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Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis.

ABSTRACT: 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.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.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.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.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.

SUBMITTER: Heisler M

PROVIDER: S-EPMC3034735 | biostudies-literature | 2010 Feb

REPOSITORIES: biostudies-literature

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Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis.

Heisler Michele M Choi Hwajung H Rosen Allison B AB Vijan Sandeep S Kabeto Mohammed M Langa Kenneth M KM Piette John D JD

Medical care 20100201 2

<h4>Context</h4>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.<h4>Objective</h4>We compared the risk of hospitalizations among 5401 and of death among 6135 middle-aged and elderly adults wi ...[more]

PMID: 20068489

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Project description:OBJECTIVE:To assess the prevalence and factors associated with cost-related underuse of medications in a nationally representative sample of Brazilians aged 50 years and over. METHODS:Among the 9,412 participants of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), 6,014 reported using at least one medication on regular basis and were included in the analysis. Underuse of medications was by stopping taking or reducing the number of tablets or the dose of any prescribed medication for financial reasons. The theoretical framework used for the selection of the exploratory variables included predisposing factors, enabling factors, and factors of need. Associations were tested by Poisson regression. RESULTS:The prevalence of underuse of medications was 10.6%. After adjustments for relevant covariables, positive and statistically significant associations (p < 0.05) with the outcome were found for females [prevalence ratio (PR) = 1.39], sufficiency of the family income for expenses (PR = 1.74 for sometimes and PR 2.42 for never), frequency with which the physician explains about the disease and treatment (PR = 1.31 for rarely or never), number of medications used (PR = 1.39 for 2-4 and 1.53 for 5 or more), fair (PR = 2.02) and poor or very poor self-rated health (PR = 2.92), and a previous medical diagnosis of depression (PR = 1.69). Negative associations were observed for the age groups of 60-79 years (PR = 0.75) and 80 years and over (PR = 0.43), socioeconomic status of the household (PR = 0.70, 0.79, and 0.60 for the second, third, and fourth quartile, respectively), and private health plan coverage (PR = 0.79). There were no associations between hypertension and self-reported diabetes and underuse of medications. CONCLUSIONS:Cost-related underuse of medications is multidimensional and complex, and it covers socio-demographic characteristics, health conditions, and the use of health services. The explanation about the disease and its treatment to the patient and the expansion of the universal access to pharmaceutical care can minimize the risks of underuse.

Project description:Background Underuse of cardiovascular medications for secondary prevention among individuals with peripheral artery disease (PAD) has been reported. Little is known about PAD treatment status in the Hispanic/Latino population in the United States, who may have limited access to health care and who have worse clinical outcomes than non-Hispanic individuals. Methods and Results We studied the use of cardiovascular therapies in 1244 Hispanic/Latino individuals recruited from 4 sites in the United States, including 826 individuals who reported diagnosis of PAD by physician and 418 individuals with coronary artery disease alone, in the Hispanic Community Health Study/Study of Latinos. We compared the prevalence of using antiplatelet therapy, lipid-lowering therapy and antihypertensive therapy by PAD and coronary artery disease status. Among those with PAD, we studied factors associated with taking cardiovascular medications, including demographic and socioeconomic factors, acculturation, access to health care and comorbidities, using multivariable regression models. The overall prevalence for individuals with PAD taking antiplatelet therapy, lipid-lowering therapy and, among hypertensive individuals, antihypertensive therapy was 31%, 26% and 57%, respectively. Individuals of Mexican background had the lowest use for all classes of cardiovascular medications. Older age, number of doctor visits and existing hypertension and diabetes mellitus were significantly associated with taking cardiovascular therapies in adjusted models. Compared with those with PAD alone, individuals with PAD and concurrent coronary artery disease were 1.52 (95% CI, 1.20-1.93) and 1.74 (1.30-2.32) times more likely to use antiplatelet agents and statins according to multivariable analysis. No significant difference of antihypertensive medication use was found among PAD patients with or without coronary artery disease. Conclusions Hispanic/Latino individuals with known PAD underuse cardiovascular medications recommended in clinical guidelines. More efforts should be directed to improve treatment in this important group.

Project description:BackgroundAs of January 7, 2020, a total of 2558 hospitalized patients with nonfatal cases and 60 patients with fatal cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) had been reported to the Centers for Disease Control and Prevention (CDC).MethodsIn a national study, we compared the characteristics of patients with fatal cases of EVALI with those of patients with nonfatal cases to improve the ability of clinicians to identify patients at increased risk for death from the condition. Health departments reported cases of EVALI to the CDC and included, when available, data from medical-record abstractions and patient interviews. Analyses included all the patients with fatal or nonfatal cases of EVALI that were reported to the CDC as of January 7, 2020. We also present three case reports of patients who died from EVALI to illustrate the clinical characteristics common among such patients.ResultsMost of the patients with fatal or nonfatal cases of EVALI were male (32 of 60 [53%] and 1666 of 2498 [67%], respectively). The proportion of patients with fatal or nonfatal cases was higher among those who were non-Hispanic white (39 of 49 [80%] and 1104 of 1818 [61%], respectively) than among those in other race or ethnic groups. The proportion of patients with fatal cases was higher among those 35 years of age or older (44 of 60 [73%]) than among those younger than 35 years, but the proportion with nonfatal cases was lower among those 35 years of age or older (551 of 2514 [22%]). Among the patients who had an available medical history, a higher proportion of those with fatal cases than those with nonfatal cases had a history of asthma (13 of 57 [23%] vs. 102 of 1297 [8%]), cardiac disease (26 of 55 [47%] vs. 115 of 1169 [10%]), or a mental health condition (32 of 49 [65%] vs. 575 of 1398 [41%]). A total of 26 of 50 patients (52%) with fatal cases had obesity. Half the patients with fatal cases (25 of 54 [46%]) were seen in an outpatient setting before hospitalization or death.ConclusionsChronic conditions, including cardiac and respiratory diseases and mental health conditions, were common among hospitalized patients with EVALI.

Project description:BackgroundPrior studies report high hospitalization rates among patients with chronic kidney disease (CKD) and approximately 10% to 20.9% of hospitalizations are potentially preventable.ObjectiveTo determine the rate, proportion, and cost of potentially preventable hospitalizations and whether this varied by CKD category.DesignRetrospective cohort study using population-based data.SettingAlberta, Canada.PatientsAll adults with an outpatient serum creatinine measurement between January 1 and December 31, 2017 in the Alberta Kidney Disease Network data repository.MeasurementsCKD risk categories were based on measures of proteinuria (where available), eGFR, and use of dialysis. Patients were linked to administrative data to capture frequency and cost of hospital encounters and followed until death or end of study (December 31, 2018). The outcomes of interest were the rate and cost of potentially preventable hospitalizations, as identified using the Canadian Institute for Health Information (CIHI)-defined ambulatory care sensitive condition (ACSC) algorithm and a CKD-related ACSC algorithm.MethodsUnadjusted and adjusted rates per 1000-patient years, proportions, and cost attributable to preventable hospitalizations were identified for the cohort as a whole and for patients within each CKD risk category.ResultsOf the 1,110,895 adults with eGFR and proteinuria measurements, 181,422 had CKD. During a median follow-up of 1 year, there were 62,023 hospitalizations among patients with CKD resulting in a total cost of $946 million CAD; 6907 (11.1%) of these hospitalizations were for CIHI-defined ACSCs while 4323 (7.0%) were for CKD-related ACSCs. Adjusted rates of hospitalization for ACSCs increased with CKD risk category and were highest among patients treated with dialysis. Among CKD patients, the total cost of potentially preventable hospitalizations was $79 million and $58 million CAD for CIHI-defined and CKD-related ACSCs (8.4% and 6.2% of total hospitalization cost, respectively).LimitationsBased on the ACSC construct, we were unable to determine if these hospitalizations were truly preventable.ConclusionsPotentially preventable hospitalizations have a substantial cost and burden on the health care system among people with CKD. Effective strategies that reduce preventable admissions among CKD patients may lead to significant cost savings.Trial registrationNot applicable-observational study design.

Project description:Background/objectivesGuideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties.DesignNational cross-sectional survey.SettingAmbulatory.ParticipantsRandom sample of geriatricians, general internists, and cardiologists from the American College of Physicians.MeasurementsElectronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases.ResultsIn each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists).ConclusionsWhile barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician-physician and physician-patient communication. J Am Geriatr Soc 68:78-86, 2019.

Project description:ObjectivesTrends in prevalence and treatments of atherosclerotic cardiovascular disease (ASCVD) remains to be documented, with frequent update of relevant guidelines. We aimed to characterize trends in prevalence of ASCVD, and risk factor control and medications among ASCVD adults.MethodsWe conducted a cross-sectional analysis of data from 55,081 adults in the National Health and Nutrition Examination Surveys (NHANES) 1999-2018.ResultsThe age-standardized prevalence of ASCVD did not change significantly from 1999-2002 (7.9 %, 95 % CI 7.1 %-8.7 %) to 2015-2018 (7.5 %, CI 6.8 %-8.3 %) (P for trend =0.18), representing an estimated 19.9 million individuals with ASCVD in 2015-2018. The prevalence of premature ASCVD was 2.0 % (CI, 1.6 %-2.5 %). Over 60.0 % of ASCVD participants were at very-high risk. From 1999-2002 to 2015-2018, the percentage with lipid control (non-high-density lipoprotein cholesterol <100 mg/dL) increased from 7.0 % (CI, 3.5 %-12.3 %) to 26.4 % (CI, 16.2 %-38.9 %). The percentage with blood-pressure control (<130/80 mmHg) increased from 51.2 % (CI, 41.0 %-61.3 %) in 1999-2002 to 57.2 % (CI, 48.4 %-65.6 %) in 2011-2014, but then declined to 52.8 % (CI, 44.4 %-81.3 %) in 2015-2018. The percentage with glycemic control (HbA1c <7.0 %) decreased from 95.0 % (CI, 90.2 %-97.9 %) to 84.0 % (CI, 75.9 %-90.3 %). The percentage who achieved all 3 targets was 18.6 % (CI, 8.2 %-33.8 %) in 2015-2018. The percentage of ASCVD participants who were taking statins increased from 1999-2002 to 2011-2014, but then leveled off. Approximately 60 % of individuals with ASCVD and less than 40 % of those with premature ASCVD were taking statins in 2015-2018. The utilization of blood-pressure-lowering drugs remained largely constant over time, whereas the use of glucose-lowering drugs increased.ConclusionsBased on NHANES data from US adults, the estimated prevalence of ASCVD remained relatively stable between 1999 and 2018. Substantial undertreatment with stains was found in individuals with ASCVD, and the percentage achieving optimal lipid control was low.

Project description:Randomized trials of anti-hypertensive treatment demonstrating reduced risk of cardiovascular events in older adults included participants with less comorbidity than clinical populations. Whether these results generalize to all older adults, most of whom have multiple chronic conditions, is uncertain.To determine the association between anti-hypertensive medications and CV events and mortality in a nationally representative population of older adults.Competing risk analysis with propensity score adjustment and matching in the Medicare Current Beneficiary Survey cohort over three-year follow-up through 2010.4,961 community-living participants with hypertension.Anti-hypertensive medication intensity, based on standardized daily dose for each anti-hypertensive medication class participants used.Cardiovascular events (myocardial infarction, unstable angina, cardiac revascularization, stroke, and hospitalizations for heart failure) and mortality.Of 4,961 participants, 14.1% received no anti-hypertensives; 54.6% received moderate, and 31.3% received high, anti-hypertensive intensity. During follow-up, 1,247 participants (25.1%) experienced cardiovascular events; 837 participants (16.9%) died. Of deaths, 430 (51.4%) occurred in participants who experienced cardiovascular events during follow-up. In the propensity score adjusted cohort, after adjusting for propensity score and other covariates, neither moderate (adjusted hazard ratio, 1.08 [95% CI, 0.89-1.32]) nor high (1.16 [0.94-1.43]) anti-hypertensive intensity was associated with experiencing cardiovascular events. The hazard ratio for death among all participants was 0.79 [0.65-0.97] in the moderate, and 0.72 [0.58-0.91] in the high intensity groups compared with those receiving no anti-hypertensives. Among participants who experienced cardiovascular events, the hazard ratio for death was 0.65 [0.48-0.87] and 0.58 [0.42-0.80] in the moderate and high intensity groups, respectively. Results were similar in the propensity score-matched subcohort.In this nationally representative cohort of older adults, anti-hypertensive treatment was associated with reduced mortality but not cardiovascular events. Whether RCT results generalize to older adults with multiple chronic conditions remains uncertain.

Dataset Information

Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis.

Publications

Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis.

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