Cost-related medication underuse: do patients with chronic illnesses tell their doctors?

Background: Although many chronically ill patients underuse prescription medications because of cost concerns, we know little about their discussions with clinicians about this issue.

Methods: Nationwide survey of 660 older adults with chronic illnesses who reported underusing medication in the prior year because of cost. We assessed whether patients discussed cost-related medication underuse with clinicians, reasons that some patients did not talk with clinicians about this problem, how clinicians responded when this issue was raised, and how helpful patients perceived clinicians to be.

Diabetes care quality in the Veterans Affairs Health Care System and commercial managed care: the TRIAD study.

Background: No studies have compared care in the Department of Veterans Affairs (VA) with that delivered in commercial managed care organizations, nor have studies focused in depth on care comparisons for chronic, outpatient conditions.

Objective: To compare the quality of diabetes care between patients in the VA system and those enrolled in commercial managed care organizations by using equivalent sampling and measurement methods.

Design: Cross-sectional patient survey with retrospective review of medical records.

Interactive behavior change technology. A partial solution to the competing demands of primary care.

Background: Primary care practices are faced with the challenge of having too much to do in too little time. As a result, behavioral counseling is often overlooked, especially for patients with multiple health behaviors in need of change.

Methods: This paper describes recent examples of the application of interactive behavior change technologies (IBCTs) to deliver health behavior change counseling before, during, and after the office visit to inform and enhance patient-clinician interactions around these issues.

The health effects of restricting prescription medication use because of cost.

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).

Depression increases diabetes symptoms by complicating patients' self-care adherence.

Purpose: This study evaluated whether diabetes patients with depressive symptoms are more likely than other diabetes patients to report symptoms of glucose dysregulation, and whether this relationship is mediated by the impact of depressive symptoms on patients' adherence to their diabetes self-care regimen.

Methods: Participants were English- and Spanish-speaking adults with type 2 diabetes. Interviewers assessed participants' depressive symptoms and diabetes-related symptoms at baseline.

Clinician identification of chronically ill patients who have problems paying for prescription medications.

Purpose: Little is known about whether health care providers are effectively identifying patients who have difficulty covering the costs of out-of-pocket prescription medications. We examined whether and how providers are identifying chronically ill adults who have potential problems paying for prescription medications.

Methods: We conducted a cross-sectional survey of a national sample of 4050 adults aged 50 years or older who use prescription medications for at least one of five chronic health conditions.

Addressing the needs of patients with multiple chronic illnesses: the case of diabetes and depression.

Objectives: To review the literature on comorbid depression and diabetes (DM/D) and present a conceptual framework for integrating depression management with diabetes care in a managed care environment.

Study Design: Literature review.

Results: Depression affects diabetes management by 1) directly affecting patients' health-related quality of life, 2) reducing physical activity levels, 3) limiting adherence to self-care regimens, and 4) impairing patients' ability to communicate effectively with clinicians.

Functional health literacy and the quality of physician-patient communication among diabetes patients.

While patients with poor functional health literacy (FHL) have difficulties reading and comprehending written medical instructions, it is not known whether these patients also experience problems with other modes of communication, such as face-to-face encounters with primary care physicians. We enrolled 408 English- and Spanish-speaking diabetes patients to examine whether patients with inadequate FHL report worse communication than patients with adequate FHL. We assessed patients' experiences of communication using sub-scales from the Interpersonal Processes of Care in Diverse Populations instrument.

Problems paying out-of-pocket medication costs among older adults with diabetes.

Objective: To identify problems faced by older adults with diabetes due to out-of-pocket medication costs.

Research Design And Methods: In this cross-sectional national survey of 875 adults with diabetes treated with hypoglycemic medication, respondents reported whether they had underused prescription medications due to cost pressures or had experienced other financial problems associated with medication costs such as forgoing basic necessities. Respondents also described their interactions with clinicians about medication costs.

Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care.

Background: Chronically ill patients often experience difficulty paying for their medications and, as a result, use less than prescribed.

Objectives: The objectives of this study were to determine the relationship between patients with diabetes' health insurance coverage and cost-related medication underuse, the association between cost-related underuse and health outcomes, and the role of comorbidity in this process.

Research Design: We used a patient survey with linkage to insurance information and hemoglobin A1C (A1C) test results.

Randomized trial of a daily electronic home monitoring system in patients with advanced heart failure: the Weight Monitoring in Heart Failure (WHARF) trial.

Background: Heart failure treatment guidelines emphasize daily weight monitoring for patients with heart failure, but data to support this practice are lacking. Using a technology-based heart failure monitoring system, we determined whether daily reporting of weight and symptoms in patients with advanced heart failure would reduce rehospitalization and mortality rates despite aggressive guideline-driven heart failure care.

Methods: This was a randomized, controlled trial.

Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population.

Background: Patient-provider communication is essential for effective care of diabetes and other chronic illnesses. However, the relative impact of general versus disease-specific communication on self-management is poorly understood, as are the determinants of these 2 communication dimensions.

Design: Cross-sectional survey.

The influence of distance on utilization of outpatient mental health aftercare following inpatient substance abuse treatment.

This study examined whether substance abuse patients who live farther from their source of outpatient mental health care were less likely to obtain aftercare following an inpatient treatment episode. For those patients who did receive aftercare, distance was evaluated as a predictor of the volume of care received. A national sample of 33,952 veterans discharged from Department of Veterans Affairs (VA) inpatient substance abuse treatment programs was analyzed using a two-part choice model utilizing logistic and linear regression.

Enhancing support via interactive technologies.

Despite some improvements in diabetes treatment processes, outcomes for many patients remain inadequate. Interactive health technologies (IHTs) can address many of the challenges that diabetes patients and their health systems face, and research on IHT applications for diabetes care are intensifying. This article describes recent evidence regarding the feasibility and impact of 1) clinic-based CD-ROM systems supporting behavior change; 2) automated telephone diabetes management allowing for ongoing monitoring and patient education between face-to-face clinical encounters; and 3) Web-based systems focusing on a range of diabetes management goals such as enhanced emotional support for patients and improved clinician adherence to treatment guidelines.

Closing the loop: physician communication with diabetic patients who have low health literacy.

Background: Patients recall or comprehend as little as half of what physicians convey during an outpatient encounter. To enhance recall, comprehension, and adherence, it is recommended that physicians elicit patients' comprehension of new concepts and tailor subsequent information, particularly for patients with low functional health literacy. It is not known how frequently physicians apply this interactive educational strategy, or whether it is associated with improved health outcomes.

Association of health literacy with diabetes outcomes.

Context: Health literacy is a measure of patients' ability to read, comprehend, and act on medical instructions. Poor health literacy is common among racial and ethnic minorities, elderly persons, and patients with chronic conditions, particularly in public-sector settings. Little is known about the extent to which health literacy affects clinical health outcomes.