Cardiovascular diseases (CVDs) are the first cause of morbidity and mortality and they contribute heavily to healthcare costs worldwide [1,2]. Diagnosis and control of cardiovascular risk factors represent the strategic approach in order to achieve successful primary and secondary prevention of CVDs.
Unfortunately, the simple detection of major cardiovascular risk factors, even if it occurs early, is inadequate: across Europe, treated patients achieving the treatment goal are 37% in type 2 diabetes, 41% in dyslipidaemia, 39% in hypertension, and many of them, though at target for the single risk factor, are maintaininig a raised residual CVD risk . Uncontrolled hypertension alone, which represents the risk factor with the highest impact on cardiovascular mortality, is responsible of 13.5% of premature death worldwide and of 92 million disability-adjusted life years in Europe [4–6]. To the human cost paid for CVD risks, the huge economic cost for the society must be added; cost that for uncontrolled hypertension is much higher than the cost of treating hypertension [7–9].
In the past, it has been largely documented that inadequate primary prevention, because of low compliance of physicians to guidelines and poor compliance of patients to drug therapy, represents the main limiting factor for all projects addressed to reduce and/or delay cardiovascular events [10,11]. In the last few years, different studies have confirmed the pivotal role of compliance to attain an effective control of cardiovascular risks in clinical practice  and documented that a low socioeconomic status reduces both drug access and adherence of the patients to physician's prescriptions [13–15]. A reduced utilization of physician's visits have been reported also in France, where the insurance plan reimburses 65% of expenditures, and the remaining 35% is covered by supplemental insurance bought on individual basis.
In this issue of the journal, Meneton et al., report their data from a cross-sectional survey in a sample of 4646 patients with CVD assessing whether the partial reimbursement by the French health insurance plan may reduce drug delivery and access to medical care of patients with a low socioeconomic status. Delivery of cardiovascular drugs and access to care were reduced by almost 50% in patients with partial health coverage as compared with those fully covered by individual supplemental insurance, which is a new and striking observation indeed. Among the eight variables (living in a poor urban area, being migrant, living alone, poor education, occupation unemployment, annual per capita or household income, full health coverage) used by Meneton et al. to describe the socioeconomic conditions of patients, health coverage was the only indicator independently associated with drugs delivery.
This association has been observed in all the models used in the regression analysis including the model adjusting for the number of physician visits. The persistence of decreased delivery of cardiovascular drugs after correction for the number of physician visits demonstrate that also the reduction of 50% of the physician access does not represent the only explanation of the reduced drugs delivery observed in the group of patients with partial coverage. The main contribution to reduced drug delivery was probably provided by patients who can buy fewer drugs, cannot fill prescriptions and, much more important, who are substantially less compliant. Poor compliance may help in understanding the lack of association of reduced drug delivery with income and education: this indicates that paying each time for the physician and prescribed drugs is not practicable, and is less acceptable for patients, independently of their social condition, than subscribing a supplemental insurance.
In the survey, cardiovascular drugs delivery has been expressed as delivery of antihypertensive, hypolipemic, and antiplatelet drugs. The last one has not been tested because of the low number of patients being treated. In the group of patients with partial health coverage, delivery of antihypertensive and hypolipemic drugs was reduced in the order of 30–40%, a percentage which is in the range of what is defined poor adherence to drug. These results suggest that a worse compliance is the main mechanism of the reduced drugs delivery in patients with partial health coverage.
The conclusion by Meneton et al. that reduced drugs delivery in patients with partial health coverage applies to all cardiovascular drug classes because it is observed both for antihypertensive and hypolipemic drugs when these classes of drugs are examined separately, represents a reasonable interpretation, though it deserves further evaluation in the future.
The observation that partial health insurance coverage is the only independent socioeconomic factor associated with drugs delivery is the most relevant finding of this survey but, as reported in the discussion, it is apparently at some variance with the results of studies performed in Italy and United States. Data obtained in a population-based study in Italy have shown the association of two socioeconomic factors, low income and migrant status, with cardiovascular drugs (mainly antihypertensive drugs) access in spite of the full reimbursement of health expenses by the Italian National Health Service . In interpreting the results of this population-based study, it is reasonable to suggest that the consistency and the role of other socioeconomic factors may increase and emerge in absence of partial health coverage. During the years of follow-up of the Italian study, performed between 1999 and 2002, a limited prescription of some classes of high-price antihypertensive drugs [angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers) as compared with lower price drugs (diuretics, β-blockers) could have influenced the access of low-income and migrant patients to the use of cheaper antihypertensive drugs. Two large studies performed on Italian populations documented a poor compliance of hypertensive patients receiving diuretics and/or β-blockers [18,19]. Therefore, it can be hypothesized that the rate of drug treatment discontinuation may have been greater in low income and migrant patients because they had more difficult access to ACE-inhibitors or angiotensin receptor blockers. It would be interesting to reanalyse the association of socioeconomic factors and cardiovascular drugs delivery now when low-cost generics of ACE-inhibitors, angiotensin receptors blockers, and statins are available in Italy and currently prescribed by family physicians.
In the United States, where a public health coverage is lacking, several classic socioeconomic factors (education, ethnicity, income, etc.) have been found associated with drugs delivery. Nevertheless, also in this country, when patients with partial health coverage are compared with those with full health coverage, partial health coverage becomes the main conditioning factor of drugs access. Data reported in a controlled trial performed in the United States  demonstrated how the elimination of copayment for drugs prescribed after myocardial infarction significantly enhances prescription coverage, improves medication adherence, reduces all cardiovascular events, and decreases patients’ expenses without increasing overall health costs. The results of this study performed in a group of patients highly motivated to assume prescribed drugs confirm that even modest copayment may reduce compliance and drugs consumption.
Eliminating copayments for essential drugs represents the first step in order to improve compliance, patient's outcome and costs, but it cannot solve entirely the problem of poor compliance, which depends on many other components in addition to costs: side effects, treatment of asymptomatic diseases, psychological aspects of patients are the most common factors. Therefore, the absence of any information on patient's compliance in the survey of Meneton et al. is an important limitation in interpreting the causes of decreased drugs delivery in hypertensive patients with partial health coverage.
The major limitation of the study by Meneton et al. consists in the absence of direct information on the patients’ compliance, which would have placed their interpretation on more solid grounds. On the contrary, the fact that their main analysis was performed in a restricted sample of 4646 cardiovascular patients with a full health coverage depending on a voluntary basis with the exclusion of those who were entirely covered by the national health insurance plan, does not represent a real limitation. Indeed, the primary analysis was dedicated to this group of patients to avoid systematic biases related to inclusion of very poor or very sick patients, as these are the one entirely covered by the national health insurance plan. The risk that this limitation could influence the results has been overcome by a second analysis performed in all cardiovascular patients (n = 6668), also including those entirely covered by the national health insurance plan. These analyses gave almost identical results as the previous one. We share the opinion of the authors that the results of these two analyses demonstrate that full health coverage represents a determinant factor in cardiovascular drug access independently of the type of coverage either on a voluntary basis or granted by the National Health System. Therefore, both private and national health insurers have a common interest in developing additional ways to improve patients compliance, not only in order to reduce their expenses but also to improve patients’ outcome .
1.1 Conflicts of interest
There are no conflicts of interest.
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