Transcript Decline CPAP treatment

First Study
The effect of drug co-payment policy on the
purchase of prescription drugs for children with
infections in the community
Haim Reuveni, MD
Health Policy 62 (2002) 1–13
Department of Health Policy and Management, Faculty of Health Sciences,
Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Introduction
• Co-payment (CP) policy - patients cover part of
treatment cost
• CP policy reduces expenditures of the insurance
carrier and unnecessary use of services
• CP reduce consumption of the medical care,
prescribed drugs mainly among low SES people
• CP cause deterioration in health state.
• Each 10% increase in CP is associated with an
8.7% decrease in total per-episode expenditure
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Aims
To examine the effect CP on the purchase of
prescribe drugs in children with acute
infectious diseases.
This was preformed in community settings
(Pediatric Health Center in the city of Kiryat-Gat)
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Objectives
1. To calculate the rates of partial or non-purchase
of antibiotics (WHO classification).
2. To assess the association between the number &
cost of prescribe drugs and the non or partial
purchase of the drugs.
3. To identify factors that can predict non or partial
purchase of prescribe drugs due to cost
considerations.
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Methods
Design: Cross-sectional study.
Setting: The Pediatric Health Center in the city of Kiryat-Gat
one of Israel’s poorest cities (high unemployment rate).
The pediatric clinic has:
a registry of 6500 children
an average of 200 visits per day.
5 pediatricians.
Data collection was for 6-weeks in May to June 1999.
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Study population
• Included: Children and adolescents aged 0–18 years,
diagnosed by a pediatrician with an acute infectious disease
for which drugs, including antibiotics, were prescribed.
• Excluded: children and adolescents that:
(1) already taking antibiotic drugs
(2) diagnosed for an acute infectious disease, but did
not receive a prescription
(3) received a prescription which did not include antibiotics.
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Data sources
1) The computerized patient visit reports
(I.e. demographics, type of drug,
dosage, date of prescription).
2) The computerized drug dispensing
reports from the clinic’s pharmacy.
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Three study groups were defined:
Full purchase- All drugs prescribed were issued by
the pharmacy.
Partial purchase- Some of the drugs and/or
amounts were issued.
Non-purchase- None of the prescribed drugs were
issued within 7 days of prescription date.
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Study protocol
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Results
During the 6-week study period, antibiotics were prescribed for the following
acute infections
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Conclusions:
• CP is a serious barrier for purchasing the
prescribed medication for children with acute
infections.
• The policy has a particularly deleterious effect in
under-privileged populations.
• CP policy is in contradiction with the proclaimed
principles of justice and equality underlying the
obligatory Israeli National Health Insurance Law.
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The incomplete purchase (partial treatment) of
antibiotics may:
• lead to an extended period of symptoms.
• Development of long-term complications such as
meningitis and rheumatic fever.
The role of partial antibiotic treatment in the
development of antibiotic resistance is not clear.
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More questions…….
• What are the drug purchasing patterns when several family
members are concurrently ill.
• What is the long-term clinical outcome for these children?
• What is the consequent extent of medical care utilization by these
children?
• How can we define a “reasonable level ” of CP ?
for essential drugs or other treatments…….. Zero CP?
for different layers of income……….. Partial/Full CP?
Further studies are required……….
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More research
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2nd Study
Determinants affecting initiation of continuous positive
airway pressure treatment.
Brin YS, Reuveni H, Greenberg S, Tal A, Tarasiuk A.
Isr Med Assoc J. 2005 Jan;7(1):13-8.
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PSG study
Diagnosis
Titration
study
CPAP
adaptation
Purchasing
Purchased
Adaptation
Acceptance
OSAS (+)
(N=128, 32%)
(N=183, 46%)
(N=324, 81%)
(N=400, 100%)
OSAS (-)
Declined
Declined
Declined
(N=76, 19%)
(N=141, 35%)
(N=55, 14%)
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Refused adaptation
70
Number of Patients (%)
60
Declined purchasing
Purchased CPAP
50
40
30
20
10
0
very low
low
mean
high
very high
Monthly income
Brin et al Figure 2
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3d Study
The effects of co-payment policy on compliance with
medical technologies: The case of chronic CPAP treatment
in patients with OSAS requiring continuous positive airway
pressure (CPAP) therapy
Haim Reuveni1, Ariel Tarasiuk2
Supported by Grant from the Israeli Institute for Health Policy
and Health Services Research, award no. A/147/2003.
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Introduction
• CPAP device is provided free of charge in countries such
as Germany, the United Kingdom, several parts of
Canada and by some health care providers in the USA.
• In these countries, treatment initiation and long-term
compliance were found to be more than 70%.
• In Israel, results strongly suggest that sharing the cost
of CPAP is a potential barrier to purchase CPAP.
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Main Objective
To develop a model for decision-makers to determine
CP policy for CPAP
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Specifically
1) To compare compliance rates according to CP policy with
that of other industrialized countries
2) To determine the cost-effectiveness of CPAP therapy.
3) To compare compliance rate to CPAP before (full CP) and
after change (partial CP) in CP policy.
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Group 1- Declining CPAP. 1a- CPAP will be re-offered CPAP with partial CP.
1b- CPAP will not re-offered
Group 2- Commencing CPAP.
Group 3- New patients, minimal CP.
followed-up for 12 m
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LOW SOCIOECONOMIC STATUS IS A RISK FACTOR
FOR CPAP ACCEPTANCE AMONG ADULT OSAS
PATIENTS REQUIRING TREATMENT
Submitted for publication
Tzahit Simon-Tuval, Haim Reuveni, Sari Greenberg,
Arie Oksenberg , Asher Tal, Ariel Tarasiuk
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PSG study
(n=278)
Requiring CPAP
treatment
Not requiring CPAP
treatment
(n=162)
(n=116)
Commence CPAP
treatment
Decline CPAP
treatment
(n=65, 40%)
(n=97, 60%)
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Patients Recruitment
PSG study
Questioner 1
CPAP Titration
CPAP Adaptation
Patient decision
Conclusion of
Adaptation
Accepting
Questioner 2
Declining
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Characteristics of OSAS Patients
OSA patients OSA patients
not requiring
requiring
CPAP
CPAP
p
value
n
116
162
Males (%)
55.2
74.7
0.001
Age (years)
49.7±13.2
54.9±12.0
0.0007
BMI (kg/m2)
30.3±7.3
32.3±5.4
0.01
HTN and/or CVD
(prevalence)
37.9%
58.02
<0.0001
Income
Low
30.4%
31.8%
0.562
Average
49.1%
43.1%
High
20.5%
25.2%
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Reasons for purchasing CPAP
Reasons for purchasing CPAP device
CPAP
purchasing
% patients
(n=60)
It solved my snoring problems
78%
It reduced by daytime sleepiness
78%
It improved my Sleep
59%
My physician and sleep laboratory team to convinced me
53%
Encouragement from partner
53%
Will improve my associated morbidity
35%
This is the best treatment available for me
33%
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Reasons for declining CPAP
Reasons for Declining CPAP device
CPAP
Declining
% patients (n=102)
I tried and could not adapt
38%
I am Interested in other treatments
31%
CPAP cost is too expensive
29%
I have side effects
28%
I feel better and don’t need this treatment
13%
Not encouraged by my partner
10%
Not encouraged by my physician
6%
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Determinants of OSAS Patients Requiring and
Accepting CPAP Treatment (n=162)
Variable
Univariate
analysis
Multivariate
analysis
OR
95% CI
OR
95% CI
Income (low, medium, high)
2.03
1.3-3.2
2.4
1.2-4.6
Age (year +1)
1.05
1.02-1.1
1.07
1.01-1.1
BMI (+1 Kg/m2)
1.02
0.96-1.1
0.98
0.9-1.1
AHI (≥35 vs. <35 events/hr)
3.0
1.54-5.7
4.2
1.4-12.0
ESS (≥10 vs. <10 score)
0.66
0.35-1.3
0.9
0.3-2.3
Partner sleeps separately (yes vs. no)
2.4
1.1-5.1
4.3
1.4-13.3
Family and/or friends experience
with CPAP (yes vs. no)
2.5
1.1-5.4
2.9
1.1-7.5
Income – individual income level; BMI body mass index; AHI – Apnea-Hypopnea Index; ESS –
Epworth Sleepiness Scale score; CVD – Cardiovascular Disease; HTN – Hypertension; Area under
the ROC 82% for patients living with partner.
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Thank You !
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