Middle-aged and older Americans with heart disease who cut back on their prescribed medications because of cost were 50% more likely to suffer heart attacks, strokes, or angina than those who did not report cost-related medication underuse, according to a new study funded in part by the National Institute on Aging, part of the National Institutes of Health. Michele Heisler, M.D., M.P.A., at the Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, and colleagues* conducted the study, which appears in the July 2004 issue of Medical Care, a journal of the American Public Health Association. 

This is the first nationally representative longitudinal study to demonstrate that patients with serious chronic illnesses experience adverse health events when they restrict their use of prescription drugs due to cost. The downturns in patients' health were observed over a relatively brief (2-3 year) period, suggesting that cost barriers to prescription drug use may have important short-term effects on older patients' health and well-being, Heisler said. 

"This study underlines how important medications can be and how important it is for people who need the medications to be able to get them," said HHS Secretary Tommy G. Thompson. "This is why a new drug benefit for Medicare was so crucial, including the interim drug card with its special benefit for low-income Americans. It's also why FDA is working to make generic products available quickly, as well as rapid review for significant new medications. We need to keep working toward better access to drugs and keep supporting the science that underlies ever-improving products."

The study included 7,991 middle-aged and older Americans who participated in a survey conducted between 1995 and 1996 as part of the Health and Retirement Study (HRS), an NIA-supported survey of adults aged 51 to 61, or the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older.** All participants reported using prescription medication, and 546 reported that they had taken less medication than prescribed because of cost. Heisler and colleagues assessed a range of important health outcomes reported in participants' subsequent surveys, conducted in 1998. 

After controlling for risk factors for poor health outcomes, 32% of adults who had restricted medications because of cost pressures reported a significant decline in their self-reported health status during their follow-up interviews compared to 21% of adults with no cost-related underuse. Self-reports of health have been found to strongly predict other serious life events, including mortality, according to the study.

"There is a growing array of effective but often expensive prescription medications that clearly improve health outcomes, especially in the field of cardiovascular disease. As medications become even more effective, differences in access to prescriptions drugs because of cost may further worsen disparities in health outcomes between rich and poor Americans," Heisler said.

"This study suggests what can happen when older people cannot get the medications they need and will help inform policy regarding prescription drug insurance coverage," said Richard M. Suzman, Ph.D., NIA Associate Director for the Behavioral and Social Research Program. "The longitudinal design employed in this study suggests that the cost of drugs can lead to drug underuse and that this underuse could in turn contribute to adverse health outcomes. Additional research will be needed to further examine the causal relationship between drug costs and health outcomes."

In addition to cardiovascular declines, older individuals who restricted medication use because of cost had increased rates of depression, according to the study. Researchers found no health differences among people with arthritis and diabetes who said they had restricted drug use due to cost. Community-dwelling people over 65 paid an average of $410 for their drugs in 1999, and adults with multiple, chronic diseases paid twice as much, according to a cited study.

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* The study was conducted by Michele Heisler, MD, M.P.A., Kenneth M. Langa, MD, Ph.D, Elizabeth L. Eby, M.P.H., A. Mark Fendrick, MD, Mohammed U. Kabeto, M.S., John D. Piette, Ph.D. 

Veterans Affairs Center for Practice Management & Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, MI (MH, KL, ELE, JDP), Department of Internal Medicine (MH, KL, AMF, MUK, JDP), Michigan Diabetes Research and Training Center (MH, JP), Institute for Social Research (KL), Patient Safety Enhancement Program, (KL), University of Michigan School of Medicine, Ann Arbor, MI. 

Heisler is a Veterans Affairs Center for Practice Management & Outcomes Research Career Development Awardee. Langa was supported by a Career Development Award from the National Institute on Aging, a New Investigator Research Grant from the Alzheimer's Association, and a Paul Beeson Physician Faculty Scholars in Aging Research award.

** The HRS and AHEAD are nationally representative, biennial longitudinal studies, sponsored by the National Institute of Aging and undertaken by the University of Michigan's Institute for Social Research. These studies target community-dwelling adults in the contiguous United States, with over-sampling of blacks, Latinos, and Florida residents, and gather in-depth economic, financial, and health information from respondents. In 1998, the two studies were combined into one HRS with identical survey procedures and questionnaires.