medication nonadherence due to cost

A national survey found that one in eight patients with atherosclerotic cardiovasc disease (ASCVD) reported nonadherence to medications because of cost (see medication nonadherence from cost circ2019 in dropbox, or DOI: 10.1161/CIRCULATIONAHA.119.041974)

 

Details:

-- 14,279 US adults with ASCVD were surveyed in the National Health Interview Survey, a nationwide survey of non-institutionalized individuals compiled annually by the CDC, assessing the trend from 2013 to 2017

    -- the responses to the survey were self-reported, with ASCVD being defined as being told by a healthcare professional that the individual had any of the full following: coronary heart disease, angina or angina pectoris, heart attack or myocardial infarction, or stroke

-- cost related-nonadherence (CRN) in the prior 12 months was determined when patients reported skipping med doses to save money, taking less medication to save money, or delaying filling prescription to save money

 

 Results:

-- CRN: 12.6% of patients, which translates to 2.2 million adults in the US with ASCVD

    -- missing doses: 8.6%, translating to 1.5 million people missing doses

    -- taking lower than prescribed doses: 8.8%, or 1.6 million people

    -- delaying to fill medications: 10.5%, or 1.9 million people

-- age <65yo: 22% reported cost-related nonadherence, versus 6% in those > 65

-- comparing those <65 vs >65yo:

    -- sex: females 25% versus males 18% if <65yo; 8% versus 5% if >65yo

    -- family income: low income 30% versus 15% of higher income if <65yo; 10% versus 4% if >65yo

    -- insurance status: uninsured 53% versus 17% insured if <65yo; 25% versus 6% if >65yo

    -- financial hardship from medical bills: 35% versus 10% if <65yo; 17% versus 3% if >65yo

    -- comorbidities (>1): 28% versus 14% if <65yo; 9% versus 3% if >65yo

-- those with CRN had 10.8-fold higher odds of requesting low-cost medications, and 8.9-fold higher odds of using alternative, nonprescription therapies

-- CRN decreased from 15.3% in 2013 to 10.9% in 2016, with a trend to an increase of 11.9% in 2017

 

Commentary:

-- medication nonadherence is remarkably common, with many studies finding it in about 50% of patients, with their attendant increased likelihood of adverse effects on their short-term and long-term health, as well as costs to the system.

-- this study suggests that financial barriers are an important factor leading to medication nonadherence and a heightened risk of morbidity and mortality. Several studies have found that the individuals highlighted above with excessive CRN (e.g. patients <65yo, women, low income and uninsured individuals) have worse clinical outcomes

-- it is likely that the decrease in CRN from 2013 to 2016 was related to increased insurance coverage through Obamacare, the recent uptick perhaps related to Trump’s economic agenda. And the increase in CRN is likely to get worse, given Trump's reversal of insurance coverage: per the Census Bureau, health insurance coverage between 2017 and 2018 deceased by 1.9 million people, with a total of 27.5 million people without health insurance coverage (see https://www.census.gov/content/dam/Census/newsroom/press-kits/2019/iphi/presentation-iphi-overview.pdf )

-- there might be several explanations for the much higher rate of CRN in those <65yo, and this is particularly striking given that this younger group is more likely to work and have more income. However access to Medicare in those >65yo may be a major driver here (and would reinforce the argument for Medicare for all)

    --but, as noted in the data above, the relative effect of lack of insurance coverage or financial hardship is particularly striking in those >65yo

-- one issue here is that there was about a nine-fold increased use of alternative, nonprescription therapies. Many of us (including me) may well attribute this to the differing health beliefs of our patients (and this is often the case), but these numbers suggest the possibility that cost is really the factor. And that when patients are taking alternative therapies, we should pursue with them this potential issue of cost, as well as pursuing other financial barriers to health and well-being, such as food insecurity, housing insecurity, and other financial burdens

-- another recent study found (not surprisingly) that distributing essential meds (basically the WHO model list of essential meds from 2013) at no charge improved medication adherence (see med adherence inc if free meds jamaintmed2020 in dropbox, or doi:10.1001/jamainternmed.2019.4472), details:

    --786 patients, mean age 52, randomized to free meds vs usual access for one year, finding 38% of patients were appropriately adherent to all meds vs 27% in usual care, and systolic BP decreased 7.2mmHg, though there was only a trend to decrease in A1c (0.38%) and LDL (-2 mg/dL)

    --and, of course, not only is it clinically better if patients take their prescribed meds, but it is likely cheaper in the long-run (fewer ED visits/admissions/tests/rehab/followup care for strokes are pretty expensive for the system…..)

 

-- there are several limitations to the study, including the fact that this is self-reported ASCVD and not documented, there are no data related to the types of ASCVD, or the types and number of meds being prescribed, or specific clinical patient outcomes over time as related to CRN

 

So, another study revealing the soft underbelly of our healthcare system, one significantly inferior to that of other industrialized countries as well as some less industrialized countries. This study documents yet another way that our system creates the poor health outcomes that we find. And, this study highlights the urgency of fundamentally changing the system to ensure access to high-quality health care for all...

 

geoff​

 

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