Out-of-pocket spending on drugs and pharmaceutical products and cost-related prescription non-adherence among Canadians with chronic disease.

BACKGROUND: Approximately one-third of Canadians' prescription medication costs are paid directly out-of-pocket. This study attempts to determine if out-of-pocket spending greater than 5% of household income on drugs and pharmaceutical products is associated with cost-related prescription non-adherence among people with cardiovascular-related chronic conditions. DATA AND METHODS: The data are from the survey on Barriers to Care for People with Chronic Health Conditions. Three categories of out-of-pocket spending on drugs and pharmaceutical products as a percentage of household income were identified: 0%, more than 0% to less than 5%, and 5% or more. Log-binomial regression was used to investigate associations between category of out-of-pocket spending and cost-related non-adherence. RESULTS: In 2012, about 80% of people aged 40 or older who lived in British Columbia, Alberta, Saskatchewan or Manitoba and had cardiovascular-related chronic conditions reported out-of-pocket spending on drugs and pharmaceutical products; 4.8% reported out-of-pocket spending of at least 5% of their household income. These individuals were significantly older, more often lived in households with incomes less than $30,000, and more often reported multiple morbidities than did people whose out-of-pocket spending on drugs and pharmaceutical products was less than 5% of household income. When the results were adjusted for age and sex, people whose spending amounted to 5% or more of household income were almost three times as likely (prevalence rate ratio = 2.6) to report cost-related prescription non-adherence than were those spending less than 5%. INTERPRETATION: Spending at least 5% of household income on drugs and pharmaceutical products was significantly associated with cost-related prescription non-adherence. Additional data are required to determine if even lower levels of spending put individuals at risk of cost related non-adherence.

Vitamin D status of refugees arriving in Canada: findings from the Calgary Refugee Health Program.

OBJECTIVE: To determine the 25-hydroxyvitamin D (25[OH]D) serum levels in refugee women of childbearing age and in refugee children; to compare their 25(OH)D levels with the recommended levels in order to determine the prevalence of deficiency; to compare their 25(OH)D levels with those in the general Canadian population in the appropriate age and sex groups; and to investigate the association of vitamin D deficiency with potential risk factors. DESIGN: Cross-sectional chart review. SETTING: The Calgary Refugee Health Program, an urban family practice that serves newly arrived refugees in Calgary, Alta. PARTICIPANTS: A total of 1217 refugee women and children screened between June 2005 and January 2010. MAIN OUTCOME MEASURES: Serum 25(OH)D values that were measured during initial screening visits. RESULTS: Overall, 1217 of the 1768 eligible participants (69%) had 25(OH)D laboratory values recorded. The mean concentration of 25(OH)D was 52.0 nmol/L (95% CI 50.6 to 53.3 nmol/L). Using the Institute of Medicine guideline for adequate serum vitamin D levels (>50 nmol/L), 61% of women and 42% of children had lower-than-desirable 25(OH)D levels. Considering the Osteoporosis Canada guidelines, 88% of women and 81% of children had lower-than-desirable 25(OH)D levels (<75 nmol/L), and 21% of women and 10% of children were vitamin D deficient (<25 nmol/L). Mean levels of 25(OH)D were significantly lower across all age and sex groupings compared with the general Canadian population (P<.001). Women from the Middle East had lower mean 25(OH)D values (24.6 nmol/L, 95% CI 21.7 to 27.5 nmol/L) compared with women from Asia, Africa, or South America (P<.001). Mean values of 25(OH)D were lower during the winter in children (P=.01) but not in women. Female refugees between the ages of 12 and 19 years old had lower mean values of 25(OH)D than male refugees in the same age group did (P=.01). CONCLUSION: Most refugees had lower-than-desirable vitamin D levels. All age groups studied had lower mean 25(OH)D levels compared with the general Canadian population. Health care providers should be aware of this concern and consider vitamin D supplementation among refugees.

The Cost of Care for People With Chronic Kidney Disease.

BACKGROUND: As the adverse clinical outcomes common in patients with chronic kidney disease (CKD) can be prevented or delayed, information on the cost of care across the spectrum of CKD can inform investments in CKD care. OBJECTIVES: To determine the cost of caring for patients with CKD who are not on dialysis or transplant at baseline. DESIGN: Population-based cohort study using administrative health data. SETTING: Alberta, Canada. PATIENTS: Cohort of 219 641 adults with CKD categorized by estimated glomerular filtration rate (eGFR) between April 1, 2012, and March 31, 2014, into Kidney Disease: Improving Global Outcomes (KDIGO) CKD categories, excluding patients on dialysis or transplant at baseline. MEASUREMENTS: The primary outcome was 1-year cumulative unadjusted health care costs, including the cost of drugs, physician visits, emergency department visits, outpatient procedures (including dialysis and other day medicine and surgery procedures), and hospitalizations for the year following each patient's index date. METHODS: Mean 1-year direct medical costs were estimated for the cohort as a whole and for patients in the different KDIGO CKD categories as defined at baseline. Costs were further categorized according to baseline demographic and clinical characteristics, and by type of care (ie, kidney care and cardiovascular care). RESULTS: In 219 641 adults with CKD, the mean unadjusted cumulative 1-year cost of care was Can$14 634 per patient (median = Can$3672; Q1 = Can$1496, Q3 = Can$10 221). Costs were higher for those with more comorbidity, those with lower eGFR, and those with more severe albuminuria. The cost of kidney and cardiovascular care was Can$230 (1.6% of total costs) and Can$720 (4.9% of total costs), respectively, for the cohort overall. These costs increased substantially for patients with lower eGFR, averaging Can$14 169 (32.3% of total costs) and Can$2395 (5.5% of total costs) for kidney and cardiovascular care, respectively, for people with eGFR<15 mL/min/1.73 m2 at baseline. LIMITATIONS: We only have estimates of the cost of health care for people with CKD, and not the costs borne by patients or their families. As we have not included costs for people without CKD in this analysis, we are unable to assess the incremental costs associated with CKD. CONCLUSIONS: We identified that patients with CKD, even when not on dialysis at baseline, had high health care costs (more than twice the cost per person in Canada in 2015), with a graded association between severity of CKD and costs. Our findings can inform current and future cost estimates across the spectrum of CKD, including an estimate of potential savings that might result from interventions that slow or prevent kidney disease.

CONTEXTE: Les événements cliniques indésirables qui surviennent fréquemment chez les patients atteints d'insuffisance rénale chronique (IRC) peuvent être prévenus ou retardés. Connaître le coût des soins liés à l'ensemble du spectre de la maladie pourrait éclairer les investissements en santé rénale. OBJECTIFS: Établir le coût des soins prodigués aux patients atteints d'IRC non dialysés ou transplantés au moment de l'inclusion. TYPE D'ÉTUDE: Une étude de cohorte représentative de la population réalisée à partir des données administratives en santé. CADRE: Alberta, Canada. SUJETS: Une cohorte de 219 641 adultes atteints d'IRC qui ont été classés entre le 1er avril 2012 et le 31 mars 2014 dans les catégories du KDIGO selon leur DFGe. Les patients dialysés ou transplantés ont été exclus. MESURES: Le résultat principal était le coût cumulatif non ajusté des soins de santé sur un an. Pour l'année suivant la date indice de chaque patient, le total incluait les coûts des médicaments, des consultations médicales, des visites aux urgences, des procédures ambulatoires (dialyse et différentes procédures de chirurgie et de médecine d'un jour) et des hospitalisations. MÉTHODOLOGIE: La moyenne des coûts médicaux directs sur un an a été estimée à l'inclusion pour l'ensemble de la cohorte et pour chaque catégorie d'IRC du KDIGO. Les coûts ont également été classés selon les caractéristiques démographiques et cliniques des patients à l'inclusion, et par types de soins (soins en néphrologie et en cardiologie). RÉSULTATS: Dans la cohorte étudiée, la moyenne des coûts cumulatifs non ajustés sur un an s'établissait à 14 634 $ CA par patient (médiane: 3 672 $; Q1: 1 496 $ et Q3: 10 221 $), et davantage pour les patients présentant des comorbidités, un faible DFGe ou une grave albuminurie. Les coûts des soins en santé rénale et cardiovasculaire pour l'ensemble de la cohorte s'élevaient respectivement à 230 $ (1,6 % du montant total) et 720 $ (4,9 % du montant total) par personne. Ces coûts augmentaient considérablement pour les patients présentant un faible DFGe (<15 ml/min/1,73 m2) à l'inclusion, soit en moyenne 14 169 $ (32,3 % du montant total) en santé rénale et 2 395 $ (5,5 % du montant total) en santé cardiovasculaire. LIMITES: L'estimation ne tient compte que du coût des soins prodigués aux patients, et non des coûts assumés par les patients ou leurs proches. L'analyse n'incluant pas les montants pour les patients non atteints d'IRC, nous n'avons pas été en mesure d'évaluer les coûts différentiels associés à la maladie. CONCLUSION: Nous avons constaté que les patients atteints d'IRC, même s'ils n'étaient pas dialysés à l'inclusion, engendraient des coûts de santé plus élevés (plus de deux fois le coût par personne au Canada en 2015) avec une association graduelle de ceux-ci à la gravité de l'IRC. Nos résultats peuvent orienter les évaluations de coût actuelles et futures pour l'ensemble du spectre de l'IRC, notamment l'estimation des économies potentielles qui pourraient résulter d'interventions visant la prévention de l'insuffisance rénale ou le ralentissement de son évolution.

The See Kidney Disease Targeted Screening Program for CKD.

BACKGROUND AND OBJECTIVES: The effectiveness of targeted screening for identification of CKD is largely unknown. The See Kidney Disease (SeeKD) targeted screening project aimed to determine the prevalence of unrecognized CKD in Canada. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The SeeKD project was conducted across Canada using a convenience sample approach and events to identify adults with risk factors for CKD (i.e., diabetes, hypertension, vascular disease, family history of kidney problems, etc.). Participants with at least one risk factor received a point-of-care creatinine measurement to identify unrecognized CKD (CKD-Epidemiology Collaboration eGFR <60 ml/min per 1.73 m(2)). Baseline information included clinical characteristics, sociodemographics, and health knowledge. Semistructured telephone interviews were conducted with each Kidney Foundation of Canada branch (regionalized locations) after the screening events to characterize local screening strategies, which were subsequently categorized as individual-targeted (specifically targeting individuals at risk of CKD) and community-targeted (event in a community location in proximity to a high-risk population). We calculated the prevalence of unrecognized CKD overall, and by screening strategy. RESULTS: Between January 2011 and February 2014, 6329 Canadians participated in SeeKD screening events. Participants were predominantly female (65.3%), middle-aged (mean, 58.5 years), and the majority (88.9%) self-reported at least one risk factor for CKD. Of participants with at least one risk factor, 92.3% (n=5194) were screened, of whom 18.8% (95% confidence interval [95% CI], 17.8 to 19.9) had unrecognized CKD; the majority (13.8%) had stage 3a CKD (eGFR=45-60 ml/min per 1.73 m(2)). The prevalence of unrecognized CKD was higher for branches with individual versus community-targeted events (21.9% [95% CI, 20.5 to 23.4] versus 14.7% [95% CI, 13.2 to 16.2]). CONCLUSIONS: Targeted screening identified a high proportion of individuals with risk factors for CKD and a high prevalence of unrecognized CKD. Future research will evaluate the ability of targeted screening to promote self-management behaviors addressing priorities for people with CKD.

Allatostatins and allatotropin in the corpus cardiacum/corpus allatum complex of larval and adult lepidopterans studied by confocal laser scanning microscopy: correlation to juvenile hormone biosynthesis.

Peptidergic innervation of the corpus cardiacum/corpus allatum (CC/CA) retrocerebral complex, and neurosecretory areas of the brain of the lepidopterans Lacanobia oleracea, Heliothis virescens and Manduca sexta was studied by immunocytochemistry linked to confocal laser scanning microscopy. The patterns of immunostaining resulting from the simultaneous application of fluorochrome-conjugated antibodies against Manduca sexta allatostatin (Mas-AS), M. sexta allatotropin (Mas-AT), and a representative of the -Y/FXFGL-NH(2) superfamily of allatostatins was correlated with the physiological effects of these putative allatoregulatory peptides on juvenile hormone (JH) biosynthesis by the corpora allata. Whereas the two types of allatostatin immunoreactivity are present in both larval and adult CA of the three species, allatotropin immunoreactivity occurs only in the adult gland. The conclusion that withdrawal of the stimulatory effect of allatotropin is unlikely to be involved in the downregulation of CA activity prior to the onset of metamorphosis, but that an inhibitory influence of at least Mas-AS is important, is borne out in physiological experiments on JH biosynthesis in M. sexta larvae (Mas-AS inhibitory, Mas-AT without effect). Immunoreactivity to the Y/FXFGL-NH(2) allatostatins is present in both larval and adult CA and CC, frequently co-localised with Mas-AS. The function of this peptide family in the retrocerebral complex remains enigmatic since experiments on JH biosynthesis, either when the peptide is administered alone, or together with Mas-AS, show no effect on JH biosynthesis.