adherence.

Objective

This study aimed to explore barriers of medication adherence on non-communicable disease prevention and care among patients in North Wollo Zone public hospitals, northeast Ethiopia.

Methods

A phenomenological study design was carried out between February 5 and February 30, 2023. The study participants were chosen using a heterogeneous purposive sampling technique. In-depth interviews and targeted focus groups were used to gather data. The focus group discussions and in-depth interviews were captured on audio, accurately transcribed, and translated into English. Atlas TI-7 was utilized to do the thematic analysis.

Results

Four main themes, intrapersonal, interpersonal, community level, and health care related, as well as seven subthemes, financial problems, lack of family support, poor communication with healthcare providers, effects of social ceremonies, remote healthcare facility, and drug scarcity, were identified by this study. In this study participants reported that lack of knowledge about the disease and drugs were the main barrier for medication adherence. The study revealed that financial problems for medication and transportation cost were the main factor for medication adherence for non-communicable disease patients.

Conclusion

This study explored that lack of knowledge, financial problem, lack of family support, poor communication with healthcare providers, social ceremony effects, remote healthcare facility, and scarcity of drugs were barriers of medication adherence among non-communicable disease patients. In order to reduce morbidity and mortality from non-communicable diseases, it is advised that all relevant bodies look for ways to reduce medication adherence barriers for patients at every level of influence.

Prescription-based cost analysis of medicines for cardiovascular risk factors at Indian Council of Medical Research-Rational Use of Medicine Centre Hospitals of India

OBJECTIVES

India has taken several initiatives to provide health care to its population while keeping the related expenditure minimum. Since cardiovascular diseases are the most prevalent chronic conditions, in the present study, we aimed to analyze the difference in prices of medicines prescribed for three cardiovascular risk factors, based on (a) listed and not listed in the National List of Essential Medicines (NLEM) and (b) generic and branded drugs.

MATERIALS AND METHODS

Outpatient prescriptions for diabetes mellitus, hypertension, and dyslipidemia were retrospectively analyzed from 12 tertiary centers. The prices of medicines prescribed were compared based on presence or absence in NLEM India-2015 and prescribing by generic versus brand name. The price was standardized and presented as average price per medicine per year for a given medicine. The results are presented in Indian rupee (INR) and as median (range).

RESULTS

Of the 4,736 prescriptions collected, 843 contained oral antidiabetic, antihypertensive, and/or hypolipidemic medicines. The price per medicine per year for NLEM oral antidiabetics was INR 2849 (2593-3104) and for non-NLEM was INR 5343 (2964-14364). It was INR 806 (243-2132) for generic and INR 3809 (1968-14364) for branded antidiabetics. Antihypertensives and hypolipidemics followed the trend. The price of branded non-NLEM medicines was 5-22 times higher compared to generic NLEM which, for a population of 1.37 billion, would translate to a potential saving of 346.8 billion INR for statins. The variability was significant for sulfonylureas, angiotensin receptor blockers, beta-blockers, diuretics, and statins (P < 0.0001).

CONCLUSION

The study highlights an urgent need for intervention to actualize the maximum benefit of government policies and minimize the out-of-pocket expenditure on medicines.

Are breast cancer patients with suboptimal adherence to cardiovascular treatment more likely to discontinue adjuvant endocrine therapy? Competing risk survival analysis in a nationwide cohort of postmenopausal women

BACKGROUND

High rates of discontinuation undermine the effectiveness of adjuvant endocrine therapy (AET) among hormone-receptive breast cancer patients. Patient prognosis also relies on the successful management of cardiovascular risk, which affects a high proportion of postmenopausal women. As with AET, adherence with cardiovascular drugs is suboptimal. We examined whether patient adherence with cardiovascular drugs was associated with the rate of AET discontinuation in a French nationwide claims database linked with hospitalisation data.

METHODS

We identified postmenopausal women starting AET between 01/01/2016 and 31/12/2020 and taking at least two drugs for the primary prevention of cardiovascular disease (antihypertensive drugs, lipid-lowering drugs and platelet aggregation inhibitors) before AET initiation. Adherence was assessed for each drug class by computing the proportion of days covered. Women were categorised as fully adherent, partially adherent or fully non-adherent with their cardiovascular drug regimen based on whether they adhered with all, part or none of their drugs. AET discontinuation was defined as a 90-day gap in AET availability. Time to AET discontinuation according to levels of cardiovascular drug adherence was estimated using cumulative incidence curves, accounting for the competing risks of death and cancer recurrence. Multivariate cause-specific Cox regressions and Fine-and-Gray regressions were used to assess the relative hazards of AET discontinuation.

RESULTS

In total, 32,075 women fit the inclusion criteria. Women who were fully adherent with their cardiovascular drugs had the lowest cumulative incidence of AET discontinuation at any point over the 5-year follow-up period. At 5 years, 40.2% of fully non-adherent women had discontinued AET compared with 33.5% of partially adherent women and 28.8% of fully adherent women. Both partial adherence and full non-adherence with cardiovascular drugs were predictors of AET discontinuation in the two models (cause-specific hazard ratios 1.16 [95% CI 1.10-1.22] and 1.49 [95% CI 1.39-1.58]; subdistribution hazard ratios 1.15 [95% CI 1.10-1.21] and 1.47 [95% CI 1.38-1.57]).

CONCLUSION

Clinicians should be aware that patients who do not adhere with their entire cardiovascular drug regimen are also more likely to discontinue AET. This stresses the importance of integrated care, as suboptimal adherence with both treatment components poses a threat to achieving ideal patient outcomes.

Gender and racialisation of pharmaceutical sector leaders in Canada: a cross-sectional study

OBJECTIVE/DESIGN

Lacking diversity in pharmaceutical leadership positions could contribute to inequities in medicine access. The objective of this cross-sectional study was to determine the gender and racial identities of individuals who hold leadership positions in the Canadian pharmaceutical sector.

PARTICIPANTS

We compiled a list of all Canadian governmental bodies, pharmaceutical companies and insurance providers. We identified individuals who were part of the leadership team, including executives and members of the board of directors.

PRIMARY OUTCOME MEASURES

The main outcomes of the study were the racialisation and gender of the individuals in leadership positions. The gender and racialisation of an individual were determined by reviewing their name, pronouns and institutional profile through internet searches. Two members of the research team performed the assessment and a third reviewer resolved disagreements.

RESULTS

We identified 957 individuals holding leadership positions within the pharmaceutical sector, including 280 drug evaluation committee members, 12 governmental executive officers, 273 insurance company executive and board members and 392 executive and board members. Reviewers identified a total of 375 (39.2% of 957) women holding leadership roles, with most of these positions being held by governmental leaders (52.4% of 292) and a minority by insurance (37.0% of 273) and pharmaceutical (30.9% of 392) leaders. There were a total of 157 (16.4% of 957) racialised leaders, with most of these positions being held by governmental (18.5% of 292) and pharmaceutical (18.1% of 392) leaders, and a minority in insurance companies (11.7% of 273). Across the pharmaceutical sector, there were a total of 48 (5.0% of 957) racialised women and 327 (34.2% of 957) white women.

CONCLUSIONS

Leaders within the Canadian pharmaceutical sector are mostly white men, and racialised women hold few leadership roles. Public policy should recognise that these institutions are mostly led by white men and reasons for this disparity could be explored.

Cross-sectional analysis of factors associated with medication adherence in western Kenya

OBJECTIVES

Poor medication adherence in low-income and middle-income countries is a major cause of suboptimal hypertension and diabetes control. We aimed to identify key factors associated with medication adherence in western Kenya, with a focus on cost-related and economic wealth factors.

SETTING

We conducted a cross-sectional analysis of baseline data of participants enrolled in the Bridging Income Generation with Group Integrated Care study in western Kenya.

PARTICIPANTS

All participants were ≥35 years old with either diabetes or hypertension who had been prescribed medications in the past 3 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

Baseline data included sociodemographic characteristics, wealth and economic status and medication adherence information. Predictors of medication adherence were separated into the five WHO dimensions of medication adherence: condition-related factors (comorbidities), patient-related factors (psychological factors, alcohol use), therapy-related factors (number of prescription medications), economic-related factors (monthly income, cost of transportation, monthly cost of medications) and health system-related factors (health insurance, time to travel to the health facility). A multivariable analysis, controlling for age and sex, was conducted to determine drivers of suboptimal medication adherence in each overarching category.

RESULTS

The analysis included 1496 participants (73.7% women) with a mean age of 60 years (range 35-97). The majority of participants had hypertension (69.2%), 8.8% had diabetes and 22.1% had both hypertension and diabetes. Suboptimal medication adherence was reported by 71.2% of participants. Economic factors were associated with medication adherence. In multivariable analysis that investigated specific subtypes of costs, transportation costs were found to be associated with worse medication adherence. In contrast, we found no evidence of association between monthly medication costs and medication adherence.

CONCLUSION

Suboptimal medication adherence is highly prevalent in Kenya, and primary-associated factors include costs, particularly indirect costs of transportation. Addressing all economic factors associated with medication adherence will be important to improve outcomes for non-communicable diseases.

TRIAL REGISTRATION NUMBER

NCT02501746.

The rising cost of rhinologic medications

BACKGROUND

The high prescription drug cost in the United States may negatively affect patient prognosis and treatment compliance.

OBJECTIVE

To fill the knowledge gap and inform clinicians regarding rhinology medications price changes by evaluating trends in price changes of highly used nasal sprays and allergy medications.

METHODS

The 2014-2020 Medicaid National Average Drug Acquisition Cost database was queried for drug pricing information for the following classes of medications: intranasal corticosteroids, oral antihistamines, antileukotrienes, intranasal antihistamines, and intranasal anticholinergics. Individual medications were identified by Food and Drug Administration-assigned National Drug Codes. Per unit, drug prices were analyzed for average annual prices, average annual percentage price changes, and inflation-adjusted annual and composite percentage price changes.

RESULTS

Beclometasone (Beconase AQ, 56.7%, QNASL, 77.5%), flunisolide (Nasalide, -14.6%), budesonide (Rhinocort Aqua, -1.2%), fluticasone (Flonase, -6.8%, Xhance, 11.7%), mometasone (Nasonex, 38.2%), ciclesonide (Omnaris, 73.8%), combination azelastine and fluticasone (Dymista, 27.3%), loratadine (Claritin, -20.5%), montelukast (Singulair, 14.5%), azelastine (Astepro, 21.9%), olopatadine (Patanase, 27.3%), and ipratropium bromide (Atrovent, 56.6%) had an overall change in inflation-adjusted per unit cost between 2014 and 2020 (% change). Of 14 drugs evaluated, 10 had an increase in inflation-adjusted prices, for an average increase of 42.06% ± 22.27%; 4 of 14 drugs had a decrease in inflation-adjusted prices, for an average decrease of 10.78% ± 7.36%.

CONCLUSION

The rising cost of highly used medications contributes to increased patient acquisition costs and may pose barriers of drug adherence to particularly vulnerable populations.

Perspectives on improving blood pressure control to reduce the clinical and economic burden of hypertension

The clinical and economic burden of hypertension is high and continues to increase globally. Uncontrolled hypertension has severe but avoidable long-term consequences, including cardiovascular diseases, which are among the most burdensome and most preventable conditions in Europe. Yet, despite clear guidelines on screening, diagnosis and management of hypertension, a large proportion of patients remain undiagnosed or undertreated. Low adherence and persistence are common, exacerbating the issue of poor blood pressure (BP) control. Although current guidelines provide clear direction, implementation is hampered by barriers at the patient-, physician- and healthcare system levels. Underestimation of the impact of uncontrolled hypertension and limited health literacy lead to low adherence and persistence among patients, treatment inertia among physicians and a lack of decisive healthcare system action. Many options to improve BP control are available or under investigation. Patients would benefit from targeted health education, improved BP measurement, individualized treatment or simplified treatment regimens through single-pill combinations. For physicians, increasing awareness of the burden of hypertension, as well as offering training on monitoring and optimal management and provision of the necessary time to collaboratively engage with patients would be useful. Healthcare systems should establish nationwide strategies for hypertension screening and management. Furthermore, there is an unmet need to implement more comprehensive BP measurements to optimize management. In conclusion, an integrative, patient-focused, multimodal multidisciplinary approach to the management of hypertension by clinicians, payers and policymakers, involving patients, is required to achieve long-term improvements in population health and cost-efficiency for healthcare systems.

Cost-related prescription non-adherence and patient-reported outcomes in systemic lupus erythematosus: The Michigan Lupus Epidemiology & Surveillance program

OBJECTIVES

Medication access and adherence play key roles in determining patient outcomes. We investigated whether cost-related non-adherence (CRNA) to prescription medications was associated with worse patient-reported outcomes in a population-based systemic lupus erythematosus (SLE) cohort.

METHODS

Sociodemographic and prescription data were collected by structured interviews in 2014-2015 from patients meeting SLE criteria in the established Michigan Lupus Epidemiology & Surveillance (MILES) Cohort. We examined the associations between CRNA and potential confounders such as sociodemographics and health insurance coverage, and outcome measures of SLE activity and damage using multivariable linear regression.

RESULTS

462 SLE participants completed the study visit: 430 (93.1%) female, 208 (45%) Black, and mean age 53.3 years. 100 (21.6%) participants with SLE reported CRNA in the preceding 12 months. After adjusting for covariates, CRNA was associated with both higher levels of current SLE disease activity [SLAQ: β coeff 2.7 (95% CI 1.3, 4.1), p < 0.001] and damage [LDIQ β coeff 1.4 (95% CI 0.5, 2.4), p = 0.003]. Race, health insurance status, and fulfilling Fibromyalgia (FM) Survey Criteria were independently associated with both higher (worse) SLAQ and LDIQ scores; female sex was further associated with higher SLAQ scores.

CONCLUSION

Patients with SLE who reported CRNA in the previous 12 months had significantly worse self-reported current disease activity and damage scores compared to those not reporting CRNA. Raising awareness and addressing barriers or concerns related to financial implications and accessibility issues in care plans may help to improve these outcomes.

Determinants of Medication Non-Adherence Among the Elderly with Co-Existing Hypertension and Type 2 Diabetes Mellitus in Rural Areas of Udupi District in Karnataka, India

Purpose

Medication adherence is a crucial component in the management of elderly with co-morbid chronic conditions. Hence, this study aimed to investigate the determinants of medication non-adherence among rural elderly with co-morbid chronic conditions of hypertension (HTN) and type 2 diabetes mellitus (T2DM) in India.

Patients and Methods

This cross-sectional study adopted the probability proportional to size (PPS) sampling technique to find the determinants of medication non-adherence among elderly residing in rural coverage areas of five randomly selected primary health centres (PHC) in Udupi district, Karnataka, India. A total of 360 elderly (72 samples from each cluster) who met the inclusion criteria and consented were interviewed using predesigned prevalidated and standardized or reliable tools. The data were coded and entered in SPSS version 16.0 and analyzed using both descriptive and inferential statistics.

Results

The study found that 55.6% (n=200) of rural elderly with co-morbid conditions HTN and T2DM were non-adherent to their medications and established Spearman correlation coefficient rank (r) value between undesirable person-related factors (r=-0.444); good family support (including financial support) (r=0.185); poor accessibility to healthcare facility (r=-0.209); detrimental medication-related factors including high cost of medication (r=-0.237) were found to be significant at 0.05 level of confidence (p < 0.05). Further, the study depicted that the chi-square test (χ²) was identified to be significantly associated (p<0.05) with a variable such as education, knowledge, number of illnesses and impairments, vision, memory, and physical impairments.

Conclusion

Medication adherence could be improved among rural elderly with co-morbid conditions by identifying and addressing the determinants at the earliest. Further, it is vital to identify the suitable intervention program to address these avoidable problems.

Pre-stroke Adherence to Hypertension Medications in a Bi-racial United States Stroke Belt

INTRODUCTION

Blood pressure is not optimally reduced in 3 of 4 patients with hypertension (HTN) in the United States.

AIM

We analyzed for factors associations with premorbid non-adherence to HTN medications in acute stroke patients.

METHODS

This cross-sectional study included 225 acute stroke patients with self-reported adherence to HTM medications in a stroke registry in the Southeastern United States. We defined medication non-adherence as < 90% of prescribed. Logistic regression analyzed demographic and socioeconomic factors for prediction of adherence.

RESULTS

There were 145 (64%) patients with adherence and 80 (36%) with non-adherence. The likelihood of adherence to HTN medications was decreased among black patients, OR 0.49 (95% CI 0.26-0.93), p = 0.03, and those without health insurance, OR 0.29 (95% CI 0.13-0.64), p = 0.002. Specific reasons for non-adherence were high medication cost in 26 (33%), side effects in 8 (10%), and other unspecified reasons in 46 (58%) patients.

CONCLUSION

In this study, adherence to HTN medications was significantly lower among black patients and those without health insurance.

The International Map of Axial Spondyloarthritis Survey: A US Patient Perspective on Diagnosis and Burden of Disease

OBJECTIVE

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that causes inflammation in the axial skeleton, resulting in structural damage and disability. We aimed to understand the effect of axSpA on work activity, day-to-day function, mental health, relationships, and quality of life and to examine barriers to early diagnosis.

METHODS

A 30-minute quantitative US version of the International Map of Axial Spondyloarthritis survey was administered online to US patients aged 18 years and older with a diagnosis of axSpA who were under the care of a health care provider from July 22 to November 10, 2021. This analysis describes demographics, clinical characteristics, journey to axSpA diagnosis, and disease burden.

RESULTS

We surveyed 228 US patients with axSpA. Patients had a mean diagnostic delay of 8.8 years, with a greater delay in women versus men (11.2 vs. 5.2 years), and 64.5% reported being misdiagnosed before receiving an axSpA diagnosis. Most patients (78.9%) had active disease (Bath Ankylosing Spondylitis Disease Activity Index score ≥4), reported psychological distress (57.0%; General Health Questionnaire 12 score ≥3), and experienced a high degree of impairment (81.6%; Assessment of Spondyloarthritis International Society Health Index score ≥6). Overall, 47% of patients had a medium or high limitation in activities of daily living, and 46% were not employed at survey completion.

CONCLUSION

The majority of US patients with axSpA had active disease, reported psychological distress, and reported impaired function. US patients experienced a substantial delay in time to diagnosis of axSpA that was twice as long in women versus men.

Descriptive phenomenology study of the reasons for the low uptake of free health service package among type II diabetic patients

BACKGROUND

Although several diabetes management and control programs are introduced in Iran, rate of using such cares in patients with Type II Diabetic in Ahvaz is low and they show no tendency for receiving free diabetes service package. The aim of this study was to identify reasons behind low uptake of free health service package among T2DM patients in Ahvaz, Iran.

METHODS

This descriptive phenomenology study based on semi-structured guided interviews of patients with Type II Diabetic in Ahvaz, was carried out in the year 2021. Through purposeful sampling, 495 patients with diabetics who not received health services package more than 6 months were interviewed until the data saturation. The gathered data were analyzed through conventional content analysis.

RESULTS

Reasons were categorized into three themes which include 13 subthemes and 57 codes. Themes included individual, accessibility, and structural factors. Besides, subthemes were lack of awareness, poor health literacy, adverse patients experience, difficulties to use services, verbal miscommunication cultural barriers, low trust, geographic barriers, time barriers, financial difficulties, lack of human resources, poor service delivery, and organizational factors were as barriers to participation.

CONCLUSION

Regarding individual level, there is a need for further training of diabetic patients. Besides, for accessibility and structural factors Iranian healthcare system needs a comprehensive integrated care for the management of diabetes, this underlines the collaboration for improving patients' uptake of free health service package.

Medication adherence and its impact on glycemic control in type 2 diabetes mellitus patients with comorbidity: A multicenter cross-sectional study in Northwest Ethiopia

Background

Medication nonadherence in patients with chronic diseases, particularly in type 2 diabetes mellitus (T2DM) with comorbidity, has continued to be the cause of treatment failure. The current study assessed medication adherence and its impact on glycemic control in T2DM patients with comorbidity.

Methods

An institutional-based multicenter cross-sectional study was conducted among T2DM patients with comorbidity at the selected hospitals in Northwest Ethiopia. Medication adherence was measured using a structured questionnaire of the General Medication Adherence Scale (GMAS). A logistic regression model was used to identify predictors of the level of medication adherence and glycemic control. P < 0.05 at 95% confidence interval (CI) was statistically significant.

Results

A total of 403 samples were included in the final study. This study showed that more than three-fourths (76.9%) of the participants were under a low level of medication adherence. Source of medication cost coverage [AOR = 10.593, 95% CI (2.628–41.835; P = 0.003], monthly income (P < 0.00), self-monitoring of blood glucose (SMBG) practice [AOR = 0.266, 95% CI (0.117–0.604); P = 0.002], number of medications [AOR = 0.068, 95% CI (0.004–0.813); P = 0.014] and medical conditions [AOR = 0.307, 95% CI (0.026–0.437); P = 0.018] were found to be significant predictors of medication adherence. Significantly, majority (74.7%) of participants had poor levels of glycemic control. Patients who had a high level of medication adherence [AOR = 0.003, 95% CI (0.000–0.113); P = 0.002] were found less likely to have poor glycemic control compared with patients who were low adherent to their medications.

Conclusion

The current study concluded that medication adherence was low and significantly associated with poor glycemic control. Number of medical conditions and medications were found to be associated with medication adherence. Management interventions of T2DM patients with comorbidity should focus on the improvement of medication adherence.

Facilitators and barriers of medication adherence amongst the geriatrics: a cross-sectional study

Objectives

To assess the rate of medication adherence, facilitators and barriers to medication adherence among elderly.

Methods

A cross-sectional study was conducted to assess the medication adherence level and the patient reported facilitators and barriers using medication adherence rating scale and a prevalidated questionnaire, respectively amongst the geriatric patients who were hospitalised in a south India tertiary care hospital. Data thus collected were categorically analysed. Predictors were assessed using odds ratio at 95% confidence interval.

Key Findings

A total of 401 patients were enrolled, majority [220 (54.86%)] were adherent to the medications. The barriers identified included forgetfulness, carelessness, lack of awareness about the disease and medication, illiteracy, lack of regular follow up and visit, social stigma on disease, polypharmacy and adverse effects. The facilitators included good access to the health care system, patient counselling, regular follow-up, and refill. The age group of 71–80 years [OR 2.02 (95% CI, 1.31–3.13)], illiteracy [OR 2.34 (95% CI 1.38–3.98)], single as marital status [OR 3.64 (95% CI, 1.13–11.67)], comorbidities (≥5) [OR 3.91 (95% CI, 1.78–8.60)], discharge medications (&gt;11) [OR 3.11 (95% CI, 1.55–6.26)], lack of awareness about the disease [OR 1.99 (95% CI, 1.30–3.032)] were found to be significant predisposing factors.

Conclusions

This study reveals as several predictive factors were identified for medication nonadherence which can aid in developing strategies to improve medication adherence.

Decreasing rates of cost-related medication non-adherence by age advancement among American generational cohorts 2004-2014: a longitudinal study

OBJECTIVES

The access barrier to medication has been a persistent and elusive challenge in the US healthcare system and around the globe. Cost-related medication non-adherence (CRN) is an important measure of medication non-adherence behaviours that aim to avoid costs. Longitudinal study of CRN behaviours for the ageing population is rare.

DESIGN

Longitudinal study using the Health and Retirement Study to evaluate self-reported CRN biennially.

SETTING

General population of older Americans.

PARTICIPANTS

Three cohorts of Americans aged between 50 and 54 (baby boomers), 65-69 (the silent generation) and 80 or above (the greatest generation) in 2004 who were followed to 2014.

INTERVENTION

Observational with no intervention.

PRIMARY AND SECONDARY OUTCOME MEASURES

Longitudinal CRN rates for three generational cohorts from 2004 to 2014. Population-averaged effects of a broad set of variables including sociodemographics, income, insurance status, limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and comorbid conditions on CRN were derived using generalised estimating equation by taking into account repeated measurements of CRN over time for the three cohorts, respectively.

RESULTS

The three cohorts of baby boomer, the silent generation and the greatest generation with 1925, 2839 and 2666 respondents represented 12.3 million, 8.2 million and 7.7 million people in 2004, respectively. Increasing age was associated with decreasing likelihood of reporting CRN in all three generational cohorts (p<0.05), controlling for demographics, income, insurance status, functional status and comorbid conditions. All three generational cohorts had a higher prevalence of diabetes, cancer, heart conditions, stroke, a higher percentage of respondents with Medicare-Medicaid dual eligibility and lower percentage with private insurance in 2014 compared with 2004 (p<0.05).

CONCLUSION

The paradox of decreasing CRN rates, independent of disease burden, income and insurance status, suggests populations' CRN behaviours change as Americans age, bearing implications to social policy.

RESPONSE TO: COST-SHARING: IMPLICATIONS OF A WELL-INTENDED BENEFITS STRATEGY

Disclosures: S. Rotolo has no conflicts of interest to disclose. No funding was received for any portion of this work.

The Effect of the COVID-19 Pandemic on the Social Inequalities of Health Care Use in Hungary: A Nationally Representative Cross-Sectional Study

Background: The social representation of restricted health care use during the COVID-19 pandemic has not been evaluated properly yet in Hungary. Objective: Our study aimed to quantify the effect of COVID-19 pandemic measures on general practitioner (GP) visits, specialist care, hospitalization, and cost-related prescription nonredemption (CRPNR) among adults, and to identify the social strata susceptible to the pandemic effect. Methods: This cross-sectional study was based on nationally representative data of 6611 (N_prepandemic = 5603 and N_pandemic = 1008) adults. Multivariable logistic regression models were applied to determine the sociodemographic and clinical factors influencing health care use by odds ratios (ORs) along with the corresponding 95% confidence intervals (CI). To identify the social strata susceptible to the pandemic effect, the interaction of the time of data collection with the level of education, marital status, and Roma ethnicity, was tested and described by iORs. Results: While the CRPNR did not change, the frequency of GP visits, specialist care, and hospitalization rates was remarkably reduced by 22.2%, 26.4%, and 6.7%, respectively, during the pandemic. Roma proved to be not specifically affected by the pandemic in any studied aspect, and the pandemic restructuring of health care impacted the social subgroups evenly with respect to hospital care. However, the pandemic effect was weaker among primary educated adults (iOR_{GP visits, high-school vs. primary-education} = 0.434; 95% CI 0.243–0.776, OR_{specialist visit, high-school vs. primary-education} = 0.598; 95% CI 0.364–0.985), and stronger among married adults (iOR_{GP visit, widowed vs. married} = 2.284; 95% CI 1.043–4.998, iOR_{specialist visit, widowed vs. married} = 1.915; 95% CI 1.157–3.168), on the frequency of GP visits and specialist visits. The prepandemic CRPNR inequality by the level of education was increased (iOR_{high-school vs. primary-education} = 0.236; 95% CI 0.075–0.743). Conclusion: Primary educated and widowed adults did not follow the general trend, and their prepandemic health care use was not reduced during the pandemic. This shows that although the management of pandemic health care use restrictions was implemented by not increasing social inequity, the drug availability for primary educated individuals could require more support.

Assessment of Hypothetical Out-of-Pocket Costs of Guideline-Recommended Medications for the Treatment of Older Adults With Multiple Chronic Conditions, 2009 and 2019

IMPORTANCE

Most adults 65 years or older have multiple chronic conditions. Managing these conditions with prescription drugs can be costly, particularly for older adults with limited incomes.

OBJECTIVE

To estimate hypothetical out-of-pocket costs associated with guideline-recommended outpatient medications for the initial treatment of 8 common chronic diseases among older adults with Medicare prescription drug plans (PDPs).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study used 2009 and 2019 Medicare prescription drug plan formulary files to estimate annual out-of-pocket costs among hypothetical patients enrolled in Medicare Advantage or stand-alone Medicare Part D plans. A total of 3599 PDPs in 2009 and 3618 PDPs in 2019 were included after inclusion and exclusion criteria were applied. Costs associated with guideline-recommended medications for 8 of the most common chronic diseases (atrial fibrillation, chronic obstructive pulmonary disease [COPD], heart failure with reduced ejection fraction, hypercholesterolemia, hypertension, osteoarthritis, osteoporosis, and type 2 diabetes), alone and in 2 clusters of commonly comorbid conditions, were examined.

MAIN OUTCOMES AND MEASURES

Annual out-of-pocket costs for each chronic condition, inflation adjusted to 2019 dollars.

RESULTS

Among 3599 Medicare PDPs in 2009, 1998 were Medicare Advantage plans and 1601 were stand-alone plans; among 3618 Medicare PDPs in 2019, 2719 were Medicare Advantage plans and 899 were stand-alone plans. For an older adult enrolled in any Medicare PDP in 2019, the median annual out-of-pocket costs for individual conditions varied, from a minimum of $32 (IQR, $6-$48) for guideline-recommended management of osteoporosis (a decrease from $128 [IQR, $102-$183] in 2009) to a maximum of $1579 (IQR, $1524-$2229) for guideline-recommended management of atrial fibrillation (an increase from $91 [IQR, $73-$124] in 2009). For an older adult with a cluster of 5 commonly comorbid conditions (COPD, hypertension, osteoarthritis, osteoporosis, and type 2 diabetes) enrolled in any PDP, the median out-of-pocket cost in 2019 was $1999 (IQR, $1630-$2564), a 12% decrease from $2284 (IQR, $1920-$3107) in 2009. For an older adult with all 8 chronic conditions (atrial fibrillation, COPD, diabetes, hypercholesterolemia, heart failure, hypertension, osteoarthritis, and osteoporosis) enrolled in any PDP, the median out-of-pocket cost in 2019 was $3630 (IQR, $3234-$5197), a 41% increase from $2571 (IQR, $2185-$3719) in 2009.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, out-of-pocket costs for guideline-recommended outpatient medications for the initial treatment of 8 common chronic diseases varied by condition. Although costs generally decreased between 2009 and 2019, particularly with regard to conditions for which generic drugs were available, out-of-pocket costs remained high and may have presented a substantial financial burden for Medicare beneficiaries, especially older adults with conditions for which brand-name drugs were guideline recommended.

Interventions for Adherence Improvement in the Primary Prevention of Cardiovascular Diseases: Expert Consensus Statement

Over the last 2 decades, the management of chronic disease in Korea has been improved, but it has gradually stagnated. In order to improve care and reduce cardiovascular morbidity and mortality, it is crucial to improve primary prevention of cardiovascular diseases. In recent international guidelines for hypertension, diabetes, hyperlipidemia, obesity, and other conditions, adherence issues have become more frequently addressed. However, in terms of implementation in practice, separate approaches by dozens of related academic specialties need to be integrated into a systematic approach including clinician’s perspectives such as the science behind adherence, clinical skills, and interaction within team approach.

In primary prevention for cardiovascular diseases, there are significant barriers to adherence including freedom from symptoms, long latency for therapeutic benefits, life-long duration of treatment, and need for combined lifestyle changes. However, to implement more systematic approaches, the focus on adherence improvement needs to be shifted away from patient factors to the effects of the treatment team and healthcare system. In addition to conventional educational approaches, more patient-oriented approaches such as patient-centered clinical communication skills, counseling using motivational strategies, decision-making by patient empowerment, and a multi-disciplinary team approach should be developed and implemented. Patients should be involved in a program of self-monitoring, self-management, and active counseling. Because most effective interventions on adherence improvement demand greater resources, the health care system and educational or training system of physicians and healthcare staff need to be supported for systematic improvement.

Contribution of cost to treatment nonadherence in the US breast cancer survivors: a population-based analysis

INTRODUCTION

Breast cancer survivors are often prescribed medications for at least 5 years to reduce recurrence risk, yet some forego this treatment due to cost. We sought to elucidate the prevalence of this and the factors contributing to it.

METHODS

The National Health Interview Survey (NHIS) is a population-based survey, representative of the civilian non-institutionalized US population, administered annually by the CDC. People diagnosed with breast cancer within the past 5 years surveyed in the 2018 NHIS formed the cohort of interest.

RESULTS

Of the 24,858 breast cancer survivors surveyed, representing 244,607,304 in the population, 6.32% stated that they needed a prescription medicine within the past 12 months, but didn't get it filled because they couldn't afford it. Of those who had gotten a prescription within the past 12 months, 5.71, 5.94 and 7.48% had either skipped doses, taken less medication than prescribed, or delayed filling a prescription, respectively, to save money. 11.99% of people had done at least one of these, thereby foregoing treatment. On bivariate analyses, factors associated with foregoing treatment included age, race, education, family income, and insurance status (p < 0.001 for all). On multivariable analysis, age, race, family income, and insurance status were all independent predictors of foregoing treatment (p < 0.001 for all); education status was not significant in the model (p = 0.211).

CONCLUSION

Roughly 12% of breast cancer survivors who are prescribed medications within the first 5 years of their diagnosis will forego treatment due to cost. Family income and insurance status are key modifiable drivers of this.

Adherence to Antiplatelet Medications among Persistent and Non-Persistent Older Patients with Peripheral Arterial Disease

Secondary prevention of peripheral arterial disease (PAD) includes administration of antiplatelet agents, and adherence to medication is a requirement for an effective treatment. The aim of this study was to analyse adherence measured using the proportion of days covered (PDC) index separately in persistent and non-persistent patients, and to identify patient- and medication-related characteristics associated with non-adherence in these patient groups. The study cohort of 9178 patients aged ≥ 65 years in whom PAD was diagnosed in 1/–12/2012 included 6146 persistent and 3032 non-persistent patients. Non-adherence was identified as PDC < 80%. Characteristics associated with non-adherence were determined using the binary logistic regression model. In the group of persistent patients, 15.3% of subjects were identified as non-adherent, while among non-persistent patients, 26.9% of subjects were non-adherent to antiplatelet medication. Administration of dual antiplatelet therapy (aspirin and clopidogrel) and a general practitioner as index prescriber were associated with adherence in both patient groups. Our study revealed a relatively high proportion of adherent patients not only in the group of persistent patients but also in the group of non-persistent patients before discontinuation. These results indicate that most non-persistent PAD patients discontinue antiplatelet treatment rapidly after a certain period of adherence.

Access and Cost-Related Nonadherence to Prescription Medications Among Lupus Patients and Controls: The Michigan Lupus Epidemiology and Surveillance Program

OBJECTIVE

Medication access and adherence are important determinants of health outcomes. We investigated factors associated with access and cost-related nonadherence to prescriptions in a population-based cohort of systemic lupus erythematosus (SLE) patients and controls.

METHODS

Detailed sociodemographic and prescription data were collected by structured interview in 2014-2015 from participants in the Michigan Lupus Epidemiology and Surveillance (MILES) cohort. We compared access between cases and frequency-matched controls and examined associated factors in separate multivariable logistic regression models.

RESULTS

A total of 654 participants (462 SLE patients, 192 controls) completed the baseline visit; 584 (89%) were female, 285 (44%) were Black, and the mean age was 53 years. SLE patients and controls reported similar frequencies of being unable to access prescribed medications (12.1% versus 9.4%, respectively; P was not significant). SLE patients were twice as likely as controls to report cost-related prescription nonadherence in the preceding 12 months to save money (21.7% versus 10.4%; P = 0.001) but were also more likely to ask their doctor for lower cost alternatives (23.8% versus 15.6%; P = 0.02). Disparities were found in association with income, race, and health insurance status, but the main findings persisted after adjusting for these and other variables in multivariable models.

CONCLUSION

SLE patients were more likely than controls from the general population to report cost-related prescription nonadherence, including skipping doses, taking less medicine, and delaying filling prescriptions; yet, <1 in 4 patients asked providers for lower cost medications. Consideration of medication costs in patient decision-making could provide a meaningful avenue for improving access and adherence to medications.

Evaluation of the Post-Training Hypotensor Effect in Paralympic and Conventional Powerlifting

High blood pressure (HBP) has been associated with several complications and causes of death. The objective of the study was to analyze the hemodynamic responses in Paralympic bench press powerlifting (PP) and conventional powerlifting (CP) before and after training and up to 60 minutes (min) after training. Ten PP and 10 CP athletes performed five sets of five repetition maximal bench press exercises, and we evaluated systolic, diastolic, and mean blood pressure (SBP, DBP, and MBP, respectively), heart rate (HR), heart pressure product (HPP), and myocardial oxygen volume (MVO₂). The SBP increased after training (p < 0.001), and there were differences in the post training and 30, 40, and 60 min later (p = 0.021), between 10 and 40 min after training (p = 0.031, η²_p = 0.570), and between CP and PP (p =0.028, η²_p = 0.570). In the MBP, there were differences between before and after (p = 0.016) and 40 min later (p = 0.040, η²_p = 0.309). In the HR, there was a difference between before and after, and 5 and 10 min later (p = 0.002), and between after and 10, 20, 30, 40, 50, and 60 min later (p < 0.001, η²_p = 0.767). In HPP and MVO₂, there were differences between before and after (p = 0.006), and between after and 5, 10, 20, 30, 40, 50, and 60 min later (p < 0.001, η²_p = 0.816). In CP and PP, there is no risk of hemodynamic overload to athletes, considering the results of the HPP, and training promotes a moderate hypotensive effect, with blood pressure adaptation after and 60 min after exercise.

Prevalence and Correlates of Cost-Related Medication Nonadherence to Immunosuppressive Drugs After Heart Transplantation: The International Multicenter Cross-sectional Bright Study

BACKGROUND

Cost-related medication nonadherence (CRMNA) refers to not taking medications as prescribed because of difficulties paying for them.

OBJECTIVES

The aims of this study were (1) to assess the prevalence of CRMNA to immunosuppressants in heart transplant recipients internationally and (2) to determine multilevel correlates (patient, center, and healthcare system levels) of CRMNA.

METHODS

Using data from the cross-sectional international BRIGHT study, applying multistaged sampling, CRMNA was assessed via 3 self-report items in 1365 patients from 36 heart transplant centers in 11 countries. Cost-related medication nonadherence was defined as any positive answer on any of the 3 items. Healthcare system-level (ie, insurance coverage, out-of-pocket expenditures) and patient-level (ie, intention, perceived financial burden, cost as a barrier, a health belief regarding medication benefits, cost-related self-efficacy, and demographic factors) CRMNA correlates were assessed. Correlates were examined using mixed logistic regression analysis.

RESULTS

Across all study countries, CRMNA had an average prevalence of 2.6% (range, 0% [Switzerland/Brazil] to 9.8% [Australia]) and was positively related to being single (odds ratio, 2.29; 95% confidence interval, 1.17-4.47), perceived financial burden (odds ratio, 2.15; 95% confidence interval, 1.55-2.99), and cost as a barrier (odds ratio, 2.60; 95% confidence interval, 1.66-4.07). Four protective factors were identified: white ethnicity (odds ratio, 0.37; 95% confidence interval, 0.19-0.74), intention to adhere (odds ratio, 0.44; 95% confidence interval, 0.31-0.63), self-efficacy (odds ratio, 0.54; 95% confidence interval, 0.43-0.67), and belief about medication benefit (odds ratio, 0.70; 95% confidence interval, 0.57-0.87). Regarding variability, 81.3% was explained at the patient level; 13.8%, at the center level; and 4.8%, at the country level.

CONCLUSION

In heart transplant recipients, the CRMNA prevalence varies across countries but is lower than in other chronically ill populations. Identified patient-level correlates are novel (ie, intention to adhere, cost-related barriers, and cost-related self-efficacy) and indicate patient-perceived medication cost burden.

Factors associated with medication adherence among people living with COPD: Pharmacists' perspectives

Background

While medication is an integral part of the effective management of COPD, more than 50% of people living with COPD do not adhere to their prescribed medications. The drivers underpinning this observed behaviour are poorly understood. As pharmacists generally have the final interaction with patients prior to their use of medications, their perspectives may offer insights about patients' medication use that may improve our understanding of this complex issue.

Objective

This study explored pharmacists' experiences of providing care for patients living with COPD to gain insight about factors that impact their medication-taking behaviour.

Methods

Fourteen pharmacists who worked in practice settings across the South-East Queensland region of Australia participated in interviews between March 2019 and January 2020. Interviews were audio-recorded, transcribed verbatim, and thematically analysed.

Results

Two overarching themes were identified which modulated medication-taking behaviour. Barriers comprised patient-related factors including, financial constraints, poor inhaler technique, and inaccurate beliefs; alongside pharmacist-related factors such as a lack of COPD-specific training and time constraints. Factors that promote adherence included patient education and monitoring and collaborative relationships between key stakeholders.

Conclusions

Medication non-adherence is common. While pharmacists expressed a desire to better support their patients, practical strategies to overcome the challenges that they face in clinical settings are lacking. Future research should focus on exploring ways to engage patients at the pharmacy level thereby enhancing the provision of services that would optimise medication adherence.

Development of measurable criteria to identify and prioritize patients for inclusion in comprehensive medication management programs within primary care settings

BACKGROUND: Pharmacists optimize medication use and ensure the safe and effective delivery of pharmacotherapy to patients using comprehensive medication management (CMM). Identifying and prioritizing individual patients who will most likely benefit from CMM can be challenging. Health systems have far more candidates for CMM than there are clinical pharmacists to provide this service. Furthermore, current evidence lacks widely accepted standards or automated mechanisms for identifying patients who would likely benefit from a pharmacist consultation. Existing tools to prioritize patients for pharmacist review often require manual chart review by a pharmacist or other clinicians or data collection by patient survey. OBJECTIVES: To (1) create new medication risk markers for identifying and prioritizing patients within a population and (2) identify patients who met these new markers, assess their clinical characteristics, and compare them with criteria that are widely used for medication therapy management (MTM). METHODS: Along with published literature, a panel of subject matter experts informed the development of 3 medication risk markers. To assess the prevalence of markers developed, we used Multum, a medication database, for medication-level characteristics, and for patient-level characteristics, we used QuintilesIMS, an administrative claims database derived from health plans across the United States, with data for 1,541,873 eligible individuals from 2014-2015. We compared the health care costs, utilization, and medication gap among patients identified through MTM criteria (both broad and narrow, as these are provided as ranges) and our new medication management score markers. RESULTS: We developed 3 claims-derivable markers: (1) instances when a patient filled a medication with high complexity that could affect adherence, (2) instances where a patient filled a medication defined as costly within a therapeutic category that could affect access, and (3) instances when a patient filled a medication defined as risky that could increase incidence of adverse drug events. In the QuintilesIMS database, individuals with 2 new medication risk markers plus at least 3 conditions and more than $3,017 in medication costs when compared with individuals meeting narrow MTM eligibility criteria (≥ 8 medications, ≥ 3 conditions, and > $3,017 medication costs) had increased costs ($36,000 vs $26,100 total; $24,800 vs 21,400 medical; $11,300 vs $4,800 pharmacy); acute care utilization (0.328 vs 0.256 inpatient admissions and 0.627 vs 0.579 emergency department visits); and 1 or more gaps in medication adherence(41.5% vs 34.7%). CONCLUSIONS: We identified novel markers of medication use risk that can be determined using insurance claims and can be useful to identify patients for CMM programs and prioritize patients who would benefit from clinical pharmacist intervention. These markers were associated with higher costs, acute care utilization, and gaps in medication use compared with the overall population and within certain subgroups. Providing CMM to these patients may improve health system performance in relevant quality measures. Evaluation of CMM services delivered by a pharmacist using these markers requires further investigation. DISCLOSURES: No outside funding supported this study. All authors are Johns Hopkins employees. The Johns Hopkins University receives royalties for nonacademic use of software based on the Johns Hopkins Adjusted Clinical Group (ACG) methodology. Chang, Kitchen, Weiner, and Kharrazi receive a portion of their salary support from this revenue. The authors have no conflicts of interests relevant to this study.

The effect of pharmaceutical co-payment increase on the use of social assistance-A natural experiment study

Health care out-of-pocket payments can create barriers to access or lead to financial distress. Out-of-pocket expenditure is often driven by outpatient pharmaceuticals. In this nationwide register study, we study the causal relationship between an increase in patients' pharmaceutical expenses and financial difficulties by exploiting a natural experiment design arising from a 2017 reform, which introduced higher co-payments for type 2 diabetes medicines in Finland. With difference-in-differences estimation, we analyze whether the reform increased the use of social assistance, a last-resort financial aid. We found that after the reform the share of social assistance recipients increased more among type 2 diabetes patients than among a patient group not affected by the co-payment increase, suggesting the reform increased the use of social assistance among those subject to it. The results indicate that increases in patients' pharmaceutical expenses can lead to serious financial difficulties even in countries with a comprehensive social security system.

Adherence at 2 years with distribution of essential medicines at no charge: The CLEAN Meds randomized clinical trial

BACKGROUND

Adherence to medicines is low for a variety of reasons, including the cost borne by patients. Some jurisdictions publicly fund medicines for the general population, but many jurisdictions do not, and such policies are contentious. To our knowledge, no trials studying free access to a wide range of medicines have been conducted.

METHODS AND FINDINGS

We randomly assigned 786 primary care patients who reported not taking medicines due to cost between June 1, 2016 and April 28, 2017 to either free distribution of essential medicines (n = 395) or to usual medicine access (n = 391). The trial was conducted in Ontario, Canada, where hospital care and physician services are publicly funded for the general population but medicines are not. The trial population was mostly female (56%), younger than 65 years (83%), white (66%), and had a low income from wages as the primary source (56%). The primary outcome was medicine adherence after 2 years. Secondary outcomes included control of diabetes, blood pressure, and low-density lipoprotein (LDL) cholesterol in patients taking relevant treatments and healthcare costs over 2 years. Adherence to all appropriate prescribed medicines was 38.7% in the free distribution group and 28.6% in the usual access group after 2 years (absolute difference 10.1%; 95% confidence interval (CI) 3.3 to 16.9, p = 0.004). There were no statistically significant differences in control of diabetes (hemoglobin A1c 0.27; 95% CI -0.25 to 0.79, p = 0.302), systolic blood pressure (-3.9; 95% CI -9.9 to 2.2, p = 0.210), or LDL cholesterol (0.26; 95% CI -0.08 to 0.60, p = 0.130) based on available data. Total healthcare costs over 2 years were lower with free distribution (difference in median CAN$1,117; 95% CI CAN$445 to CAN$1,778, p = 0.006). In the free distribution group, 51 participants experienced a serious adverse event, while 68 participants in the usual access group experienced a serious adverse event (p = 0.091). Participants were not blinded, and some outcomes depended on participant reports.

CONCLUSIONS

In this study, we observed that free distribution of essential medicines to patients with cost-related nonadherence substantially increased adherence, did not affect surrogate health outcomes, and reduced total healthcare costs over 2 years.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02744963.

Cost-related nonadherence for prescription medications: a cross-sectional study in Jordan

Background: Cost-related nonadherence to medications is a commonly encountered problem posed by many patients, and specifically among elderly patients who use multiple chronic medications. This study aims to explore the prevalence of medication cost-related nonadherence and its predictors in Jordan.Method: A cross-sectional study was conducted between February 2019 and May 2019 in Jordan. The CRN questionnaire was used as a measure to assess the prevalence of cost-related nonadherence. Logistic regression was used to determine predictors of medication cost-related nonadherence.Results: The prevalence rate of CRN was 29.6% (95% CI: 27.0-32.3). Participants who are married or widowed were found to have higher odds of being non-adherent due to medication costs, with an odds ratio of 1.55 (95%CI: 1.19-2.00) and 1.95 (95%CI: 1.20-3.15), respectively. Lower educational level was associated with higher odds of being non-adherent 1.95 (95%CI: 1.25-3.05). Being retired was associated with higher odds of being non-adherent (2.20 (95%CI: 1.49-3.27)).Conclusion: Cost-related nonadherence is a common problem in Jordan and was most prevalent among those with hypertension and diabetes mellitus, low-income, and low levels of education. Our findings could help in developing interventions to improve cost-related medication nonadherence in developing countries.

Medicine in motion: Opportunities, challenges and data analytics-based solutions for traditional medicine integration into western medical practice

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional pharmacopeias have been developed by multiple cultures and evaluated for efficacy and safety through both historical/empirical iteration and more recently through controlled studies using Western scientific paradigms and an increasing emphasis on data science methodologies for network pharmacology. Traditional medicines represent likely sources of relatively inexpensive drugs for symptomatic management as well as potential libraries of new therapeutic approaches. Leveraging this potential requires hard evidence for efficacy that separates science from pseudoscience.

MATERIALS AND METHODS

We performed a review of non-Western medical systems and developed case studies that illustrate the epistemological and practical translative barriers that hamper their transition to integration with Western approaches. We developed a new data analytics approach, in silico convergence analysis, to deconvolve modes of action, and potentially predict desirable components of TM-derived formulations based on computational consensus analysis across cultures and medical systems.

RESULTS

Abstraction, simplification and altered dose and delivery modalities were identified as factors that influence actual and perceived efficacy once a medicine is moved from a non-Western to Western setting. Case studies on these factors highlighted issues with translation between non-Western and Western epistemologies, including those where epistemological and medicinal systems drive markets that can be epicenters for zoonoses such as the novel Coronavirus. The proposed novel data science approach demonstrated the ability to identify and predict desirable medicinal components for a test indication, pain.

CONCLUSIONS

Relegation of traditional therapies to the relatively unregulated nutraceutical industry may lead healthcare providers and patients to underestimate the therapeutic potential of these medicines. We suggest three areas of emphasis for this field: First, vertical integration and embedding of traditional medicines into healthcare systems would subject them to appropriate regulation and evidence-based practice, as viable integrative implementation mode. Second, we offer a new Bradford-Hill-like framework for setting research priorities and evaluating efficacy, with the goal of rescuing potentially valuable therapies from the nutraceutical market and discrediting those that are pseudoscience. Third, data analytics pipelines offer new capacity to generate new types of TMS-inspired medicines that are rationally-designed based on integrated knowledge across cultures, and also provide an evaluative framework against which to test claims of fidelity and efficacy to TMS made for nutraceuticals.

Cost-related nonadherence with glaucoma medications in Ontario

OBJECTIVE

To determine the proportion of glaucoma patients in Ontario aged 25-64 who lack insurance coverage for glaucoma medications and to assess the frequency of cost-related nonadherence to glaucoma medications.

DESIGN

Cross-sectional study.

PARTICIPANTS

Glaucoma patients on medication from 2 glaucoma clinics in Toronto, Ontario.

METHODS

100 consecutive glaucoma patients aged 25-64 (not entitled to provincial drug benefit) and 100 consecutive glaucoma patients aged 65+ (entitled to provincial drug benefit), all on topical glaucoma therapy, completed a standardized questionnaire. Questions included insurance coverage for glaucoma medications, cost concerns when paying for glaucoma medications, cost-related nonadherence, and sociodemographics.

RESULTS

25.8% of those aged 25-64 express concerns about the cost of their glaucoma medications compared to 7.1% of those aged 65+ (p < 0.001). Patients aged 25-64 were also significantly more likely to report at least one form of cost-related nonadherence (15.5% vs 2.0%, p = 0.001) and significantly more likely to report missing eye drops in a given week than patients aged 65+ (32.0% vs 16.7%, p = 0.01). 17% (95% confidence interval 11%-26%) of patients aged 25-64 self-reported having no insurance coverage for their glaucoma medications. Of those with coverage, the most common source of insurance was employer-sponsored (68.6%) with 44% requiring a copayment. The average copayment was $18 (range $2-$250) for those aged 25-64 compared with $5 in the 65+ group (range $0.62-$100).

CONCLUSIONS

17% of glaucoma patients aged 25-64 do not have coverage for their drops. One in four expressed concerns about the cost of their glaucoma medications, and 15.5% reported cost-related nonadherence.

Cost-related medication nonadherence in Canada: a systematic review of prevalence, predictors, and clinical impact

BACKGROUND

Cost-related nonadherence to medications (CRNA) is common in many countries and thought to be associated with adverse outcomes. The characteristics of CRNA in Canada, with its patchwork coverage of increasingly expensive medications, are unclear.

OBJECTIVES

Our objective in this systematic review was to summarize the literature evaluating CRNA in Canada in three domains: prevalence, predictors, and effect on clinical outcomes.

METHODS

We searched MEDLINE, Embase, Google Scholar, and the Cochrane Library from 1992 to December 2019 using search terms covering medication adherence, costs, and Canada. Eligible studies, without restriction on design, had to have original data on at least one of the three domains specifically for Canadian participants. Articles were identified and reviewed in duplicate. Risk of bias was assessed using design-specific tools.

RESULTS

Twenty-six studies of varying quality (n = 483,065 Canadians) were eligible for inclusion. Sixteen studies reported on the overall prevalence of CRNA, with population-based estimates ranging from 5.1 to 10.2%. Factors predicting CRNA included high out-of-pocket spending, low income or financial flexibility, lack of drug insurance, younger age, and poorer health. A single randomized trial of free essential medications with free delivery in Ontario improved adherence but did not find any change in clinical outcomes at 1 year.

CONCLUSION

CRNA affects many Canadians. The estimated percentage depends on the sampling frame, the main predictors tend to be financial, and its association with clinical outcomes in Canada remains unproven.

The Impact of Prescription Medication Cost Coverage on Oral Medication Use for Hypertension and Type 2 Diabetes Mellitus

BACKGROUND

No previous study, to the best of our knowledge, has examined both the time trend and impact of not having insurance or prescription medication cost coverage (PMCC) on the usage of type 2 diabetes and hypertension oral medications in Ontario and New Brunswick, Canada.

METHODS

We used data from the Canadian Community Health Survey (CCHS) from 2007 to 2014 to examine the time trend and impact of PMCC. A multivariable-adjusted logistic regression model was fitted.

RESULTS

The pseudo-cohort included 23,215 individuals representing a population of approximately 8.7 million people. Overall, 20.0% of respondents reported absence of PMCC. This proportion increased slightly from 19.6% (95% confidence interval [CI] 95% CI [17.5, 22.5]) to 20.7% (95% CI [16.9, 23.1]). Adjusted odds ratios (OR) showed that uninsured individuals were 23% less likely to use their medications (OR = 0.77, 95% CI [0.657, 0.911]).

CONCLUSION

There was a slight decline in PMCC over time and this decline was associated with reduced use of medications for type 2 diabetes and hypertension.

Medication adherence: understanding the issues and finding solutions

Medication is the most frequent treatment intervention, and its success depends on patients taking their medicines in line with their prescribed regimen to yield the full benefit of the treatment. Adherence is especially difficult to ensure in those with multimorbidity, who take multiple medications to manage their conditions. Non-adherence is costly for the health service, both through wastage and increased ill health. Non-adherence may be intentional or non-intentional, and many factors affect an individual's compliance with a medication regimen. There are a variety of aids that may be helpful; however, the interaction with a health professional is very important, both for understanding the reason for non-adherence and for promoting adherence.

Age and gender differences in financial distress among hematopoietic cell transplant survivors

PURPOSE

Cancer has long-term financial consequences. Adolescent and young adult (AYA) and middle-aged cancer survivors may experience more financial toxicity than older adults. This study examined age differences in financial distress in hematopoietic cell transplant survivors and whether these differences result from measurement bias, more financial barriers to care, or an overall higher level of distress.

METHODS

Hematologic malignancy survivors (n = 1135, 2-10 years post-transplant) completed the Cancer and Treatment Distress Scale (CTXD) and demographics as part of the baseline assessment for a randomized clinical trial. The CTXD has seven subscales, but for this study, we examined the financial distress subscale and the overall score. Item response theory analyses tested for bias by age and gender. Multivariate linear regression tested the association of age and gender with the CTXD scores while controlling for financial barriers to care.

RESULTS

No bias was found on the CTXD. AYA (p < 0.01) and middle-aged adults (p < 0.001) reported more financial and overall distress than older (age 65+) adults. The same association of age and financial distress was observed in women (p < 0.01). However, only middle-aged men (p < 0.01) reported more financial and overall distress than older men; AYA men did not (p > 0.18). Financial barriers to care were not associated with financial or overall distress.

CONCLUSIONS

Part of the increase in financial distress with younger age may be due to a higher risk of general distress. Policy initiatives to control cancer costs should consider life stage and the unique financial challenges at different ages for men and women.

Strategies to Reduce Out-of-Pocket Medication Costs for Canadians Living with Heart Failure

INTRODUCTION

Daily medication is the cornerstone of evidence-based therapy to reduce mortality and morbidity in patients with heart failure (HF). Up to 20% of Canadian patients pay for medications out of pocket. We sought to identify strategies that patients and prescribers can employ to reduce these costs.

METHODS

We collected data from outpatient pharmacies in Hamilton, Ontario. We determined prices for different medications in each of the drug classes recommended for HF with reduced ejection fraction in the Canadian Cardiovascular Society's guidelines. We examined differences in dispensing and delivery fees and inquired about other cost-saving strategies.

RESULTS

We collected data from 24 different pharmacies, including a selection of hospital-based, independent, and larger chain pharmacies. In the most extreme scenario (i.e., 90-day prescription instead of a 30-day prescription and the least expensive generic drug instead of the most expensive brand name drug), total medication costs can differ by up to $495.56 per month. Costs were affected by choice of agent within a drug class, generic versus brand-name drug, quantity dispensed, dispensing fee, and delivery cost.

CONCLUSIONS

Prescription content, dispensing practice, and pharmacy choice can remarkably impact out-of-pocket costs for HF medications. Prescribers can reduce costs by writing 90-day prescriptions and choosing the lowest-cost generic drugs in each therapeutic class. Patients should consider the services received for their pharmacy dispensing fees, use free delivery services where needed, and request inexpensive generic drugs. Pharmacists can facilitate cost minimization without compromising therapeutic efficacy.

Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days

OBJECTIVE

To evaluate the hypothesis that nonadherence to medication changes made at hospital discharge is associated with an increased risk of adverse events in the 30 days postdischarge.

STUDY SETTING

Patients admitted to hospitals in Montreal, Quebec, between 2014 and 2016.

STUDY DESIGN

Prospective cohort study.

DATA COLLECTION

Nonadherence to medication changes was measured by comparing medications dispensed in the community with those prescribed at hospital discharge. Patient, health system, and drug regimen-level covariates were measured using medical services and pharmacy claims data as well as data abstracted from the patient's hospital chart. Multivariable Cox models were used to determine the association between nonadherence to medication changes and the risk of adverse events.

PRINCIPAL FINDINGS

Among 2655 patients who met our inclusion criteria, mean age was 69.5 years (SD 14.7) and 1581 (60%) were males. Almost half of patients (n = 1161, 44%) were nonadherent to at least one medication change, and 860 (32%) were readmitted to hospital, visited the emergency department, or died in the 30 days postdischarge. Patients who were not adherent to any of their medication changes had a 35% higher risk of adverse events compared to those who were adherent to all medication changes (1.41 vs 1.27 events/100 person-days, adjusted hazard ratio: 1.35, 95% CI: 1.06-1.71).

CONCLUSIONS

Almost half of all patients were not adherent to some or all changes made to their medications at hospital discharge. Nonadherence to all changes was associated with an increased risk of adverse events. Interventions addressing barriers to adherence should be considered moving forward.

Patient-physician communication about financial problems: A cross-sectional study among over-indebted individuals

Background

About every tenth household across Europe is unable to meet payment obligations and living expenses on an ongoing basis and is thus considered over-indebted. Previous research suggests that over-indebtedness reflects a potential cause and consequence of psychosomatic health problems and limited access to care. However, it is unclear whether those affected discuss their financial problems with general practitioners. Therefore, this study examined patient-physician communication about financial problems in general practice among over-indebted individuals.

Methods

We conducted a cross-sectional survey among clients of 70 debt advice agencies in North Rhine-Westphalia, Germany, in 2017. We assessed the prevalence of patient-physician communication about financial problems and its association with patient characteristics using descriptive statistics and logistic regression analysis. Of 699 individuals who returned the questionnaire (response rate:50.2%), we included 598 respondents enrolled in statutory health insurance with complete outcome data in the analyses.

Results

Conversations about financial problems with general practitioners were reported by 22.6% (n = 135) of respondents. Individuals with a high educational level were less likely to report such conversations than those with medium educational level (aOR 0.11; 95%CI 0.01–0.83) after adjustment for other sociodemographic characteristics, health status and measures of financial distress. Those without a migrant background(aOR 2.09; 95%CI 1.32–3.32), the chronically ill(aOR 1.90; 95%CI 1.16–3.13) and individuals who reported high financial distress(aOR 2.15; 95%CI 1.22–3.78) and cutting on necessities to pay for medications(aOR 1.86; 95%CI 1.12–3.09) were more likely to discuss financial problems than their counterparts.

Conclusions

Few over-indebted individuals discussed financial problems with their general practitioner. Patients’ health status, coping strategies and perception of financial distress might contribute to variations in disclosure of financial problems. Thus, enhancing communication and screening by routine assessment of financial problems in clinical practice can help to identify vulnerable patients and promote access to health care and social services and well-being for all.

Universal drug coverage and income-related disparities in glycaemic control

AIMS

To examine whether income-related disparities in glycaemic control decline after the age of 65 years, when publicly funded universal drug insurance is acquired in Ontario, Canada.

METHODS

We conducted a population-based cross-sectional study using linked administrative healthcare databases. Adults with diabetes, aged 40-89 years, with available HbA_1c data were included (N = 716 297). Income was based on median neighbourhood household income. Multiple linear regression was used to test for effect modification of age ≥65 years on the relationship between income and HbA_1c .

RESULTS

There was a significant inverse association between income and HbA_1c level. After adjusting for baseline factors, the effect of income on HbA_1c level was significantly greater for individuals aged <65 years (mean difference HbA_1c for lowest vs highest income group +2.5 mmol/mol, 95% CI +2.3 to +2.7 [+0.23%, 95% CI 0.21 to 0.24]) than for those aged ≥65 years (+1.2 mmol/mol, 95% CI +1.0 to +1.3 [+0.11%, 95% CI 0.10 to 0.12]; P < 0.0001 for interaction).

CONCLUSIONS

Despite universal access to healthcare, people with diabetes with lower incomes had significantly worse glycaemic control compared with their counterparts on higher incomes. However, income gradients in glycaemic control were markedly reduced after the age of 65 years, possibly as a result of access to prescription drug coverage.

CHC for pelvic pain in women with endometriosis: ineffectiveness or discontinuation due to side-effects

STUDY QUESTION

What are the use patterns and factors associated with combined hormonal contraception (CHC) ineffectiveness or discontinuation due to side-effects in patients with endometriosis and pelvic pain?

SUMMARY ANSWER

Worse chronic pelvic pain (CPP) severity and pelvic floor myalgia were associated with continuous CHC ineffectiveness, while poorer quality-of-life was associated with continuous CHC discontinuation due to side-effects.

WHAT IS KNOWN ALREADY

CHC is a first line of therapy for endometriosis-associated pelvic pain in women. However, some patients state that CHC is ineffective for their pain, while others have to discontinue CHC due to side-effects.

STUDY DESIGN, SIZE, DURATION

Analysis of a prospective patient database from a tertiary care referral center for patients with endometriosis and pelvic pain between December 2013 and April 2015 was carried out.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

A total of 373 patients of reproductive age with endometriosis from the database were included in the study. Data included patient self-reported questionnaires, physical examination findings and validated instruments. There were four variables of interest: history of cyclical CHC ineffectiveness (yes/no), history of cyclical CHC discontinuation due to side-effects (yes/no), history of continuous CHC ineffectiveness (yes/no) and history of continuous CHC discontinuation due to side-effects (yes/no). The primary outcome was CPP severity for the past 3 months (score of 0–10), and secondary outcomes were other pelvic pain scores, quality-of-life on the Endometriosis Health Profile 30 (EHP-30) and underlying conditions including irritable bowel syndrome, painful bladder syndrome, abdominal wall pain, pelvic floor myalgia and depression, anxiety and pain catastrophizing.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 373 cases in the dataset, prior cyclical CHC use was reported by 228 (61.1%) women, of which 103 (27.6%) stated it was ineffective for their pain and 94 (25.2%) stated they discontinued CHC due to side-effects. Previous continuous CHC use was reported by 175 (46.9%) women, of which 67 (18.0%) stated it was ineffective and 59 (15.8%) stated they discontinued due to side-effects. Worse CPP severity in the last 3 months was associated with a history of continuous CHC ineffectiveness (P < 0.001). Poorer quality-of-life was present in women who reported a history of continuous CHC discontinuation due to side-effects (P = 0.005). Among the underlying conditions, pelvic floor tenderness (as a marker of pelvic floor myalgia) was associated with CHC ineffectiveness.

LIMITATIONS AND REASONS FOR CAUTION

This study involved patient recall and no longitudinal follow-up. Also, we do not have data on the type of side-effect that led to discontinuation. Medication ineffectiveness was reported subjectively by the patient rather than using standardized criteria. Finally, the diagnosis of endometriosis was based on previous surgery or a current nodule or endometrioma on examination/ultrasound; without prospective surgical data on all the patients, it was not possible to do a sub-analysis by current surgical features (e.g. stage).

WIDER IMPLICATIONS OF THE FINDINGS

In women with endometriosis, CHC ineffectiveness was associated with worse CPP and pelvic floor myalgia, which suggests myofascial or nervous system contributors to CPP that does not respond to hormonal suppression. A tender pelvic floor, as a sign of pelvic floor myalgia, may be a clinical marker of patients with endometriosis who are less likely to have an optimal response to hormonal suppression. For women who discontinue CHC due to side-effects, research is needed to help alleviate these side-effects as these patients report worse quality-of-life.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a Canadian Institutes of Health Research (CIHR) Transitional Open Operating Grant (MOP-142273) as well as BC Women’s Hospital and the Women’s Health Research Institute. PY is also supported by a Health Professional Investigator Award from the Michael Smith Foundation for Health Research. MB/CA has financial affiliations with Abbvie and Allergan; the other authors have no conflicts of interest.

The impact of prescription drug co-payments for publicly insured families

Co-payments for prescription drugs are a common feature of many healthcare systems, although often with exemptions for vulnerable population groups. International evidence demonstrates that cost-sharing for medicines may delay necessary care, increase use of other forms of healthcare and result in poorer health outcomes. Existing studies concentrate on adults and older people, particularly in the US, with relatively less attention afforded to paediatric and European populations. In Ireland, prescription drug co-payments were introduced for the first time for medical cardholders (i.e. those with public health insurance) in October 2010, initially at a cost of €0.50 per item, rising to €1.50 in January 2013, and further increasing to €2.50 in December 2013. Using data from the Growing Up in Ireland longitudinal study of children, and a difference-in-difference research design, we estimate the impact of the introduction (and increase) of these co-payments on health, healthcare utilisation and household financial wellbeing. The introduction of modest co-payments on prescription items was not estimated to impinge on the health of children and parents from low-income families. For the younger Infant Cohort, difference-in-difference estimates indicated that the introduction (and increase) in co-payments was associated with a decrease in GP visits and hospital nights, and a decrease in the proportion of households reporting 'difficulties with making ends meet'. In contrast, for the older cohort of children (the Child Cohort), co-payments were associated with an increase in GP visiting, and an increase in household deprivation. While the parallel trends assumption for difference-in-difference analysis appeared to be satisfied, further investigation revealed that there were other time-varying observable factors (such as exposure to the economic recession over the period) that affected the treatment and control groups, as well as the two cohorts of children differentially, that may partly explain these divergent results. For example, while the analysis suggests that the introduction of the €0.50 co-payment in 2010 was associated with an increase in the probability of treated families in the Child Cohort being deprived by 9.4 percentage points, the proportion of treated families experiencing unemployment and reductions in household income also increased significantly around the time of the co-payment introduction. This highlights the difficulty in identifying the effect of the co-payment policy in an environment in which assignment to the treatment (i.e. medical cardholder status) was not randomly assigned.

Universal Pharmacare in Canada: A Prescription for Equity in Healthcare

Despite progressive universal drug coverage and pharmaceutical policies found in other countries, Canada remains the only developed nation with a publicly funded healthcare system that does not include universal coverage for prescription drugs. In the absence of a national pharmacare plan, a province may choose to cover a specific sub-population for certain drugs. Although different provinces have individually attempted to extend coverage to certain subpopulations within their jurisdictions, out-of-pocket expenses on drugs and pharmaceutical products (OPEDP) accounts for a large proportion of out-of-pocket health expenses (OPHE) that are catastrophic in nature. Pharmaceutical drug coverage is a major source of public scrutiny among politicians and policy-makers in Canada. In this editorial, we focus on social inequalities in the burden of OPEDP in Canada. Prescription drugs are inconsistently covered under patchworks of public insurance coverage, and this inconsistency represents a major source of inequity of healthcare financing. Residents of certain provinces, rural households and Canadians from poorer households are more likely to be affected by this inequity and suffer disproportionately higher proportions of catastrophic out-of-pocket expenses on drugs and pharmaceutical products (COPEDP). Universal pharmacare would reduce COPEDP and promote a more equitable healthcare system in Canada.