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Stroke Survivors Often Noncompliant with Medications Due to Cost

Laino, Charlene

doi: 10.1097/01.NT.0000396254.23605.dc
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Thirty percent of stroke survivors aged 45 to 54 surveyed from 2006 to 2009 reported that they were nonadherent because they could not afford medications.

LOS ANGELES — Many stroke survivors, particularly the young and uninsured, do not take prescribed medications because the cost is too high — and the situation is getting worse, researchers reported here.

Thirty percent of stroke survivors aged 45 to 54 surveyed from 2006 to 2009 reported that they were nonadherent because they could not afford medications, said Deborah A. Levine, MD, MPH, assistant professor of medicine in the Division of General Medicine at the University of Michigan in Ann Arbor.

That's a significant increase from the 18 percent of patients in this age group surveyed from 1998 to 2002 who reported being noncompliant due to cost, she reported here at the American Stroke Association International Stroke Conference 2011.

Dr. Levine noted that stroke survivors are discharged from rehabilitation with an average of 11 different medications to prevent recurrent stroke and to treat comorbid conditions such as hypertension, diabetes, and chronic pain.

Medication nonadherence due to cost among the uninsured increased significantly from 39 percent in the earlier survey to 60 percent in the latter survey, she said.

Overall, the proportion of stroke survivors aged 45 years and older reporting medication nonadherence due to cost increased from 8.6 percent — for the years 1998-2002 — to 11.9 percent for the period of 2006-2009, the study showed.

In 2009, about 150,000 US stroke survivors reported medication non-adherence due to cost, Dr. Levine said.

“Despite federal and local programs, medication is still unaffordable for many stroke survivors. The bottom line is that medication nonadherence due to cost prevents the translation of remarkable research and public health advances to our stroke patients,” she said.

What was particularly surprising, Dr. Levine said, is that the latter survey showed that Medicare beneficiaries with Part D prescription drug coverage were twice as likely to report cost-related nonadherence than survivors who did not have the drug benefit: 12 percent versus 6 percent. Part D was implemented in 2006.



After adjusting for differences in age, gender, race, household income, health status, co-morbidities, neurological disability due to stroke, and private health insurance between Part D enrollees and non-enrollees, however, the difference was no longer statistically significant, Dr. Levine said.

“There was no evidence that Medicare Part D solved the problem of medication nonadherence due to cost among stroke survivors with Medicare,” she said. “The reason why is unclear, but seems to be related to higher rates of poverty and comorbidities, and a lack of private insurance, all of which are risk factors for nonadherence, among enrollees.”

This finding “is extremely important, as it tells us that the program is not working as intended,” said Chelsea S. Kidwell, MD, medical director of the Georgetown Stroke Center in Washington, DC, who was asked to review the findings for comment.

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For the study, Dr. Levine and colleagues examined data on 2,656 stroke survivors aged 45 and older who responded to the National Health Interview Survey from 2006 to 2009. That sample was representative of the estimated 5.3 million stroke survivors in the US, 3.6 million of whom were Medicare beneficiaries and 1.5 million of whom reported Medicare Part D insurance, she said.

Patients were considered to be medication nonadherent due to cost if they responded affirmatively to the question: “During the past 12 months, was there any time when you needed prescription medicines, but didn't get them because you couldn't afford them?”

Those results were compared to those of the group's 1998 to 2002 survey, which was published in the Archives of Neurology in 2007.

Dr. Levine said that situation may continue to get worse “because adults take more medications with higher costs, and the economy is worse with a greater number of adults living in poverty. And more adults are uninsured,” she said.

But “we can attack this problem on many fronts,” she said. “Clinicians need to screen for cost-related medication adherence, asking stroke survivors if they can afford their medications, particularly patients who are younger and uninsured. For those who can't, we need to prescribe cost-effective medications whenever possible,” Dr. Levine said.

Dr. Kidwell added “many drug companies have programs that may provide free medication to uninsured patients who can't afford them.” She also suggested substitution of expensive medications with generic agents whenever possible.

“Finally, just overall education of the patients is important. You need to stress to your patients how compliance can reduce their risk of recurrence” and often overall costs in the long run, Dr. Kidwell said.

“Secondary prevention, which includes medication compliance, provides an enormous opportunity to prevent further disability and death from stroke,” she said.



Dr. Levine said that from a public policy perspective, “we need affordable health insurance and prescription drug coverage for uninsured stroke survivors.

“Also, [the government] should think about providing free medications for secondary stroke prevention for those who can't afford them,” Dr. Levine continued. She noted that the cost-effectiveness of providing drugs for secondary prevention is currently being studied in another trial of survivors of acute myocardial infarction.

Dr. Levine said her group's surveys have several limitations, including the use of self-reported stroke history and potential unmeasured confounding due to stroke features (type, severity, or timing), and medication-taking attitudes or behaviors. Also, the results are generalizable only to non-institutionalized stroke survivors, she said.

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Levine DA, Kiefe CI, Ayanian JZ, et al. Younger stroke survivors have reduced access to physician care and medications: National Health Interview survey from years 1998 to 2002. Arch Neurol 2007; 64:37–42.
©2011 American Academy of Neurology