Impact of a prescription copayment increase on lipid-lowering medication adherence in veterans.
Impact of a prescription copayment increase on lipid-lowering medication adherence in veterans.
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DOI：
10.1161/circulationaha.108.783944
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发表时间：
2009-01-27
期刊：
影响因子：
37.8
通讯作者：
Volpp KG
中科院分区：
文献类型：
--
作者：
Doshi JA;Zhu J;Lee BY;Kimmel SE;Volpp KG
2002年2月，退伍军人事务部将许多退伍军人每30天的药物供应从2美元增加到7美元。我们检查了共付额增加对降脂药物依从性的影响。利用1999年11月至2004年4月在费城退伍军人医疗中心接受治疗的5604名退伍军人的电子记录进行准实验研究。“全部共付”组包括所有药物的共同支付，没有年度上限。退伍军人只有在与服务无关的情况下才需要共同支付药物，每年的自付费用上限为840美元，包括“部分共付”组。免除共同支付的退伍军人组成了一个自然对照组（“无共同支付”组）。如果使用降脂药物的天数（PDC）比例>= 80%，则认为患者为“坚持”。如果患者至少有一次连续发作且未使用降脂药物达90天，则认为患者存在“持续间隔”。一种差异-无差异的方法比较在24个月的降脂药物依从性的变化，在退伍军人的共同支付增加前和后的共同支付变化与那些没有。在共同支付额增加后，所有三组的依从性都下降了。然而，与豁免组（-11.9%）相比，在全部共付组（-19.2%）和部分共付组（-19.3%）中，坚持治疗的患者百分比（PDC>=80%）下降明显更多。连续缺口的发生率在两个共付组（全部共付组+24.6%，部分共付组+ 24.1%）均显著高于免付组（+11.7%）。与豁免组相比，在所有共同支付组（OR 3.04 95% CI 2.29-4.03）和部分共同支付组（OR 1.85 95% CI 1.43-2.40）中，相对于前期，在后期出现持续差距的几率明显更高。同样的结果也出现在高冠心病风险患者、高药物使用者和老年退伍军人的亚组中。共同支付额的增加对包括冠心病高危人群在内的退伍军人的降脂药物依从性产生不利影响。
In February 2002, the VA increased copayments from $2 to $7 per 30-day drug supply of each medication for many veterans. We examined the impact of the copayment increase on lipid lowering medication adherence. Quasi-experimental study using electronic records of 5,604 veterans receiving care at the Philadelphia VA Medical Center from November, 1999 to April, 2004. The “All Copayment” group included veterans subject to copayments for all drugs with no annual cap. Veterans subject to copayments for drugs only if indicated for a non-service connected condition with an annual cap of $840 for out-of-pocket costs comprised the “Some Copayment” group. Veterans who remained copayment exempt formed a natural control group (“No copayment” group). Patients were identified as “adherent” if the proportion of days covered (PDC) with lipid-lowering medications was >= 80%. Patients were identified as having a “continuous gap” if they had at least one continuous episode with no lipid lowering medications for >= 90 days. A difference-indifference approach comparing changes in lipid lowering medication adherence during the 24 months pre- and post- copayment increase among veterans subject to the copayment change versus those who were not. Adherence declined in all three groups after the copayment increase. However, the percent of patients who were adherent (PDC>=80%) declined significantly more in the all copayment (-19.2%) and some copayment (-19.3%) groups relative to the exempt group (-11.9%). The incidence of a continuous gap increased significantly at twice the rate in both copayment groups (+24.6% all copayment group and 24.1% some copayment group) than the exempt group (+11.7%). Compared to the exempt group, the odds of having a continuous gap in the post- relative to the pre-period were significantly higher in both the all copayment group (OR 3.04 95% CI 2.29-4.03) and the some copayment group (OR 1.85 95% CI 1.43-2.40). Similar results were seen in subgroups of high CHD risk patients, high medication users, and elderly veterans. The copayment increase adversely impacted lipid lowering medication adherence among veterans including those at high CHD risk.