EDITORIAL

Too Important to Fail

The societal and economic costs of medical nonadher-ence in the United States each year are staggering: at

least 10% of all hospital admissions, significant increasesin morbidity, and approximately 125,000 deaths, all at acost of between $100 and $289 billion.1 Efforts to bettercharacterize, understand, and reduce medical nonadher-ence are part of large-scale initiatives—supported by bothprivate and public organizations—to improve the overallquality of medical care. In a recent analysis of broadlydefined interventions to improve medication adherence,factors such as reduced out-of-pocket expenses, case man-agement, and patient education with behavioral supportwere all shown to be effective for >1 condition.1 Identi-fying effective, large-scale interventions to reduce medicalnonadherence for specific conditions, however, has beenmore challenging.

In the current issue of Annals of Neurology, Levine etal2 hypothesized that cost-related nonadherence (CRN) tomedications in stroke survivors would increase in youngersurvivors (aged 45–64 years), increase in the uninsured(aged 45–64 years), and decrease in patients with Medi-care and access to the Part D drug benefit. In an earliercross-sectional survey among Medicare beneficiaries,implementation of Part D resulted in decreased CRN andreduced use of household income for medications ratherthan basic needs.3 Medicare enrollees in Part D have alsobeen shown to have increased drug utilization and reducedout-of-pocket expenditures when compared to eligiblenonenrollees.4 Others have demonstrated that reducingmedication costs by eliminating copayments can improveadherence and decrease adverse outcomes in specificpopulations.5

In their analysis, however, Levine et al2 found thatimplementation of Part D did not reduce CRN in strokesurvivors aged �65 years. CRN was actually 2-foldhigher among Part D enrollees compared with nonenroll-ees; this was attributed to the observation that early Med-icare Part D adopters tend to have higher risks for CRN:less education, poor health status, low income, and lessprivate insurance. The authors speculated that the imple-mentation of Part D may have mitigated the negativeimpact of the economic recession on CRN in olderstroke survivors; in other words, things could have beenworse.

In younger stroke survivors, things actually wereworse. In stroke survivors aged 45 to 64 years, CRNincreased significantly between the years 1999–2005 and

2006–2010, effectively doubling from 13% to 27%. Forthose younger stroke survivors without insurance, rates ofCRN increased from 43% to 57% across the same timehorizon. These findings underscore previous observationsthat younger patients with lower incomes, higher medica-tion costs, and chronic disabling illnesses such as strokeare particularly vulnerable to economic crises and declin-ing household income. Furthermore, rates of CRN inthis population are seemingly imperturbable to policychanges such as Medicare Part D. Finally, in the currentstudy, even if enrollment in Medicare Part D had beeneffective in lowering CRN, only 38% of eligible individ-uals in this age group were enrolled, thereby diminishingready access to insurance coverage that in turn couldreduce out-of-pocket medication expenditures.

Despite its mixed results, this paper adds signifi-cantly to the growing body of literature examining medi-cal nonadherence. The high cost of medication is widelyaccepted as a major contributor to medical nonadher-ence, and policy initiatives such as the Medicare Part Dprogram were designed primarily to reduce those costs.Accordingly, as gauged by overall reductions in rates ofCRN, Part D has achieved some level of success.6 Never-theless, problem areas remain. Medicare beneficiarieswith poor health, multiple chronic conditions, or depres-sion6 continue to have high rates of CRN, and manyindividuals continue to struggle with gaps in coverage;stroke survivors clearly comprise a unique and challeng-ing group in this heterogeneous population. Patients withstroke incur significant disability, utilize substantialresources in recovery, endure marked reductions in pro-ductivity, take a large number of medications, andaccordingly spend a large portion of their family incomeon health care.7,8

Reducing CRN is but 1 strategy proposed inresponse to calls for comprehensive approaches to nar-rowing the gap between evidence-based guidelines andwidespread implementation of effective treatments forstroke prevention.9–11 Challenges in achieving this goalare profound and varied: limited access to care, racial/ethnic disparities, lack of awareness of risk factors, inad-equate mechanisms for providing preventive care, and ofcourse medical nonadherence.12–14 Clearly, gains havebeen made in better understanding the causes of nonad-herence,15,16 and effective programs exist for improvingadherence in both inpatient and outpatient settings.17,18

Use of specific performance improvement tools,

VC 2013 American Neurological Association 153

treatment algorithms, behavioral interventions, andpatient educational materials have all been associatedwith improved adherence.15–18 Nevertheless, Levine et al2

have illustrated that stroke survivors, both young andold, pose unique challenges and may not realize the ben-efits of otherwise effective national policies.

Efforts are underway to improve these policies on alarge scale. For example, the Affordable Care Act hasstrengthened Medicare Part D by shrinking the “donuthole” and reducing out-of-pocket costs for medications forbeneficiaries through rebates, discounts on brand medica-tions, and broader generic drug coverage. Attention shouldalso be focused on other innovative strategies—tailored forpatients with stroke—for improving adherence, such as theMedicare Advantage program, utilizing e-prescribing sys-tems, and realigning payment structures and physicianincentives within accountable care organizations, along withlowering the out-of-pocket costs for medications. Approach-ing medical noncompliance is similar to treating patientswith cerebrovascular disease; the burden is heavy, the costhigh, the causes many, and the treatments multifaceted.

Potential Conflicts of Interest

R.G.H.: consultancy, American Academy of Neurology,Milliman Guideline.

Curtis G. Benesch, MD, MPH

and Robert G. Holloway, MD, MPH

Department of Neurology

University of Rochester Medical Center

Rochester, NY

References1. Viswanathan M, Golin CE, Jones CD, et al. Interventions to

improve adherence to self-administered medications for chronicdiseases in the United States. Ann Intern Med 2012;157:785–795.

2. Levine DA, Morgenstern LB, Langa KM, et al. Recent trends incost-related medication nonadherence among stroke survivors inthe United States. Ann Neurol 2013;73:180–188.

3. Madden JM, Graves AJ, Zhang F, et al. Cost-related medicationnonadherence and spending on basic needs following implemen-tation of Medicare Part D. JAMA 2008;299:1922–1928.

4. Yin W, Basu A, Zhang JX, et al. The effect of the Medicare Part Dprescription benefit on drug utilization and expenditures. AnnIntern Med 2008;148:169–177.

5. Choudry NK, Patrick AR, Antman EM, et al. Cost-effectiveness ofproviding full drug coverage to increase medication adherence inpost-myocardial infarction in Medicare beneficiaries. Circulation2008;117:1261–1268.

6. Kennedy JJ, Maciejewski M, Liu D, Blodgett E. Cost-related non-adherence in the Medicare Program: the impact of Part D. MedCare 2011;49:522–526.

7. Ostwald SK, Wasserman J, Davis S. Medications, comorbidities,and medical complications in stroke survivors: the CAReS study.Rehabil Nurs 2006;31:10–14.

8. Banthin JS, Bernard DM. Changes in financial burdens for healthcare: national estimates for the population younger than 65 years,1996 to 2003. JAMA 2006;296:2712–2719.

9. Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the preventionof stroke in patients with stroke or transient ischemic attack: aguideline for healthcare professionals from the American HeartAssociation/American Stroke Association. Stroke 2011;42:227–276.

10. National Institutes of Health Roadmap. Available at: http://commonfund.nih.gov/aboutroadmap.aspx Accessed December, 2012.

11. Committee on Quality of Health Care in America, Institute ofMedicine. Crossing the quality chasm: a new health system for the21st century. Washington, DC: National Academy Press, 2001.

12. Earnest MP, Norris JM, Eberhardt MS, Sands GH; Task Force onAccess to Health Care of the American Academy of Neurology.Report of the AAN Task Force on access to health care: the effectof no personal health insurance on health care for people withneurologic disorders. Neurology 1996;46:1471–1480.

13. Kenton EJ III, Gorelick PB, Cooper ES. Stroke in elderly African-Americans. Am J Geriatr Cardiol 1997;6:39–49.

14. Holloway RG, Benesch C, Rush SR. Stroke prevention: narrowingthe evidence-practice gap. Neurology 2000;54:1899–1906.

15. Bushnell CD, Olson DM, Zhao X, et al. Secondary preventivemedication persistence and adherence 1 year after stroke. Neurol-ogy 2011;77:1182–1190.

16. Bushnell CD, Zimmer LO, Pan W, et al. Persistence with strokeprevention medications 3 months after hospitalization. Arch Neu-rol 2010;67:1456–1463.

17. Schwamm LH, Fonarow GC, Reeves MJ, et al. Get With theGuidelines-Stroke is associated with sustained improvement incare for patients hospitalized with acute stroke or transient ische-mic attack. Circulation 2009:119:107–115.

18. Ovbiagele B, Saver JL, Fredieu A, et al. In-hospital initiation ofsecondary stroke prevention therapies yields high rates of adher-ence at follow-up. Stroke 2004;35:2879–2883.

DOI: 10.1002/ana.23848

ANNALS of Neurology

154 Volume 73, No. 2