Hme601972 1.5

Original Research Health Services Research andManagerial Epidemiology Medicines Compliance and 1-5ª The Author(s) 2015 Reimbursement Level in Portugal Reprints and permission:DOI: 10.1177/2333392815601972 Maria da Conceic¸a˜o Constantino Portela1and Adalberto Campos Fernandes2 AbstractDuring a severe financial crisis, it is a priority to use scientific evidence to identify factors that enable therapeutic complianceby patients. This study aimed to evaluate a possible association between the number of patients who attended a medicalappointment and had medicine prescribed and the number of these same patients who purchased the prescribed medicine andwhether the level of reimbursement was a deciding factor. We perform a correlation analysis at primary care centers in Portugal,between 2010 and 2012 (n ¼ 96). We found a moderate to high positive association, which is statistical significant, between thenumber of the patients with medicines dispensing and medicines reimbursement levels. The correlation coefficient varies from.5 to .63 (P < .01). The compliance increases along with the increase in the reimbursement levels.
Keywordsaccess to care, community health centers, efficiency, health economics, primary care A Conceptual Perspective During a severe financial crisis, it is a priority to use scientific On an individual basis, ‘‘adherence to medical therapy (the evidence to identify factors that enable therapeutic compliance, extent to which recommendations are followed as defined) is based on the following main drivers: information to the patients a complex and dynamic behavioural process that is strongly about their illness, motivation, and behavioral skills.1,2 Among influenced by the patient, his or her support environment, prac- the latter is the ability to comply with a medical prescription tices of healthcare providers, and the characteristics of care when prescribed medicines are purchased by the patients. Eco- delivery systems'', pp.47.2 nomic factors can be a threat to medicines accessibility, the Reimbursement systems can alleviate patients from the reimbursement systems being part of the solution.
financial burden of diseases and promote therapeutic compli- This study aimed to evaluate reimbursement impact as an ance. However, adverse side effects should be avoided, mainly economic driver of therapeutic compliance. It considers a for lower income individuals, patients requiring polytherapy, possible association between the number of patients who and those with chronic diseases and sustained medical expen- attended a medical appointment, and had medicine pre- ditures. Indeed, ‘‘healthcare expenditure is a very important scribed, and the number of these same patients who purchased factor for patients with chronic diseases because the treatment the prescribed medicine and whether reimbursement level could be life-long so the cost of therapy would constitute a was a deciding compliance-related factor. Several studies large portion of their disposable income'', pp.282.7 have shown that therapeutic compliance increases healthbenefits,3-5 following which a decrease in health care-relatedexpenditure is expected.
In order to support medication compliance, health care sys- 1 Universidade Cato´lica Portuguesa, Palma de Cima, Lisboa, Portugal tems monitoring programs can be implemented. They should 2 Universidade Nova de Lisboa, Lisboa, Portugal involve all of the stakeholders—patients, medical doctors, and Corresponding Author: pharmacists—to ensure that health outcomes actually follow Maria da Conceic¸a˜o Constantino Portela, Universidade Cato´lica Portuguesa, prescribed therapeutic regimens, as pointed out by the World Palma de Cima, Lisboa, 1649-023, Portugal.
Health Organization.6 Creative Commons CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License(http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without furtherpermission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/open-access-at-sage).
Health Services Research and Managerial Epidemiology Therefore, it is critical to define copayment according to the prescribed medication as the cost of that medication increases. In expected therapeutic benefits in specific groups of patients, by these cases, discontinuation of either the ongoing or the begin- decreasing therapeutical costs and fostering health outcomes.8 ning of therapeutic medication negatively affected health The reimbursement system in Portugal is established accord- ing to disease severity, and the acute or chronic condition ofdiseases. The lower levels of copayment are applied to mild severity and acute diseases, being the highest ones related tosevere and chronic conditions.
Portuguese patients attending a medical appointment between There are 4 levels of reimbursement: level D, at15%, is the 2010 and the first half of 2012 at 64 public health care centers lowest one and includes medicines in a transitory situation in (Continental Portugal ACES) were identified. The sample which the price evaluation is still ongoing in terms of reimbur- includes patients with diagnosis related to the most prevailing sement; level C, at 37%, is for transitory and mild conditions; diseases in Portugal, which represent the highest percentage of level B, at 69%, includes medicines for moderate chronic public health costs: diabetes, hypertension, cerebrovascular diseases; and level A, at 95%, is for medicines prescribed for diseases, asthma, and ulcer disease, as displayed at Table 1.
severe chronic diseases. Insulin is a special case in level A, The number of patients with prescriptions has been col- benefitting from a 100% reimbursement. The prescription of lected from the Health System Central Office (Administrac¸a˜o medicines at public health care centers relies on national ther- Central do Sistema de Sau´de). Data concerning the number of apeutic guidelines published by the Department of Quality in patients with purchased prescribed medicines were obtained Health (Departamento da Qualidade na Sau´de) of the Health from the Invoice Checking Centre (Central de Conferˆencia Directorate (Direc¸a˜o Geral de Sau´de).
de Faturas). The percentage of variation between the numberof patients with prescriptions and the number who actually hadtheir medicines dispensed provides a measure of therapeutic An Empirical Perspective compliance in terms of prescribed medicines purchased.
A review of the literature shows 50% therapeutic compliance A conservative approach was taken with respect to the miss- in patients having chronic diseases in developed countries.6 ing data of patients who had had prescriptions and medicine However, these generic data do not identify the specific varia- dispensed during the second semester of 2012. We elected to tions in different pharmacotherapeutic groups and their associ- apply the same profiles as the previous years. The annual data ated health outcomes.
came to a total of 96 observations, a total of 32 observations When there is full compliance for hypertension, the risk of collected per year during the 3 years. They concern each one of cardiac ischemic disease decreases by 3 or 4-fold.9 Regarding the disease segments related to the 16 International Classifica- patients who experience a first myocardial infarction, those tion of Primary Care codes of diseases. Following a descriptive who had statin compliance lower than 80% had a more than longitudinal and retrospective analysis, we pursue with an esti- 4-fold increase in risk of recurrent myocardial infarction and mation of the normality presuppositions in order to conduct a a more than 2-fold higher risk of all cause mortality when compared to those who experienced an adherence equaled orhigher than 80%.2 For antidyslipidemic drugs 12 months after therapy initiation, a study reported adherence of 84% to 89%,but another study reported only 50%.10,11 For diabetes, it was A major asymmetry was observed concerning the number of found that only 28% of the patients in Europe achieved ade- patients in each of the identified segments, with patients having quate glycemic control.12 Similar results were found in patients arterial hypertension being the most numerous. Average num- with asthma using prophylactic therapy, while for patients using bers of 3 475 016 (standard deviation [SD] ¼ 323,481) patients maintenance therapy, the number reaches 30% to 70%.13,14 with medical prescriptions and 3 191 672 (SD ¼ 186,209) Financial factors are the most important reason for these results, patients with prescribed medicines dispensed by pharmacies followed by the number of different medicines prescribed for the were observed.
patient.15 Low levels of compliance reinforce the economic bur- Between 2010 and 2012, the average number of patients in the den related to the most common diseases.2 diabetes segment of the pharmacotherapeutic groups with medi- In Portugal, a study aimed at identifying the determinants cal prescriptions was 831 410 (SD ¼ 315 413), which decreased to for therapeutic compliance showed that the main reason for an average of 749 078 (SD ¼ 264 796) patients who purchased nonadherence was forgetfulness followed by ‘‘lack of economic their prescribed medicines in the pharmacy. For those taking resources/being more expensive,'' with the latter being the sec- antiplatelet, antiulcer, and antiasthmatic therapies, the average ond most stated reason. The third reason was not wanting to take number of patients with medical prescriptions was 73 418 the medicines or not liking the medication. However, the third (SD ¼ 79,563), 174 396 (SD ¼ 90,730), and 100 660 (SD ¼ factor remains the same as previously mentioned that of cost.
73,055), respectively. For the same segments, the average number This study also showed that about 33% of patients with chronic of patients with prescriptions who purchased the prescribed med- conditions ceased taking the prescribed medication for economic icines from a pharmacy was 76 990 (SD ¼ 92 135), 127 024 reasons.16 Further studies have shown a decrease in the intake of (SD ¼ 66 510), and 86 386 (SD ¼ 65 429), respectively (Table 2).
Constantino Portela and Campos Fernandes Table 1. Norms Issued by Health Directorate, code ICPC, Pharmacoterapeutic Group (PTG), and Associated Reimbursement Levels.
001/2011 Type 2 diabetes mellitus Non-insulin dependent diabetes therapy: metformin Oral antidiabetics 003/2010 Hypertension therapy: K86 Hypertension without complications 3.4.
Thiazides and similars 3.4.1.6. Association of diuretics 014/2011 Use and selection of K74 Ischemic heart disease with angina 4.3.1.4 Antiplatelet drugs antiplatelet drugs K75 Acute myocardial infarctionK76 Ischemic heart disease with anginaK89 Transient cerebral ischemicK90 StrokeK91 Cerebrovascular diseaseK92 Atherosclerosis/Peripheral 016/2011 Asthma control Adrenergic agonists b Cholinergic antagonists 036/2011 Acid suppression: use of D84 Esophagus disease 6.2.2.2 H2 receptor antagonists proton-pump inhibitors and D86 Peptic Ulcer, other 6.2.2.3 Proton-pump inhibitors therapeutic alternatives D87 Altered stomach functions Abbreviations: ICPC, International classification of primary care; PTG, Pharmacoterapeutic group, as established by Decree law 924-A/2010, September 17.
Table 2. Descriptive Statistics Concerning the Number of Patients With Medicine Prescription and Dispensing for the Segments AssociatedAccording to the Pharmacotherapeutical Groups, for the Period Between 2010 and 2012.a Patients Segments According toDrug Therapy Maximum Minimum No. of Patients Maximum Minimum No. of Patients Antihypertensives 3 475 016 323 481 4 538 410 3 191 672 186 209 4 303 946 Abbreviation: SD, standard deviation.
aCalculation by the authors, based on data at Health System Central Office and Invoice Checking Centre. Data obtained in September 2012.
The percentage of variation observed between the average Table 3. Spearman Correlation Coefficient Between the Percentage number of patients with a medical prescription and the average Variation Observed Between the Number of Patients With Prescrip- number of the same patients who effectively purchased the tion and Dispensing of Medicines Belonging to 5 Pharmacoterapeutic prescribed medicines between 2010 and 2012 decreased by Groups and the Associated Reimbursement Level, Between 2010 and 32% for the antiulcer and by 16%, 9%, 5%, and 7% for the antiasthmatic, antiplatelet, antihypertensive, and antidiabetic Spearman Coefficient We found a positive correlation between the percentage of variation in the number of the same patients with prescriptions and with medicines dispensed belonging to the various pharma- cotherapeutic groups and the reimbursement level associated aCalculation based on data from Health System Central Office and Invoice with the pharmacotherapeutic groups (Table 3). The positive Checking Centre. Data obtained in September, 2012.
association between these 2 variables decreased from a high bP value <.01.
Health Services Research and Managerial Epidemiology correlation coefficient of .629 in 2010 to a moderate correlation coefficient of .498 in 2012, being statistically significant for the The author received no financial support for the research, authorship, 3 correlations (P < .01).
and/or publication of this article.
1. Guti´errez-Angulo ML, Lopetegi-Uranga P, Sa´nchez-Martı´n I, Therapy nonadherence by diabetic patients and those with car- Garaigordobil Landazabal M. Therapeutic compliance in patients diovascular diseases is a major concern considering the with arterial hypertension and type 2 diabetes mellitus. Rev Calid increase in morbidity and mortality in Portugal. This study has identified a shortcoming in the health service that leads to a 2. Vlasnik JJ, Aliotta SL, DeLor B. Medication adherence: Factors medical appointment that eventually requires additional diag- influencing compliance with prescribed medication plans. Case nostic examinations to identify the most suitable therapy and adequate regimen for the patient. The most appropriate treat- 3. Vik S, Maxwell C, Hogan D. Measurement, correlates and health ment therapy could be concluded with the patient purchasing outcomes of medication adherence among seniors. Ann Pharmac- from a pharmacy and taking the medicine. This was the weak- ness in the health service that was observed in the study, in 4. Sokol MC, Mc Guigan KA, Verbrugge RR, Epstein RS. Impact of which purchasing of the medicine by the patient was not fully medication adherence on hospitalization risk and healthcare cost.
Med Care. 2005;43(6):521-530.
The results showed that compliance was greater when the 5. Goldfarb N, Weston C, Hartmann CW, et al. Impact of appropri- reimbursement level was higher, as the correlation coefficient ate pharmaceutical therapy for chronic conditions on direct med- showed a statistically significant moderate to high positive ical costs and workplace productivity: a review of the literature.
association. It is possible that these observations may be related Dis Manag. 2004:7(1):61-75.
to the diseases included in each reimbursement level that are 6. World Health Organization. Adherence to long term therapies.
defined according to their severity and chronicity. The higher Evidence for action. 2003. Web site. levels of reimbursement include the pharmacotherapeutic Accessed November 3, 2012.
groups associated with more severe and chronic diseases that demand long-term therapies, while the lower levels can be Accessed May 3, 2015.
long-term or intermittent conditions, but the drug therapy is for 7. Jin J, Sklar GE, Oh VMS, Li SC. Factors affecting therapeutic mild and acute diseases. This may be the reason why chronic compliance: A review from the patient's perspective. Ther Clin patients with diseases demanding more frequent medical sur- Risk Manag. 2008;4(1):269-286.
veillance are more aware of the need to comply with the pre- 8. Doshi JA, Zhu J, Lee BY, Kimmel SE, Volpp KG. Impact of a scribed therapeutic regimen compared to the others who are not prescription copayment increase on lipid-lowering medication subject to such frequent clinical surveillance.
adherence in veterans. Circulation. 2009;119(3):390-397.
This study has several limitations, as neither the number 9. Berenson GS, et al. Association between multiple cardiovas- of competitors nor their respective prices were identified in cular risk factors and atherosclerosis in children and young adults.
each market segment. Another aspect is related to patients' The Bogalusa Hearth Study. N Engl J Med. 1998;338(23): socioeconomic status, which defines their ability to pay and is therefore directly related to medicine purchase in line 10. Boggon R, van Staa TP, Timmis A, et al. Clopidogrel disconti- with other basic and essential goods, potentially influencing nuation after acute coronary syndromes: frequency, predictors medicine compliance. It is essential to ensure that medical and associations with death and myocardial infarction–a hospital appointment resources are efficiently used to promote public registry-primary care linked cohort (MINAP-GPRD). Eur Heart 11. Schneeweiss S, Patrick AR, Maclure M, Dormuth CR, Glynn RJ.
Adherence to statin therapy under drug cost sharing in patients with and without acute myocardial infarction: a population-based The reimbursement level is a potentially modifying factor in natural experiment. Circulation. 2007;115(16):2128-2135.
patients' behavior in relation to the prescribed medicine pur- 12. Liebl A, Neiss A, Spannheimer A, et al. Complications, co mor- chases. Contributing to providing holistic medicine reimburse- bidity and blood glucose control in type 2 diabetes mellitus ment systems will optimize the use of public resources in the patients in Germany—results from the CODE-2 study. Exp Clin health sector.
Endocrinol Diabetes. 2002;110(1):10-16.
13. Reid D, Abramson M, Raven J, Walters HE. Management and treatment perceptions among young adults with asthma Declaration of Conflicting Interests in Melbourne: the Australian experience from the European The author declared no potential conflicts of interest with respect to Community Respiratory Health Survey. Respirology. 2000; the research, authorship, and/or publication of this article.
Constantino Portela and Campos Fernandes 14. Bender B, Milgrom H, Rand C. Non adherence in asthmatic 17. Gibson TB, Ozminkowski RJ, Goetzel RZ. The effects of pre- patients: is there a solution to the problem? Ann Allergy Asthma scription drug cost sharing: a review of the evidence. The Amer J Manag Care. 2005;11(11):730-740.
15. Guedes MV, Arau´jo TL, Lopes MV, Silva LF, Freitas MC, 18. Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing.
Almeida PC. Barriers to hypertension treatment. Rev Bras Associations with medication and medical utilization and spend- ing and health. JAMA. 2007;298(1):61-69.
16. Cabral MV, Silva PA. A adesa˜o a terapˆeutica em Portugal: atitudes e comportamentos da populac¸a˜o portuguesa perante as Author Biographies prescric¸o˜es m´edicas. Associac¸a˜o Portuguesa da Indu´stria Farm-ac ˆeutica.2010. Web site. Maria da Conceic¸a˜o Constantino Portela is PhD in Health Econom- ics and PharmD from Universidade Nova de Lisboa. He is a research fellow in Centro de Investigac¸a˜o Interdisciplinar em Sau´de from Uni- November 3, 2012. versidade Cato´lica Portuguesa.
Adalberto Campos Fernandes is MSc in Public Health and MD from . Accessed May 3, Universidade Nova de Lisboa. He is also an assistant professor in National School of Public Health in Universidade Nova de Lisboa.

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