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Background and objectiveSome patients continue taking their medication as prescribed despite serious financial pressures, while others with the ability to pay forego treatment due to cost concerns. The primary goal of this study was to explore how patients’ beliefs about the necessity of treatment and treatment side effects, influence cost-related non-adherence (CRN).Methods27,302 participants in the Harris Interactive Chronic Illness Panel completed an internet survey. The current study focused on two subsamples representing: (a) the most economically-vulnerable survey respondents (ie, individuals with household incomes of US$25,000 per year or less and monthly out-of-pocket medication costs of at least US$60, n = 1321); and (b) respondents who were the most likely to have the financial resources to pay for medications (ie, those with incomes of US$125,000 or more and monthly medication costs of less than US$60.00, n = 1195). Multivariate models were constructed for each group to determine the independent impact on CRN of perceived need for medications and side-effect concerns. Increased risk for CRN associated with depression and asthma diagnoses also was examined.ResultsTwenty-one percent of economically vulnerable respondents reported continuing to take their medication as prescribed despite serious cost pressures, while 14% of high-income respondents reported CRN despite apparently manageable out-of-pocket costs. Both low perceived need for medications and concerns about side-effects affected CRN risk in low-income and high-income groups. Within groups of both low-income and high-income respondents, depression and asthma significantly increased patients’ odds of reporting CRN.ConclusionBeyond objective financial measures, CRN is influenced by patient beliefs, which can influence the perceived value of prescription drugs. Addressing these beliefs, as well as the unique adherence concerns of patients with depression and asthma, could decrease CRN rates even if cost pressures themselves cannot be reduced.

Background Performance measures that emphasize only a treat-to-target approach may motivate overtreatment with high dose statins, potentially leading to adverse events and unnecessary costs. We developed a clinical action performance measure for lipid management in patients with diabetes that is designed to encourage appropriate treatment with moderate dose statins while minimizing overtreatment. Methods and Results We examined data from July 2010 to June 2011 for 964,818 active VA primary care patients >=18 years with diabetes. We defined 3 conditions as successfully meeting the clinical action measure for patients 50-75 years old: 1) LDL < 100 mg/dL; 2) On a moderate dose statin, regardless of LDL level or measurement; or 3) If LDL > 100 mg/dL, received appropriate clinical action (starting, switching or intensifying statin therapy). We examined possible overtreatment for patients 18 and older by examining the proportion of patients without ischemic heart disease who were on a high dose statin. We then examined variability in measure attainment across 881 facilities using two level hierarchical multivariable logistic models. Of 668,209 patients with diabetes aged 50-75 years, 84.6% passed the clinical action measure: 67.2% with LDL <100 mg/dL; 13.0% with LDL >=100 mg/dL and on either a moderate dose statin (7.5%) or with appropriate clinical action (5.5%); and 4.4% with no index LDL on at least a moderate dose statin. Of the entire cohort aged >=18 years, 13.7% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100 mg/dL) had higher rates of potential overtreatment (p <0.001). Conclusions Use of a performance measure that credits appropriate clinical action indicates that almost 85% of diabetic Veterans aged 50-75 are receiving appropriate dyslipidemia management. However, many patients are potentially overtreated with high dose statins.

Objective. To examine if patients with arthritis who reported using complementary and alternative medicine (CAM) were more likely to tell their physicians about their CAM use if they rated their rheumatologist as using a more participatory decision-making style and what reasons patients gave for telling or not telling their rheumatologist about their CAM use. Methods. A survey that asked about CAM use, health status, demographics, physician use of a participatory decisionmaking style, and medical skepticism was sent to individuals with arthritis who saw 23 rheumatologists at universities and private practice clinics in North Carolina. Generalized estimating equations were used to analyze the data. Results. A total of 92% of patients reported using CAM for their arthritis and 54% of these patients discussed their CAM use with their rheumatologist. Women, patients who used more types of CAM, and patients who rated their rheumatologist as using a more participatory decision-making style were significantly more likely to tell their physicians about their CAM use. Conclusion. Our findings suggest that if rheumatologists use more participatory styles of decision making with patients and involve them when making treatment decisions, patients are more likely to tell them about their CAM use.

Objective. To examine the frequency with which medication costs are discussed, and the predictors of these discussions, during visits between rheumatologists and their patients with rheumatoid arthritis (RA). Results. Despite medication changes being made in more than 50% of the visits, only 34% of those visits included discussions of medication-related costs; 48% of these discussions were initiated by patients. In multivariable logistic regression models, communication about medication costs occurred more often when patients were white (compared with nonwhite) and reported an annual income of $20,000 -$59,999 (compared with those earning >$60,000). Discussions about medication costs also were more common when physicians were white. Conclusion. Although medication changes were common, medication costs were only discussed in one-third of the visits. Communication about medication costs was more common among patients who were white and in a middle income category. Disparities in communication about medication costs have the potential to negatively impact prescribing and subsequent medication use. Further research should examine potential disparities in communication about medication costs.