Medication cost barriers to chronic disease management in Atlantic Canada seniors

¶ … Drug Therapy for Chronic Disease Management of Seniors and Aging in Atlantic Canada

The concern of the research is to understand the link between management of chronic illnesses in seniors and general health care costs, since many chronic conditions increase with age.There is rising drug costs, high use in the elderly, and dwindling access to realistic and inexpensive coverage has been the highlight on the debate regarding what needs to be done to provide prescription drugs to seniors. Rise in medicine costs for illness management is a major concern for aging as well as senior citizens in Atlantic Canada, with different medicines annually produced gaining Health Canada approval.Many elderly and chronically sick patients take less prescribed medication because of cost concerns, particularly patients with low income, multiple chronic health issues, or no prescription drug coverage. There are consequences associated with underuse of medication due to cost and they include: increased visits to emergency department, psychiatric and nursing home admissions, and reduced health status (Piette, Heisler & Wagner, 2004).

The high costs of drugs and the absence of prescription coverage often result in additional impacts. Clinicians that are sure that their patients are not in a position to pay for high cost medications are not likely to prescribe them despite the fact that they are effective. Moreover, for the elderly people a large portion of their salary is used to cater for their health care; hence, impacting greatly on the poor seniors. For the seniors with a low income they are faced with the challenge of having to restrict their spending on medication for the favor of food, clothes and various utilities. Even for the seniors that do not restrict their spending on medications they often forego some goods and services that are vital for their wellness (Steinman, Sands & Covinsky, 2001)

Although cost-related importance in public health medication underuse is gaining attention, there is a limited understanding of the way medication costs impact the elderly with different clinical and socioeconomic features.The insufficient amount of data on the problems of adhering to medication due to cost restrictions has significance on a number of factors. It has an effect on the clinical issues and also limits the understanding of the adherence problems among different socioeconomic groups. The existing estimates that give the relation between the personal costs and underuse are likely to mask paramount differences in treatment procedures. With this you can have an individual that is very sensitive to the cost pressures especially if they hold the perception that taking the medication will have little to no effect on their well-being and longevity. On the other hand, the patient that holds the idea that the medication is important is likely to adhere even when there are high costs to be incurred (Piette, Heisler & Wagner, 2004).

Therefore, it is vital to understand the association of chronic illness management among seniors with overall cost of healthcare, given that prevalence of numerous chronic problems rises with age. Canadian seniors account for roughly 44% of the nation's publicly-financed healthcare expenditure (Canadian Institute for Health Information, 2009). Costs of prescription medications are rising more rapidly than that of all other healthcare segments. Thus, this study intends to establish a link between drug therapy costs and chronic illness management in Atlantic Canada's elderly population.

Statement of problem

With the huge financial impact in Canada that is due to chronic conditions, the direct influence that it has on the health care costs and the indirect influences such as decrease in productivity; there is a considerable need for the research to focus on the subject. The research serves to give one an understanding of the relationship that exists between the overall costs in health care and the proper management of the chronic conditions among the seniors. This is important since the prevalence of most chronic illnesses is more with age (Canadian Institute for Health Information, 2011).

Objectives of the study

The study will focus on seniors since they are likely to have chronic conditions, particularly comorbidities that tend to be complex and difficult to manage. This research aims to:

Assess how rise in medication expenses for Atlantic Canada's aging and senior population impacts their illness management

Examines experiences of seniors in Atlantic Canada under medication for chronic conditions within primary health care (PHC) setting

Focus on the patients that are not under any insurance cover and have cost restrictions to access the appropriate medication

Determine the frequency of the medication restriction behavior

Determine the particular patients that are most likely to get the medication restriction, and the modifications that prescription coverage has on the risk.

Rationale of the study

The concept of disease management involves reduction in healthcare spending and improvements to QOL of patients suffering chronic illnesses, through prevention or minimization of disease effects via integrated patient care (Academy of Managed Care Pharmacy, n.d). The study's rationale will be determining how chronic illness management is impacted by rise in costs of drug therapy. In order to evaluate the link between cost of medication and management of chronic disease in elderly individuals, the study will use literature review to formulate the problem and to come up with the research problem (Conrad & Serlin, 2011).

The findings and methodology in the studies used in the study will be useful in showing, shaping and informing both the research method and research question.The study will persuasively use literature review to inform and justify research methods and questions in the study.Illness management of Atlantic Canada's aging and senior citizens will be the study's dependent variable, whereas rise in expenses linked to drug treatment for different conditions impacting Atlantic Canada's aging and senior citizens will be the independent variable. In addition, pharmaceutical companies and the government (i.e., developers of healthcare policy) will be potential co-variables.

The research will provide policymakers, doctors and clinicians with more information on the effect that cost has on the use of prescription medications among patients that have chronic illnesses. This would be helpful as the research focuses on persons with chronic conditions with the aim of identifying factors such as prevalence, risk factors, and factors that affect the adherence to medication whilst considering the cost restrictions. The research builds on the evidence on medication underuse due to cost, the measures that are involved in the documentation of the underuse of specific medications, the measures used in the identification of persons that are commonly affected by the adherence problems, and the differences that are present in the socioeconomic factors that affect underuse of different treatments (Piette, Heisler & Wagner, 2004).

Therefore, the national governmentwill be charged with the responsibility to look into the concerns of the senior's healthcare. A good approach would be to come up with a health strategy that focuses on the aged to give the seniors undivided health care attention that focuses on the prevention as well as the management of chronic conditions. Also there should be a focus on giving support to the primary care services such as the home care services that put emphasis on building collaborative teams. Lastly, a useful approach would also be to redirect the funding of health to preventive programs and services and more so the public health personnel (Canadian Nurses Association, 2011).

Lastly, examining incomes of individuals suffering from chronic illnesses can actually enable researchers to uncover differences in levels of adherence. For better explaining this finding, researchers can include income as a key determinant for adherence to medication. Moreover, the findings in the study may be useful in enhancing the understanding of elderly patients' utilization of health care services, health status and medication management.

Literature review

According to Canadian Institute for Health Information (2011) many seniors accounting to 94% report to a regular place of care. The same proportion of seniors has a regular medical doctor, which is higher than in other age groups, including the age between 45 and 64 (90%), age between 25 and 44 (82%) and age between 18 and 24 (78%). Seniors with one and two chronic condition(s) take an average of 3 and 4 prescription medications, respectively. Those with three chronic conditions take on average 6 prescription medications. This is the same trend that has been observed in adults of age 45 to 64. Previous research indicates that the various age groups among the elderly people the seniors that have more than three chronic diseases need more attention. The estimate is that their number of visits to a health care facility is up to three times that of their counterparts that lack chronic conditions. These seniors with three or more chronic conditions have a higher number of visits and appointments with nurses, counselors, therapists and social workers. They also have more visits to diet experts, special doctors and pharmacists are two times higher than those of fellow seniors without a chronic condition (Canadian Institute for Health Information, 2011).

Seniors in Canada account for close to 44% of public health care costs. There is a study that was conducted in 2000 whose findings indicated that arthritis had a huge impact on the total economy of Canada. Its impact on the cumulative economy was 6.4 billion dollars and the seniors accounted for a large portion of this that amounted to about 1.7 billion dollars. It is evident that an increase in the efforts put in place to enhance the preventive primary health care among the seniors in Canada would actually be beneficial. This is the case whilst considering that the public sector accounts for up to 70% of all the healthcare cost in Canada and the fact that there is an extreme effect of the high comorbidity on the health care use for seniors (Canadian Institute for Health Information, 2011).

Financial costs have considerable impact on patients with chronic illnesses in Canada; direct effects on healthcare expenses as well as indirect impacts (e.g., decreased productivity) are subjects of extensive research. For instance, a Canadian Public Health Agencyresearch revealed that the nation's overall cardiovascular disease burden in the year 2000 was 22.2 billion dollars, of which 7.6 billion dollars constituted direct expenses and the indirect expenses amounted to 14.6 billion dollars (Public Health Agency of Canada, 2009).

An estimate indicates that Canada has about 1.6 million cases of heart disease and/or persons living with stroke effects. For seniors who are within the age group 65 to 74 years, about 14.8% are diagnosed with heart disease and the proportion increases to about 22.9% for those above the age of 75 years. Moreover, 7.1% of the same age group in Canada are said to be living with stroke effects (Public Health Agency of Canada, 2009).As they age, seniors majorly have one chronic illness and those above 85 years are likely to have a minimum of three conditions. The chronic conditions have an impact whose measure is the overall effect on health and the resources meant for health care. When the health status has a poor perception this is an indicator that the chronic conditions have a negative effect on the patients (Canadian Institute for Health Information, 2011). Implementation of suitable solutions for curbing rising expense burdens of chronic illness prevention and management is a great challenge encountered by lawmakers, healthcare professionals, and administrators.

Though the overall population of Canada is regarded as largely healthy, particularly when taken relative to the populations of numerous other nations, chronic illness prevention and management in Canada denotes the greatest challenge to the nation's healthcare system. Sixty-eight billion dollars (i.e., 58% of total annual Canadian healthcare expenditure) in 2010 were spent towards chronic illness prevention/management.In a third of the Canadian population; there is at least one case of a chronic illness. However, there is a likelihood that these figures will increase since there is an expectation that the population of the seniors above 65 years will increase up to 9.8 million before 2036 (Canadian Nurses Association, 2011).

To date the seniors have longer life spans and are said to be healthy and economically stable that those in the previous years. However, as they become older, research indicates that they are more likely to suffer from chronic diseases resulting to a burden in the healthcare system. Since most of the senior persons are affected by poverty there will be several demands for shelter, community and care services. However, there are inadequate nurses that provide home care and there is insufficient support to informal care from the government; therefore, negatively affecting the seniors that have chronic conditions. The seniors are only left with a health care option to use an ambulance to visit emergency departments and hospital admissions (Canadian Nurses Association, 2011).

There are anecdotal reports that draw focus to the patients that are not under any insurance cover and have cost restrictions to access the appropriate medication. Even with this, it is surprising that there are few research works that have focused on determining the frequency of the behavior, the particular patients that are most likely to get the medication restriction, and the modifications that prescription coverage has on the risk. With several seniors that lack prescription coverage the restrictions in medications is rampant among the vulnerable section of the population that include ethnic minorities, sick, poor, frail and those whose out-of-pocket costs are high. In contrary, the section of the seniors that are among the ones with a high risk and have prescription coverage, either partial or full, have a lower likelihood to have a restriction on their medications. Low income levels and high out-of-pocket costs of drugs are important influencing factors on medication restrictions in consistency with the prevailing economic principles (Steinman, Sands & Covinsky, 2001).

The seniors who have good health require little to no health care. Ideally, the level of health care attention that a senior receives is majorly dependent on the number of chronic conditions that they are diagnosed with. This means that one's age is not quite a big contributor. Important to note is that these estimates are only subject to the medications that are prescribed and the number could be more if there was an inclusion of medications that are received over the counter. Another factor to consider for the seniors is that those with more prescriptions are likely to experience more side effects. Consequently, they require more medical attention that requires an extra cost yet most of the seniors do not have medication reviews. Concerns regarding care of patients with chronic illnesses are growing in Canada, with increase in cases of high blood pressure, diabetes, and other chronic health conditions (Canadian Institute for Health Information, 2011).

For a number of chronic issues, an increase is noted in disease prevalence with age, leading to an uneven disease burden on the nation's senior citizens (i.e., citizens aged 65+). Elderly people suffering chronic illnesses, particularly multiple chronic illnesses (also known as comorbidity) are normally characterized by lower levels of QOL (quality of life), and are in need of substantial healthcare-related resources. Therefore, there is need to have an effective program whose aim is to prevent and manage chronic conditions especially in Canada where there is a boom of those in the senior age (Canadian Institute for Health Information, 2011).

Research question

How is chronic illness management of Atlantic Canada's aging and senior citizens impacted by rise in drug therapy costs?

Research methodology

The sample

This study will be in the form of an observational (cross sectional) research, focusing on pharmaceutical data that will be patient-specific (Atlantic Canada's aging and senior citizens), and depicting the various kinds of diseases suffered by elderly patients, drug dosage prescribed to them by the doctor, and individual drug costs, for understanding the link between disease management and rise in drug therapy costs.Establishment of study group characteristics will be dependent on access of medical prescriptions of aging and senior patients suffering from different conditions, in palliative homes, nursing homes, hospitals, and long-term care centers.The study will attempt to identify the patients unable to afford their prescribed medication owing to absence of finances and increased drug costs.

The study will be based on a survey of Canadians. The study will review Canadian Institute for Health Information (CIHI) reports. As such, the survey will be used to document various findings of Primary Health Care experiences in seniors living with chronic illnesses.For analysis, provincial comparisons will be standardized by age to control differences between populations. The sample studies to be used will be designed to generate pan-Canadian and provincial estimates. As well, a response weighting strategy will be used to guarantee representativeness of the distribution in the elderly population. This study will be based on data from the 2008 Canadian Survey of Experiences with Primary Health Care (CSE-PHC). Statistics Canada began out the 2008 CSE-PHC in April 14, 2008 and completedin June 30, 2008 through the use of computer-assisted telephone interviews. The sample for the survey will be a subsample of respondents used in Canadian Community Health Survey according to Statistics Canada (2008) who were 18 and older. In this survey, there willbe no residents of Crown land and First Nations reserves, Canadian Forces members who are full-time, inmates or residents in isolated areas. The sample will be developed to produce provincial and pan-Canadian estimates.

Testing procedures

A response weighting strategy will be used to guarantee representativeness in both age and sex distributions in the population. The final sample will involve a small number of respondents from the territory to ensure pan-Canadian representativeness; nevertheless, the sample will be too small to generate territorial estimates. Within analysis of the study, the term "seniors" denotes adults age 65 and older while the term "adults" denotes adults aged above 18 years unless otherwise stated. In instances that are appropriate, analyses by region will be age- and sex-standardized to compensate age and sex differences.

Expectations regarding the time of sample collections

The study will use information from panel members' enrollment surveys in identifying individuals aged 65 years and above who report that they used prescription medication for chronic diseases such as depression, diabetes, hypertension, heart problems, or high cholesterol. After 3 personalized e-mail requests, the respondents will be emailed online informed consent form and questionnaire, which has been adapted from a previous research namely NPDUIS (2011).

Research Design

The study will create four measures associated with medication underuse. The first measure will be treatment-specific by identifying all respondents who indicate cost-related underuse linked to every medication type. Second measure will identify individuals who report some form of underuse like "taking fewer pills or a smaller dose" for each medication form at least once a month. Third measure willidentify respondents who report cost-related underuse within the previous year in any medication for chronic conditions. This measure is akin to those employed in earlier survey-based studies.Lastly, the fourth measure will identify individuals who report some type of underuse in at leastone of the medications once per month.The study will calculatefrequency of medication underuse associated with cost using all the 4 measures in both the sample and among the respondents who use specific medication for chronic conditions. The study will then use logistic regression models that predict cost-related underuse in the most common chronic treatments as a function of the respondents' age, income, number of prescriptions, prescription drug coverage, and monthly out-of-pocket medication costs.

Comments about previous pilot work in this area

According to Luffman (2005), financial burden associated with prescription drugs in fixed-income homes has attracted widespread publicity. In her study, Luffman established that the most vulnerable are seniors in this position because they are unlikely to be subscribers of private insurance. In addition, seniors are prone to chronic health problems that require regular medication. Hence, all provinces in Canada have initialized some type of drug plan targeting seniors above 65 years old. In spite ofthe public plans, Luffman showed that it is still likely senior households will report out-of-pocket spending on prescription drug and tendsto be higher-than-average expenditures.Prescription drugs constitute the biggestshare of out-of-pocket spending in health care for senior households; seniors allocate 27.3% of health care spendingto out-of-pocket costcompared to 17.7% allocated by non-senior households (Luffman, 2005).

Challenges and limitations

First, one may not be able to generalize results to every patient suffering chronic illness, because of the study population's unique nature (Ramasamy, 2009). Second, studies indicate that people are less inclined by social desirability bias in cases where they report information to computers than when engaging in-person or written survey, it is still possible that social desirability or recall bias can lead some respondents to either underreport or over report adherence issues. Third, since the study uses literature review, it will have time and resource limitation. Fourth, using literature review shows only findings instead of critically reviewing and interpreting findings. Lastly, the study may miss relevant segments of the literature or major studies (Conrad & Serlin, 2011)