Association between medication adherence and non-drug healthcare utilisation and costs: a retrospective longitudinal cohort study among US women age 65 and older.

OBJECTIVES: To explore the association between hormone therapy (HT) adherence and non-drug healthcare utilisation and healthcare costs among patients with breast cancer. DESIGN: Retrospective longitudinal cohort study. SETTING: The US Medicare beneficiaries in the SEER-Medicare-linked database PARTICIPANTS: Women aged ≥ 65 with hormone-receptor positive breast cancer from 2007 through mid-2009 in the USA. INTERVENTIONS: We examined the relationship between HT and adherence and outcomes of our interests. PRIMARY AND SECONDARY OUTCOME MEASURES: Our study cohort's HT adherence, non-drug healthcare utilisation and healthcare costs for the first year of HT and each year, thereafter, for a total of 5 years. RESULTS: 6045 eligible Medicare beneficiaries that met our selection criteria were included. We found that patients who were adherent to HT were associated with lower healthcare utilisation of all kinds (inpatient (0.35 vs 0.43, p<0.001), length of study during hospitalisation (4.19 vs 4.89, p<0.01), physician office visits (25.16 vs 26.17, p<0.001)), and significant reductions in many types of medical costs and neutral total healthcare costs despite the increased pharmacy costs. Half of the total medical cost reduction came from savings in hospitalisation costs. CONCLUSIONS: Our study suggests that the added cost of HT adherence was all but offset by the reduced cost for other medical care. Our study provides evidence on the potential success of implementing value-based insurance design (VBID) plans among patients with breast cancer to improve their long-term oral medication adherence. Policymakers should consider adherence improvement strategies such as VBID plans, given that the costs likely will not surpass the total savings.

Cost sharing for breast cancer hormone therapy: How do dual eligible patients' copayment impact adherence.

OBJECTIVE: To examine the different levels of copayment assistance and treatment adherence among Medicare and Medicaid dual eligible beneficiaries with breast cancer in the U.S. RESEARCH DESIGN: Propensity Score methodology was adopted to minimize potential selection bias from the nonrandom allocation of the treatment group (i.e., full Medicaid beneficiaries) and control group (i.e., Medicare Savings Programs [MSPs] beneficiaries). Longitudinal hierarchical model and Cox proportional-hazard model were adopted to examine patients' adherence over their full five-year course of adjuvant hormone therapy. RESULTS: Our study cohort consisted of 1,133 dual eligible beneficiaries diagnosed with hormone receptor-positive early stage breast cancer in years 2007 -mid 2009. About 80.5% of them received MSPs benefits, while the rest received full Medicaid benefits. On average for a standardized 30-day hormone therapy medication, full Medicaid beneficiaries spent $0.5-$2.0 and MSP beneficiaries spent $1.4-$4.8 in copayment. After adjusting for other factors, this copayment reduction wasn't associated with a significantly better adherence. However, when the catastrophic coverage threshold was reached (copayments reduced to zero), significant improvement in adherence was found in both groups. CONCLUSIONS: Our study found that small amount of cost-sharing reduction did not affect Medicare and Medicaid dual eligible patients' medication treatment adherence, however, the elimination of cost-sharing (even a minimal amount) was associated with improved adherence. Future legislative and advocacy efforts should be paid on eliminating cost sharing for dual eligibles, and possibly even a broader group of financially vulnerable patients.

The impact of the introduction of generic aromatase inhibitors on adherence to hormonal therapy over the full course of 5-year treatment for breast cancer.

BACKGROUND: High out-of-pocket costs (OOPCs) often are found to be inversely associated with adherence to medical treatment. The introduction of generic aromatase inhibitors (GAIs) significantly reduced the OOPCs of patients. The objective of the current study was to explore the impact of the introduction of GAIs on adjuvant hormone therapy (AHT) adherence over the full course of breast cancer treatment. METHODS: Women aged ≥65 years who were diagnosed with hormone receptor-positive breast cancer from 2007 through mid-2009 were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Multivariate logistic regression was used to estimate the likelihood of AHT initiation and an interrupted time series model was used to predict the association between the introduction of GAIs and AHT adherence. The model was stratified further using Medicare low-income subsidy (LIS) status. RESULTS: A total of 10,905 women were included, approximately 62.8% of whom initiated AHT within the first year of their breast cancer diagnosis. Adjusted adherence among LIS beneficiaries was 11.4% higher than among non-LIS beneficiaries (P < .001). Non-LIS beneficiaries had an overall decreasing trend of adherence (-0.035; P < .001) prior to the introduction of GAIs. They experienced a 3.4% increase in the slope 6 months after the first GAI, anastrozole, entered the market, and an additional 0.8% increase in the slope 6 months after letrozole and exemestane were introduced (P < .001). Adherence change among LIS patients was small and statistically insignificant. CONCLUSIONS: With the introduction of GAIs, the decrease trend of adherence to therapy atteunated over the course of treatment. Although the successful implementation of the Medicare LIS program minimized the OOPCs for financially vulnerable patients, policymakers should be cautious not to introduce disparities for those who may be of low income but ineligible for such a program.

Comprehensive assessment of the elderly cancer patient: the feasibility of self-report methodology.

PURPOSE: Comprehensive geriatric assessment (CGA) has aided the medical community greatly in understanding the quality-of-life issues and functional needs of older patients. With its professional team assessment approach, however, CGA may be time consuming and costly. The goal of the present study was to assess the ability of cancer patients to complete a self-administered CGA and then to characterize cancer patients across multiple domains and age groups. PATIENTS AND METHODS: Two hundred sixty-six male outpatient oncology patients at the Durham Veterans Affairs Medical Center were asked to fill out a survey assessing 10 domains (demographics, comorbid conditions, activities of daily living, functional status, pain, financial well being, social support, emotional state, spiritual well-being, and quality of life). RESULTS: Seventy-six percent of the patients who received their surveys and kept their appointments returned the assessment tool. Older oncology patients had significantly less education (P <.0001), income (P =.05), frequent exercise (P =.01), and chance of being disease free (P =.003) than younger patients. Other findings in older patients were a higher rate of marriage (P =.02), more difficulty in taking medications (P =.05), and less cigarette (P =.03) and alcohol (P =.03) use. Members of all age cohorts reported a sense of social support, with younger patients deriving this more from family and friends than older patients, and older patients deriving social support more from membership in religious communities than younger patients. No differences were found across age groups for number and impact of comorbid illnesses, number of medications, basic and instrumental activities of daily living, pain, overall health rating, financial adequacy, anxiety, depression, and quality of life. CONCLUSION: CGA can be conducted in an outpatient cancer community using a self-report format. Despite the fact that this population varied demographically across age groups and is limited to veterans, this study demonstrated remarkable similarities between younger and older cancer patients in terms of functional status, health states, and quality of life.