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Strategies for Addressing the Cost of Nonadherence in Diabetes
Candis M. Morello, PharmD, CDE, and Jan D. Hirsch, BSPharm, PhD
Utilizing Advances in Diabetes and Targeting Medication Adherence to Enhance Clinical Outcomes and Manage Costs for Type 2 Diabetes Posttest

Strategies for Addressing the Cost of Nonadherence in Diabetes

Candis M. Morello, PharmD, CDE, and Jan D. Hirsch, BSPharm, PhD
Patient-Related Barriers to Treatment Adherence
Patient-related barriers include patient demographics, such as age, gender, ethnicity, level of education, sociocultural factors, socioeconomic status, marital status, comorbid conditions, fear, or health beliefs.3,9,10,14 An interesting study highlights how a combination of demographics can differentially impact adherence. A study of Hispanic men and women with diabetes showed that Hispanic women were less likely to receive treatment support and faced greater barriers to treatment than Hispanic men. Among Hispanic women, perceived support was significantly associated with better self-efficacy, which in turn was significantly associated with better self-care adherence.14

Health literacy and medication beliefs, along with the patient’s knowledge of the disease and its treatment, also play an important role in whether the patient will adhere to the treatment regimen.9 Positive attitudes tend to be associated with better adherence outcomes.12 One survey of patients with T2D showed that beliefs about treatment benefit were significantly associated with the intent to adhere to treatment, while negative beliefs were associated with reduced medication adherence.15 Disease education plays a crucial role in how the patient views the disease and its perceived threat.9 However, knowledge of diabetes alone is not sufficient for successful self-management.12 Studies of patients with diabetes consistently show that knowledge of diabetes is not the only factor related to adherence to self-care, diet, exercise, or medication. Confidence, motivation, and access to care also play important roles.9,12 Finally, comorbidities and behavioral factors, such as cognitive function, mental illness, stress, and substance abuse, are important patient factors that determine adherence.9,10

Provider-Related Barriers to Treatment Adherence
Healthcare providers play a key role in treatment adherence through their relationship with the patient. Creating an environment that is patient centered, ensuring open communication and providing patient education, can help patients successfully overcome barriers to adherence.3,9,10 Ensuring that patients meet their follow-up appointments and have adequate support and patient monitoring are important factors in providing effective healthcare and encouraging patients to adhere to treatment.9 Systematic patient assessment methods, such as the medication therapy management (MTM) Spider Web, which explicitly considers patient adherence as among the many factors affecting clinical outcomes, can be helpful for training clinicians to consistently integrate adherence considerations into patient-centered care plans that promote, not hinder, patient adherence.11

External Barriers to Treatment Adherence
External factors can be related to the disease or the treatment itself.9,10 The severity of the disease, its duration, and response to treatment all play important factors that influence a patient’s perception of their disease and likelihood of adherence. Factors related to the medication are some of the most common reasons for nonadherence to insulin treatment. These include regimen complexity, pain and fear associated with injections, cost, access to care, or adverse effects.3,9,10,13 A cross-sectional study of 507 patients with diabetes demonstrated that only 22.3% of patients with type 1 diabetes and 24.9% of patients with T2D had high adherence to treatment.16 Adverse events related to the treatment, including injection-site reactions, feeling worse after insulin injection, and weight gain, were significantly associated with low adherence (P <.01).16 Insulin shortage, cost, and difficulties in preparing the injection were also significantly associated with low adherence (P ≤.01).16

Cost of treatment, particularly for patients with a low socioeconomic status, may be a limiting factor to medication adherence.12 Studies have shown that the cost of diabetes treatment may result in newly diagnosed patients not seeking medical care after a diagnosis, or inconsistent or inappropriate use of medication.12

A bivariate and regression analysis of the 2011-2013 Medical Expenditure Panel Survey and the National Health Interview Survey 2012-2014 showed that, among privately insured adults with diabetes, comparing individuals with no deductible with those with a low deductible (<$1000 for an individual or <$2400 for a family), the low-deductible group had 27% fewer primary care visits, 39% fewer checkups, and 77% fewer specialty care visits.17 This disparity was even greater when comparing individuals with no deductible to those with a high deductible (>$1000 for an individual or >$2400 for a family). Those with a high deductible had 42% fewer primary care visits, 65% fewer checkups, and 86% fewer specialty care visits. Lower-income patients can also be those with greater medication usage rates, making cost barriers of possibly greater consequence. A study using MarketScan data revealed that for patients with diabetes using insulin, the Medicare-Medicaid dual-eligible group had higher overall medication usage (87.0 vs 54.4 mean annual prescription claims, P <.001) and insulin usage (8.6 vs 5.7 mean annual prescription claims, P <.001) than the more affluent traditional Medicare patients.18

It is important to educate patients that saving some money today by nonadherence to treatment may mean spending much more money in the future. For patients with diabetes, nonadherence can increase risk for all-cause hospitalization (odds ratio [OR]: 1.58; P <.001) and can increase risk for all-cause mortality (OR: 1.81; P <.001).19 Studies have also shown that lack of medication adherence can result in approximately 3 times higher hospitalization rates and almost double the associated healthcare costs.20,21 The results of one retrospective study showed that the annual healthcare cost for a low-adherence (between 1% and 19% adherence) patient with T2D was $16,498 compared with $8886 for a high-adherence (between 80% and 100%) patient.21 In addition, the risk of hospitalization was 25% less for high-adherence patients with T2D. This study also demonstrated that a 20% increase in adherence can save $1074 in total healthcare spending for each patient with T2D.21

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