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March 31, 2020; 94 (13) Article

Association of out-of-pocket costs on adherence to common neurologic medications

View ORCID ProfileEvan L. Reynolds, James F. Burke, Mousumi Banerjee, Kevin A. Kerber, Lesli E. Skolarus, Brandon Magliocco, Gregory J. Esper, View ORCID ProfileBrian C. Callaghan
First published February 19, 2020, DOI: https://doi.org/10.1212/WNL.0000000000009039
Evan L. Reynolds
From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA.
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  • ORCID record for Evan L. Reynolds
James F. Burke
From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA.
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Mousumi Banerjee
From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA.
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Kevin A. Kerber
From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA.
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Lesli E. Skolarus
From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA.
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Brandon Magliocco
From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA.
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Gregory J. Esper
From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA.
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Brian C. Callaghan
From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA.
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Association of out-of-pocket costs on adherence to common neurologic medications
Evan L. Reynolds, James F. Burke, Mousumi Banerjee, Kevin A. Kerber, Lesli E. Skolarus, Brandon Magliocco, Gregory J. Esper, Brian C. Callaghan
Neurology Mar 2020, 94 (13) e1415-e1426; DOI: 10.1212/WNL.0000000000009039

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Abstract

Objective To determine the association between out-of-pocket costs and medication adherence in 3 common neurologic diseases.

Methods Utilizing privately insured claims from 2001 to 2016, we identified patients with incident neuropathy, dementia, or Parkinson disease (PD). We selected patients who were prescribed medications with similar efficacy and tolerability, but differential out-of-pocket costs (neuropathy with gabapentinoids or mixed serotonin/norepinephrine reuptake inhibitors [SNRIs], dementia with cholinesterase inhibitors, PD with dopamine agonists). Medication adherence was defined as the number of days supplied in the first 6 months. Instrumental variable analysis was used to estimate the association of out-of-pocket costs and other patient factors on medication adherence.

Results We identified 52,249 patients with neuropathy on gabapentinoids, 5,246 patients with neuropathy on SNRIs, 19,820 patients with dementia on cholinesterase inhibitors, and 3,130 patients with PD on dopamine agonists. Increasing out-of-pocket costs by $50 was associated with significantly lower medication adherence for patients with neuropathy on gabapentinoids (adjusted incidence rate ratio [IRR] 0.91, 0.89–0.93) and dementia (adjusted IRR 0.88, 0.86–0.91). Increased out-of-pocket costs for patients with neuropathy on SNRIs (adjusted IRR 0.97, 0.88–1.08) and patients with PD (adjusted IRR 0.90, 0.81–1.00) were not significantly associated with medication adherence. Minority populations had lower adherence with gabapentinoids and cholinesterase inhibitors compared to white patients.

Conclusions Higher out-of-pocket costs were associated with lower medication adherence in 3 common neurologic conditions. When prescribing medications, physicians should consider these costs in order to increase adherence, especially as out-of-pocket costs continue to rise. Racial/ethnic disparities were also observed; therefore, minority populations should receive additional focus in future intervention efforts to improve adherence.

Glossary

CCI=
Charlson comorbidity index;
CDSS=
clinical decision support systems;
ICD-9=
International Classification of Diseases–9;
ICD-10=
International Classification of Diseases–10;
IRR=
incidence rate ratio;
MPR=
medication possession ratio;
OOP=
out-of-pocket;
PD=
Parkinson disease;
SMD=
standardized mean difference;
SNRI=
serotonin/norepinephrine reuptake inhibitor

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • CME Course: NPub.org/cmelist

  • Received May 28, 2019.
  • Accepted in final form November 4, 2019.
  • © 2020 American Academy of Neurology
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Disputes & Debates: Rapid online correspondence

  • Author response: Association of out-of-pocket costs on adherence to common neurologic medications
    • Brian C. Callaghan, Neurologist, University of Michigan
    Submitted April 14, 2020
  • Reader response: Association of out-of-pocket costs on adherence to common neurologic medications
    • Khichar Shubhakaran, Professor and Head Neurology, Dr.S.N. Medical College, Dr. S.N. Medical College (Jodhpur, India)
    Submitted April 05, 2020
  • Author response: Association of out-of-pocket costs on adherence to common neurologic medications
    • Brian C. Callaghan, Neurologist, University of Michigan
    Submitted March 19, 2020
  • Reader response: Association of out-of-pocket costs on adherence to common neurologic medications
    • Nitin K. Sethi, Associate Professor of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center (New York, NY)
    Submitted March 09, 2020
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