@article {7476, title = {Factors influencing cost-related nonadherence to medication in older adults: a conceptually based approach.}, journal = {Value Health}, volume = {13}, year = {2010}, month = {2010 Jun-Jul}, pages = {338-45}, publisher = {13}, abstract = {

OBJECTIVE: Although multiple noncost factors likely influence a patient{\textquoteright}s propensity to forego treatment in the face of cost pressures, little is known about how patients{\textquoteright} sociodemographic characteristics, physical and behavioral health comorbidities, and prescription regimens influence cost-related nonadherence (CRN) to medications. We sought to determine both financial and nonfinancial factors associated with CRN in a nationally representative sample of older adults.

METHODS: We used a conceptual model developed by Piette and colleagues that describes financial and nonfinancial factors that could increase someone{\textquoteright}s risk of CRN, including income, comorbidities, and medication regimen complexity. We used data from the 2004 wave of the Health and Retirement Study and the 2005 HRS Prescription Drug Study to examine the influence of factors within each of these domains on measures of CRN (including not filling, stopping, or skipping doses) in a nationally representative sample of Americans age 65+ in 2005.

RESULTS: Of the 3071 respondents who met study criteria, 20\% reported some form of CRN in 2005. As in prior studies, indicators of financial stress such as higher out-of-pocket payments for medications and lower net worth were significantly associated with CRN in multivariable analyses. Controlling for these economic pressures, relatively younger respondents (ages 65-74) and depressive symptoms were consistent independent risk factors for CRN.

CONCLUSIONS: Noncost factors influenced patients{\textquoteright} propensity to forego treatment even in the context of cost concerns. Future research encompassing clinician and health system factors should identify additional determinants of CRN beyond patients{\textquoteright} cost pressures.

}, keywords = {Aged, Aged, 80 and over, Chronic disease, Female, Financing, Personal, Health Status, Humans, Logistic Models, Male, Medication Adherence, Models, Econometric, Multivariate Analysis, Prescription Fees, Risk Factors, Socioeconomic factors, United States}, issn = {1524-4733}, doi = {10.1111/j.1524-4733.2009.00679.x}, author = {Zivin, Kara and Scott M Ratliff and Michele M Heisler and Kenneth M. Langa and John D Piette} } @article {7450, title = {Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis.}, journal = {Med Care}, volume = {48}, year = {2010}, note = {Using Smart Source Parsing Feb Comment In: Med Care. 2010 Feb;48(2):85-6 20057326 Index Medicus}, month = {2010 Feb}, pages = {87-94}, publisher = {48}, abstract = {

CONTEXT: It is well-documented that the financial burden of out-of-pocket expenditures for prescription drugs often leads people with medication-sensitive chronic illnesses to restrict their use of these medications. Less is known about the extent to which such cost-related medication underuse is associated with increases in subsequent hospitalizations and deaths.

OBJECTIVE: We compared the risk of hospitalizations among 5401 and of death among 6135 middle-aged and elderly adults with one or more cardiovascular diseases (diabetes, coronary artery disease, heart failure, and history of stroke) according to whether participants did or did not report restricting prescription medications because of cost.

DESIGN AND SETTING: A retrospective biannual cohort study across 4 cross-sectional waves of the Health and Retirement Study, a nationally representative survey of adults older than age 50. Using multivariate logistic regression to adjust for baseline differences in sociodemographic and health characteristics, we assessed subsequent hospitalizations and deaths between 1998 and 2006 for respondents who reported that they had or had not taken less medicine than prescribed because of cost.

RESULTS: Respondents with cardiovascular disease who reported underusing medications due to cost were significantly more likely to be hospitalized in the next 2 years, even after adjusting for other patient characteristics (adjusted predicted probability of 47\% compared with 38\%, P < 0.001). The more survey waves respondents reported cost-related medication underuse during 1998 to 2004, the higher the probability of being hospitalized in 2006 (adjusted predicted probability of 54\% among respondents reporting cost-related medication underuse in all 4 survey waves compared with 42\% among respondents reporting no underuse, P < 0.001). There was no independent association of cost-related medication underuse with death.

CONCLUSIONS: In this nationally representative cohort, middle-aged and elderly adults with cardiovascular disease who reported cutting back on medication use because of cost were more likely to report being hospitalized over a subsequent 2-year period after they had reported medication underuse. The more extensively respondents reported cost-related underuse over time, the higher their adjusted predicted probability of subsequent hospitalization.

}, keywords = {Aged, Aged, 80 and over, Cardiovascular Diseases, Female, Financing, Personal, Health Care Costs, Health Services Accessibility, Health Status Disparities, Hospitalization, Humans, Logistic Models, Longitudinal Studies, Male, Medication Adherence, Middle Aged, Multivariate Analysis, Risk Factors, United States}, issn = {1537-1948}, doi = {10.1097/MLR.0b013e3181c12e53}, author = {Michele M Heisler and Choi, Hwajung and Allison B Rosen and Sandeep Vijan and Mohammed U Kabeto and Kenneth M. Langa and John D Piette} } @article {6920, title = {The health effects of restricting prescription medication use because of cost.}, journal = {Med Care}, volume = {42}, year = {2004}, note = {Comment in: Med Care. 2004 Jul;42(7):623-5 AN=15213485}, month = {2004 Jul}, pages = {626-34}, publisher = {42}, abstract = {

BACKGROUND: High out-of-pocket expenditures for prescription medications could lead people with chronic illnesses to restrict their use of these medications. Whether adults experience adverse health outcomes after having restricted medication use because of cost is not known.

METHODS: We analyzed data from 2 prospective cohort studies of adults who reported regularly taking prescription medications using 2 waves of the Health and Retirement Study (HRS), a national survey of adults aged 51 to 61 in 1992, and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older in 1993 (n = 7991). We used multivariable logistic and Poisson regression models to assess the independent effect on health outcomes over 2 to 3 years of follow up of reporting in 1995-1996 having taken less medicine than prescribed because of cost during the prior 2 years. After adjusting for differences in sociodemographic characteristics, health status, smoking, alcohol consumption, body mass index (BMI), and comorbid chronic conditions, we determined the risk of a significant decline in overall health among respondents in good to excellent health at baseline and of developing new disease-related adverse outcomes among respondents with cardiovascular disease, diabetes, arthritis, and depression.

RESULTS: In adjusted analyses, 32.1\% of those who had restricted medications because of cost reported a significant decline in their health status compared with 21.2\% of those who had not (adjusted odds ratio [AOR], 1.76; confidence interval [CI], 1.27-2.44). Respondents with cardiovascular disease who restricted medications reported higher rates of angina (11.9\% vs. 8.2\%; AOR, 1.50; CI, 1.09-2.07) and experienced higher rates of nonfatal heart attacks or strokes (7.8\% vs. 5.3\%; AOR, 1.51; CI, 1.02-2.25). After adjusting for potential confounders, we found no differences in disease-specific complications among respondents with arthritis and diabetes, and increased rates of depression only among the older cohort.

CONCLUSIONS: Cost-related medication restriction among middle-aged and elderly Americans is associated with an increased risk of a subsequent decline in their self-reported health status, and among those with preexisting cardiovascular disease with higher rates of angina and nonfatal heart attacks or strokes. Such cost-related medication restriction could be a mechanism for worse health outcomes among low-income and other vulnerable populations who lack adequate insurance coverage.

}, keywords = {Aged, Chronic disease, Female, Financing, Personal, Health Services Accessibility, Health Status, Humans, Male, Middle Aged, Multivariate Analysis, Patient Compliance, Prospective Studies, Risk, United States}, issn = {0025-7079}, doi = {10.1097/01.mlr.0000129352.36733.cc}, author = {Michele M Heisler and Kenneth M. Langa and Eby, Elizabeth L. and A. Mark Fendrick and Mohammed U Kabeto and John D Piette} }