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Am Fam Physician. 2005;72(4):686-689

Out-of-pocket costs for medications can have a significant impact on patients’ use of these drugs. Patients with chronic illnesses commonly are on multiple drug regimens and are at risk for not filling and taking medications as prescribed. Various studies have shown that patients with chronic illnesses not only restrict their medication use because of cost, but that they also restrict their use of essential medications such as hypoglycemic agents, diuretics, bronchodilators, and antipsychotic medications. Restricting medications because of out-of-pocket expense increases emergency department visits, nursing home admissions, and acute psychiatric hospitalizations and negatively affects patients’ self-reported health status. Knowledge of risk factors for underuse of medication could help physicians identify patients who are at highest risk, but this information has been unreliable. Piette and associates identified the characteristics of patients who are least likely to inform their physicians about cost concerns, the reasons patients do not tell their physicians about these concerns, and patients’ satisfaction with various responses when the issue is raised.

The study was a nationwide survey of randomly selected adults in the United States. Participants in the Web-based survey were asked questions on a wide range of topics. Using the information gathered, the authors identified members who were 50 years and older who reported using medications for the treatment of diabetes, depression, heart problems, hypertension, or high cholesterol. The survey asked if the respondents took less of their medication in the past 12 months because of cost, and only data from those who responded positively were used in the analysis. The survey asked participants if they told their physician or nurse in advance that cost would restrict their medication use, if they told their physician or nurse after they had stopped taking their medications because of cost, and if they asked their physician or nurse to help reduce the cost of their medications. Participants who reported never addressing this issue were asked why.

A total of 660 adults participated in the study, and two thirds reported never telling their physician in advance that they planned to underuse their medication because of cost. In addition, 35 percent of the respondents never discussed the issue with their physician. Sixty-six percent of those who never told their physician about their underuse of medication reported that they were never asked about their ability to pay for medications, and 58 percent thought that their physician could not help them. Seventy-two percent of participants who discussed cost issues with their physician found them to be helpful all or most of the time. However, 31 percent reported that their medications were never changed to less expensive alternatives. Only 30 percent of the respondents reported that they were given information about programs to assist with their medication cost, and 28 percent were given advice about where to purchase less expensive medications. Physicians who were reported to be most helpful to their patients were those who provided free medication samples, asked about problems with paying for prescriptions, and offered advice about how to pay for medications.

The authors conclude that about two thirds of adults with chronic illnesses underuse their medications because of the cost and do not talk to their physicians in advance about their concerns. To resolve this problem, physicians should take a more active role in identifying and assisting patients who have difficulty paying for prescription drugs.

editor’s note: One of the most frustrating aspects of medical care is when patients do not comply with physician instructions. Noncompliance is a complex aspect of patient care with multiple causes. One cause identified in this study was the cost of medications. In an editorial in the same issue,1 Federman adds that it is the physician’s responsibility to develop relationships with patients that allow for free discussions about matters that can affect patients’ health care. Taking time to address medication cost issues with patients has the potential to prevent a catastrophic event related to noncompliance.—k.e.m.

REFERENCEFederman ADDon’t ask, don’t tell: the status of doctor-patient communication about health care costs.Arch Intern Med2004;164:1723–4.

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