Cost-related medication nonadherence associated with increased ED utilization

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1. Among Medicare beneficiaries studied, 7.5% reported a reduction in dose or delay in filling medications, and 8.2% reported not filling a medication at all, due to cost concerns.

2. Disabled Medicare beneficiaries with severe cost-related medication nonadherence had a 1.53 greater odds of any Emergency Department (ED) visit within the following year compared to those without cost-related medication nonadherence.

Evidence Rating Level: 2 (Good)

Study Rundown: In 2006, Medicare Part D was implemented to improve pharmaceutical coverage for the elderly and disabled. This program has resulted in a decrease in both cost-related medication nonadherence and out-of-pocket costs among the Medicare population, though these effects have been weaker among disabled beneficiaries. Overall, 11% of Medicare recipients report skipping doses, splitting pills, or not filling medications due to cost, and this figure jumps to 20-26% among those with poor health status.  This study demonstrates that severe cost-related medication nonadherence is associated with a statistically significant increased risk of ED use. Even after adjusting for demographic and clinical variables that affect utilization, disabled Medicare beneficiaries reporting severe cost-related medication nonadherence were more likely to have at least one ED visit in the following year.

Despite demonstrating the correlation between cost-related medication nonadherence and ED use, this study cannot prove that nonadherence leads to increased ED utilization.

Because the study looked at any type of ED visit as its primary outcome, with no attempt to identify visits directly linked to medication nonadherence, a presumed causal link is even more difficult to ascertain.  Further research into the qualitative factors leading to medication nonadherence, especially among vulnerable populations, is necessary to reduce healthcare spending; anticipate the effect of the ACA and other policies on cost-related medication nonadherence and utilization; and to design EDs to address nonadherence and thereby improve overall health status.

Click to read the study in Annals of Emergency Medicine

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

In-Depth [retrospective cohort study]: aimed to evaluate the relationship between self-reported cost-related nonadherence to prescription medications and emergency department (ED) utilization among Medicare beneficiaries. The study consisted of 7,177 Medicare Current Beneficiary Survey respondents between 2006 and 2007. Multivariate logistic regression was used to  test the hypothesis that persons who reported cost-related medication nonadherence would be more likely to have at least one ED visit and would have a higher total mean number of ED visits compared with persons without cost-related medication nonadherence. The authors assessed whether mild (reduction in dose or delay in filling medications) or severe (not filling a medication at all) cost-related medication nonadherence was associated with an increased rate of ED visits within a 364-day period after an interview assessing cost-related medication nonadherence.

Approximately 7.5% of respondents in the weighted study sample reported mild cost-related medication nonadherence only (n=541), and another 8.2% reported severe cost-related medication nonadherence (n=581). Compared with Medicare beneficiaries with no cost-related medication nonadherence, those reporting severe cost-related medication nonadherence were both more likely to have at least one ED visit (39.3% vs 28.7%) and had a higher average number of ED visits within the year (0.84 vs 0.50).  These differences were not significant among those with mild vs no cost-related medication nonadherence. Among disabled individuals in the adjusted analysis, those with severe cost-related medication nonadherence had a 1.53 greater odds of any ED visit compared to those without cost-related medication nonadherence (95% CI 1.03 – 2.26).

By Elizabeth Kersten and Andrew Bishara

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