Too important to fail

The societal and economic costs of medical nonadherence in the United States each year are staggering: at least 10% of all hospital admissions, significant increases in morbidity, and approximately 125,000 deaths, all at a cost of between $100 and $289 billion. Efforts to better characterize, understand, and reduce medical nonadherence are part of large-scale initiatives—supported by both private and public organizations—to improve the overall quality of medical care. In a recent analysis of broadly defined interventions to improve medication adherence, factors such as reduced out-of-pocket expenses, case management, and patient education with behavioral support were all shown to be effective for >1 condition. Identifying effective, large-scale interventions to reduce medical nonadherence for specific conditions, however, has been more challenging. In the current issue of Annals of Neurology, Levine et al hypothesized that cost-related nonadherence (CRN) to medications in stroke survivors would increase in younger survivors (aged 45–64 years), increase in the uninsured (aged 45–64 years), and decrease in patients with Medicare and access to the Part D drug benefit. In an earlier cross-sectional survey among Medicare beneficiaries, implementation of Part D resulted in decreased CRN and reduced use of household income for medications rather than basic needs. Medicare enrollees in Part D have also been shown to have increased drug utilization and reduced out-of-pocket expenditures when compared to eligible nonenrollees. Others have demonstrated that reducing medication costs by eliminating copayments can improve adherence and decrease adverse outcomes in specific populations. In their analysis, however, Levine et al found that implementation of Part D did not reduce CRN in stroke survivors aged 65 years. CRN was actually 2-fold higher among Part D enrollees compared with nonenrollees; this was attributed to the observation that early Medicare Part D adopters tend to have higher risks for CRN: less education, poor health status, low income, and less private insurance. The authors speculated that the implementation of Part D may have mitigated the negative impact of the economic recession on CRN in older stroke survivors; in other words, things could have been worse. In younger stroke survivors, things actually were worse. In stroke survivors aged 45 to 64 years, CRN increased significantly between the years 1999–2005 and 2006–2010, effectively doubling from 13% to 27%. For those younger stroke survivors without insurance, rates of CRN increased from 43% to 57% across the same time horizon. These findings underscore previous observations that younger patients with lower incomes, higher medication costs, and chronic disabling illnesses such as stroke are particularly vulnerable to economic crises and declining household income. Furthermore, rates of CRN in this population are seemingly imperturbable to policy changes such as Medicare Part D. Finally, in the current study, even if enrollment in Medicare Part D had been effective in lowering CRN, only 38% of eligible individuals in this age group were enrolled, thereby diminishing ready access to insurance coverage that in turn could reduce out-of-pocket medication expenditures. Despite its mixed results, this paper adds significantly to the growing body of literature examining medical nonadherence. The high cost of medication is widely accepted as a major contributor to medical nonadherence, and policy initiatives such as the Medicare Part D program were designed primarily to reduce those costs. Accordingly, as gauged by overall reductions in rates of CRN, Part D has achieved some level of success. Nevertheless, problem areas remain. Medicare beneficiaries with poor health, multiple chronic conditions, or depression continue to have high rates of CRN, and many individuals continue to struggle with gaps in coverage; stroke survivors clearly comprise a unique and challenging group in this heterogeneous population. Patients with stroke incur significant disability, utilize substantial resources in recovery, endure marked reductions in productivity, take a large number of medications, and accordingly spend a large portion of their family income on health care. Reducing CRN is but 1 strategy proposed in response to calls for comprehensive approaches to narrowing the gap between evidence-based guidelines and widespread implementation of effective treatments for stroke prevention. Challenges in achieving this goal are profound and varied: limited access to care, racial/ ethnic disparities, lack of awareness of risk factors, inadequate mechanisms for providing preventive care, and of course medical nonadherence. Clearly, gains have been made in better understanding the causes of nonadherence, and effective programs exist for improving adherence in both inpatient and outpatient settings. Use of specific performance improvement tools,