Underusing Medications Because of Cost May Lead to Adverse Health Outcomes
Middle-aged and older Americans with heart disease who cut back
on their prescribed medications because of cost were 50% more likely
to suffer heart attacks, strokes, or angina than those who did not
report cost-related medication underuse, according to a new study
funded in part by the National Institute on Aging, part of the National
Institutes of Health. Michele Heisler, M.D., M.P.A., at the Veterans
Affairs Ann Arbor Healthcare System, Ann Arbor, MI, and colleagues*
conducted the study, which appears in the July 2004 issue of Medical
Care, a journal of the American Public Health Association.
This is the first nationally representative longitudinal study to
demonstrate that patients with serious chronic illnesses experience
adverse health events when they restrict their use of prescription
drugs due to cost. The downturns in patients' health were observed
over a relatively brief (2-3 year) period, suggesting that cost
barriers to prescription drug use may have important short-term
effects on older patients' health and well-being, Heisler said.
"This study underlines how important medications can be and
how important it is for people who need the medications to be able
to get them," said HHS Secretary Tommy G. Thompson. "This
is why a new drug benefit for Medicare was so crucial, including
the interim drug card with its special benefit for low-income Americans.
It's also why FDA is working to make generic products available
quickly, as well as rapid review for significant new medications.
We need to keep working toward better access to drugs and keep supporting
the science that underlies ever-improving products."
The study included 7,991 middle-aged and older Americans who participated
in a survey conducted between 1995 and 1996 as part of the Health
and Retirement Study (HRS), an NIA-supported survey of adults aged
51 to 61, or the Asset and Health Dynamics Among the Oldest Old
(AHEAD) Study, a national survey of adults aged 70 or older.** All
participants reported using prescription medication, and 546 reported
that they had taken less medication than prescribed because of cost.
Heisler and colleagues assessed a range of important health outcomes
reported in participants' subsequent surveys, conducted in 1998.
After controlling for risk factors for poor health outcomes, 32%
of adults who had restricted medications because of cost pressures
reported a significant decline in their self-reported health status
during their follow-up interviews compared to 21% of adults with
no cost-related underuse. Self-reports of health have been found
to strongly predict other serious life events, including mortality,
according to the study.
"There is a growing array of effective but often expensive
prescription medications that clearly improve health outcomes, especially
in the field of cardiovascular disease. As medications become even
more effective, differences in access to prescriptions drugs because
of cost may further worsen disparities in health outcomes between
rich and poor Americans," Heisler said.
"This study suggests what can happen when older people cannot
get the medications they need and will help inform policy regarding
prescription drug insurance coverage," said Richard M. Suzman,
Ph.D., NIA Associate Director for the Behavioral and Social Research
Program. "The longitudinal design employed in this study suggests
that the cost of drugs can lead to drug underuse and that this underuse
could in turn contribute to adverse health outcomes. Additional
research will be needed to further examine the causal relationship
between drug costs and health outcomes."
In addition to cardiovascular declines, older individuals who restricted
medication use because of cost had increased rates of depression,
according to the study. Researchers found no health differences
among people with arthritis and diabetes who said they had restricted
drug use due to cost. Community-dwelling people over 65 paid an
average of $410 for their drugs in 1999, and adults with multiple,
chronic diseases paid twice as much, according to a cited study.
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* The study was conducted by Michele Heisler, MD, M.P.A., Kenneth
M. Langa, MD, Ph.D, Elizabeth L. Eby, M.P.H., A. Mark Fendrick,
MD, Mohammed U. Kabeto, M.S., John D. Piette, Ph.D.
Veterans Affairs Center for Practice Management & Outcomes
Research, VA Ann Arbor Healthcare System, Ann Arbor, MI (MH, KL,
ELE, JDP), Department of Internal Medicine (MH, KL, AMF, MUK, JDP),
Michigan Diabetes Research and Training Center (MH, JP), Institute
for Social Research (KL), Patient Safety Enhancement Program, (KL),
University of Michigan School of Medicine, Ann Arbor, MI.
Heisler is a Veterans Affairs Center for Practice Management &
Outcomes Research Career Development Awardee. Langa was supported
by a Career Development Award from the National Institute on Aging,
a New Investigator Research Grant from the Alzheimer's Association,
and a Paul Beeson Physician Faculty Scholars in Aging Research award.
** The HRS and AHEAD are nationally representative, biennial longitudinal
studies, sponsored by the National Institute of Aging and undertaken
by the University of Michigan's Institute for Social Research. These
studies target community-dwelling adults in the contiguous United
States, with over-sampling of blacks, Latinos, and Florida residents,
and gather in-depth economic, financial, and health information
from respondents. In 1998, the two studies were combined into one
HRS with identical survey procedures and questionnaires.