One in six adults with asthma did not follow their treatment because of the cost

— They were also more likely to have asthma attacks and visit the emergency room

by Sophie Putka, Corporate and investigative writer, MedPage Today December 9, 2024

Despite a downward trend, the number of U.S. adults who report not adhering to their asthma treatment because of costs remains high, an observational study finds.

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From 2011 to 2022, the prevalence of cost-related nonadherence decreased from 23.2 % to 13.1 %. However, about one in six adults with asthma (17.8 %) reported not adhering to their asthma medications in the previous year because of cost, reported Dr. Chung-Hsuen Wu, from Taipei Medical University in Taiwan, and colleagues in Thorax.

Wu told MedPage Today that his team was “very surprised that the cost-related events went down in the past 12 years — however, cost-related events are still a problem for patients with asthma. »

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“And you can see from our study that, compared to patients without cost-related non-adherence, patients with cost-related non-adherence … are more likely to have asthma attacks and ER visits,” he added.

Indeed, adults with asthma who reported skipping or delaying taking asthma medications due to cost had significantly higher odds of having asthma attacks (adjusted OR 1.95, 95% CI 1.78-2.13) and asthma emergency department visits (adjusted OR 1.63, 95% CI 1.44-1.84) compared with patients who did not report cost-related nonadherence.

Next to 8 % of the American population suffers from asthma, making it one of the most common chronic diseases, with a heavy economic and societal burden. Financial hardship is a major factor in high rates of nonadherence to asthma medications, which have ranged from 22 % to 66 % in past estimates. When patients delay or skip doses in an effort to save money, they may be at higher risk of hospitalization.

Younger and female patients were significantly more likely to report cost-related nonadherence. Individuals who were non-Hispanic, lived in the South, had less than a high school education, lacked health insurance, reported low income, smoked, had poor health perceptions, and were single or living alone were also more likely to report cost-related nonadherence to asthma medications.

Wu also noted that the "near-poor," who have incomes just above the federal poverty line and may not be eligible for Medicaid, had the greatest cost-related nonadherence.

Accordingly, co-author Chun-Tse Hung, PharmD, also of Taipei Medical University, said at MedPage Today that the decline in this problem in recent years could be due to the Affordable Care Act (ACA) of 2010 and the expansion of Medicaid, "so the financial burdens [for] some kinds of patients might decrease, so they have less financial burden to receive these medications."

Emily Graul, of Emory University School of Medicine in Atlanta, and Christer Janson, PhD, of Uppsala University in Sweden, pointed out in a accompanying editorial the "greater burden" of the problem in the southern United States

“These results should be contextualized by history and the present,” they wrote. “The legacy of racism and inequality built within healthcare, labor, and unionization policy in the South has contributed to higher proportions of people being uninsured and facing cost-related barriers to healthcare. »

They also noted that the recent Medicare drug price negotiation program of the Inflation Reduction Act reduced drug costs for some chronic conditions, but not for asthma, adding: "The results of this study beg the question: Should certain asthma medications be part of the next batch of drug negotiations?"

Wu stressed that health care providers should consider cost, not just treatment effects, when prescribing asthma medications.

The researchers used data from the 2011 to 2022 National Health Interview Survey (NHIS), which includes information from questionnaires administered by trained interviewers. Adults with current asthma were included. A total of 2,985,882 participants reported cost-related nonadherence to asthma treatment, defined as answering “yes” to one of three questions:

• Have you skipped any medication doses to save money in the past 12 months?
• Have you taken fewer medications to save money in the past 12 months?
• Have you delayed refilling your medications to save money in the past 12 months?

To assess asthma-related adverse events, researchers used responses to questions about asthma attacks and emergency room or urgent care visits due to asthma in the past 12 months. To assess factors associated with cost-related treatment nonadherence, researchers included covariates such as age, sex, race/ethnicity, region, education level, health insurance, poverty status, employment status, and various health indicators.

The authors were limited by the NHIS data, which are self-reported, and did not include information on asthma severity. The study design meant that the results could not be interpreted as causal. The researchers also could not include variables that reflect economic indicators, such as the Consumer Price Index. It is also possible that cost-related medical adherence has more to do with other comorbidities and not asthma, because the questions were broad.