Patients with lupus more likely to skip doses, delay filling prescriptions due to cost
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Patients with systemic lupus erythematosus are more likely than those in the general population to skip doses, take less medicine and delay filling prescriptions due to cost, according to data published in Arthritis Care & Research.
“Poor outcomes such as increased flares, emergency department visits, hospitalizations, and renal disease have been noted in association with non-adherence in SLE, making it essential to improve understanding of factors that compromise adherence,” Deeba Minhas, MD, of the University of Michigan, and colleagues wrote. “Several studies have documented non-adherence in SLE, and a review by Costedoat-Chalumeau found the most common cause of nonadherence was fear of side effects. However, cost-related aspects of non-adherence have not been a central focus in the existing studies.”
To examine the factors associated with access and cost-related nonadherence among patients with SLE compared with the general population, Minhas and colleagues conducted structured interviews with participants from the Michigan Lupus Epidemiology & Surveillance (MILES) Cohort. Created in 2014-2015, the MILES Cohort includes patients with SLE and controls from southeastern Michigan. Its precursor was the MILES Surveillance Registry, one of the National U.S. Lupus Registries supported by CDC.
The researchers collected detailed clinical and sociodemographic information, as well as health care access and use data, through structured interviews at the MILES baseline visit. Interviews included questions related to prescription medication access and adherence in the preceding 12 months. Participants were also asked whether they had been unable to obtain necessary prescription medicines in the preceding 12 months and, if so, why. Cost-related prescription nonadherence was defined based on participants reporting of at least one of the following: Skipped doses, taking less medicine or a delay in filling a prescription.
In all, 654 participants, including 462 patients with SLE and 192 controls, completed the baseline visit.
According to the researchers, 12.1% of patients with SLE and 9.4% of control participants reported being unable to access prescribed medications. However, those with SLE were about twice as likely as control participants to report cost-related prescription nonadherence in the preceding 12 months — 21.7% compared with 10.4% (P = .001). Among patients with SLE, 23.8% reported asking their physician for lower-cost alternatives, compared with 15.6% among controls (P = .02). The researchers found disparities associated with income, race and health insurance status, but the main findings persisted after adjusting for these and other variables in multivariable models.
“Our data from this epidemiologic study reveal that SLE patients were more likely than controls from the general population to report cost-related non-adherence to prescriptions,” Minhas and colleagues wrote. “Disparities were found in association with income and health insurance status. Racial disparities were noted in strategies to reduce costs.”
“Overall, fewer than one in four patients asked providers for lower cost medications,” they added. “These findings point to the importance of physicians trying to ascertain adherence and being aware of medication costs to individual patients when planning treatment changes and prescribing medications, which could provide a meaningful avenue for improving medication access and adherence through shared decision-making.”
Perspective
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Many rheumatologists share similar frustrations in our journey to provide optimal care for patients with chronic autoimmune conditions such as SLE. Although we take pride in our careful, thoughtful selection of therapeutic agents, which we firmly believe will minimize the short- and long-term sequela of the immune dysregulation, the facts unfortunately reveal that some patients lack access to therapies or fail to adhere to the regimen over the long haul.
In their study, Minhas and colleagues sought to ascertain the specific demographics and characteristics associated with nonadherence within a sizeable cohort of SLE patients residing in southeast Michigan. Their survey revealed that access to medications, although unsurprisingly linked to insurer parameters, was not different overall when compared to the control group. On the other hand, skipping doses, taking less medication than prescribed, and/or delaying refills was significantly more common in the lupus cohort compared to the control cases and this was even more pronounced in younger patients and those without insurance.
Overall, lupus patients were nearly 2-3 times more likely to exhibit cost-related nonadherence and this remained significant even after adjusting for sex, race, age, insurance status and household income. In addition, although lupus patients were more likely than the control cohort to ask their provider for lower cost medication, less than one in four actually do so.
Previous studies have clearly demonstrated that nonadherence in lupus leads to worse outcomes, including more ED visits, hospitalizations and development of end stage renal disease. This report conveys important information for all who provide care to SLE patients, particularly chronic care, highlighting the challenges to maintain therapies over the long term. The data from this cohort point to cost-related factors and insurance status as major obstacles in this regard. In addition, communication between provider and patient clearly needs improvement to optimize long term therapy.
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Laura P. Kimble, PhD, RN, FNP-C, CNE, FAHA, FAAN
Adherence to prescriptions is a critical component of SLE patients’ self-management of their illness. Data from this study support that SLE patients had higher non-adherence to prescription medications related to cost than the general population. Overall, patients were reticent about raising the issue of prescription costs with providers.
It is important that providers be proactive in asking patients about financial resources related to prescription medications, be willing to consider different and lower-cost treatment options and work collaboratively with patients to prescribe a medication regimen that is affordable.
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