Study ID, design | Demographics | Definition of CRNA | Prevalence of CRNA | Predictors of CRNAa | Impact on clinical outcomes |
---|---|---|---|---|---|
Brand 1977 [35] Survey with in-person interviews over a 3-month period, year unspecified | N = 225 patients discharged from hospital in Halifax, NS (mean age 57.0) | Not complying with ≥ 1 physician order(s) due to cost of drugs | 13.8% | “Cost of drugs” (p < 0.001) | N/A |
Kennedy 2006 [36] 2002–2003 Joint Canada-US Survey of Health | N = 3505 Canadian adults ≥ 18 years | Failure to obtain a prescribed medication due to cost | 5.1% | No Canada-specific data | N/A |
Hirth 2008 [37] 2002–2004 DOPPS patient questionnaires | N = 503 Canadian adult hemodialysis patients from 20 facilities (mean age 62.1, SD 14.7) | Not purchasing medication due to cost | 12.9% | Out-of-pocket spending burden (R2 = 0.44) | N/A |
Kennedy 2009 [38] 2007 IHP phone survey | N = 2980 Canadian adults ≥ 18 years | Not filling a prescription or skipping doses of medication due to cost during the previous 12 months | 8.0% | Younger (< 65 years), multiple chronic conditions, lower household income, each p < 0.01 (OR not reported); Quebec (compulsory coverage) compared to Ontario (OR = 0.5, 95% CI 0.3–0.8) | N/A |
Kemp 2010 [39] 2007 IHP phone survey | N = 2183 Canadian adults ≥ 18 years (median age 50, SE 0.3) | Not filling a prescription or skipping doses of medication due to cost during the previous 12 months | 8.0% | Younger age RR = 3.9 (95% CI 2.2–6.9); income below average RR = 3.1 (95% CI 2.1–4.7); high out-of-pocket prescription costs (RR = 4.6 (95% CI 3.8–6.7); first nations RR = 2.1 (95% CI 1.4–3.2); self-reported poor health status RR = 1.5 (95% CI 1.2–2.0); not feeling involved in treatment decisions RR = 1.3 (95% CI 1.1–1.4) | N/A |
Law 2012 [40] 2007 CCHS phone survey | N = 5732 community-dwelling Canadians ≥ 12 years who received a prescription in the previous year | Altering a prescription to make it last longer or not filling a new prescription or renewing an ongoing prescription, due to cost | Canadian sample, 9.6% (95% CI 8.4–10.7%); QB, 7.2% (4.5–9.8); ON, 9.1% (7.2–11.0%); BC, 17.0% (12.6–21.4%) | Younger age (OR = 4.70, 95% CI 2.91–7.60); low household income (OR = 3.29, 95% CI 2.03–5.33); lack of insurance coverage for drugs (OR = 4.52, 95% CI 3.29–6.20); several chronic health conditions (OR = 1.61, 95% CI 1.07–2.43); fair or poor self-assessed health status (OR = 2.64, 95% CI 1.77–3.94); residing in BC (compared to Ontario) (OR = 2.56, 95% CI 1.49–4.42) | N/A |
Zheng 2012 [41] Cross-sectional survey with in-person interviews between March 10 and April 19, 2011 | N = 60 adult patients attending a general internal medicine rapid assessment outpatient clinic in Hamilton, ON (mean age 60.3, SD 14.3) | Left prescriptions unfilled, delayed filling prescriptions, took prescriptions with reduced frequency or lowered dosages in the previous year because of the cost | 15.0% | No drug insurance (OR = 20.7, 95% CI 1.46–292.75); high out-of-pocket expenses (OR = 42.52, 95% CI 2.02–894.03) | N/A |
Hunter 2015 [42] HHiT study in-person interviews between January and December 2009 | N = 716 homeless or vulnerably housed single adults in Vancouver, Toronto, and Ottawa and prescribed ≥ 1 current medication | Not actually taking a current medication prescribed by a doctor as “the medication is too expensive” | 3.6% | N/A | N/A |
Hennessy 2016 [2] BCPCHC survey between February 2011 and March 2012 | N = 1849 ≥ 40 year from BC, AB, SK, or MB who reported having heart disease, stroke, diabetes, or hypertension (mean age 65.1, 95% CI 64.3–65.9) | For the previous 12 months, due to cost, either (a) not getting necessary prescription medication or (b) stopping one or more prescribed drug for a week or more | 4.1% (95% CI 2.6–6.3%) | Out-of-pocket spending greater than 5% of household income (prevalence RR = 2.6; 95% CI 1.0–6.4) | N/A |
Lee 2017 [43] 2014 IHP phone survey | N = 4690 community-dwelling Canadians ≥ 55 years | Not filling a prescription or skipping doses within the last 12 months because of out-of-pocket costs | 8.3% | QC (compared to ON) (adjusted OR = 0.49, 95% CI 0.29–0.82); younger age (compared to ≥ 65 years): 55–64 years (OR = 3.13, 95% CI 2.27–5.40); poor health status (OR = 1.75, 95% CI 1.12–2.38); low income (OR = 3.59, 95% CI 2.32–5.55); lack of private insurance (OR = 2.33, 95% CI 1.56–3.10) | N/A |
Morgan 2017 [3] 2014 IHP phone survey | N = 4696 community-dwelling Canadians ≥ 55 years | Not filling a prescription or skipped doses within the last 12 months because of out-of-pocket costs | 8.3% | Canadians (compared to the UK) (adjusted OR = 2.25, 95% CI 1.08–4.69); lower income (compared to UK) (OR = 1.23, 95% CI 0.64–2.40) | N/A |
Sarnak 2017 [44] OECD data, 2016 IHP phone survey and other sources | N = 4547 Canadian adults ≥ 18 years | Not filling/collecting a prescription for medicine or skipped doses because of cost in the past 12 months | Overall: 10.2%; 0 chronic diseases 5.0% vs. 1 chronic disease 12.0% vs. 2+ chronic diseases 16.0% | N/A | N/A |
Soril 2017 [45] 2004-14 IHP phone surveys (selected years) | N = 25,740 Canadian adults ≥ 18 years | Not filling a prescription because of costs in the previous 12 months | Overall: range 7.1–8.2%; older/sicker adult cohort: range 6.5–19.8% | N/A | N/A |
Law 2018 [46] 2016 CCHS phone survey | N = 28,091 community-dwelling Canadians ≥ 12 years | Skipping or reducing dosages, or delaying refill prescriptions or not filling prescriptions at all to reduce drug costs | 5.5% (95% CI 5.1–6.0%) | Younger adult (p < 0.001); out-of-pocket prescription drug spending (p < 0.001); lack of drug insurance (p < 0.001); lower income (p < 0.001); poorer health status (p < 0.001) | N/A |
Laba 2018 [47] 2016 CCHS phone survey | N = 8420 community-dwelling Canadians ≥ 12 years old with ≥ 2 chronic conditions | Skipping or reducing dosages, delaying refill prescriptions, or not filling prescriptions at all to reduce drug costs | 10.2% (95% CI 8.6–11.9%); 15.2% (95% CI 11.6–18.8) for respiratory and 16.6% (95% CI 13.2–9.9%) for mental health disorders | Age between 19 and 44 years (OR 2.74, 95%CI 1.76, 4.26); out-of-pocket spending on prescription medicines > CAD500 OR 2.56, 95% CI 1.49, 4.40; lack of drug insurance (OR 3.26, 95% CI 2.12, 4.80); fair to poor health status (OR 3.42, 95% CI 1.46, 8.02); residing in certain provinces, e.g., BC (OR 4.20, 95% CI 2.55, 6.91) | N/A |
Men 2019 [48] 2016 CCHS phone survey | N = 11,172 community-dwelling Canadians with a prescription within the previous year and answering a food security questionnaire | Skipping or reducing dosages, delaying refill prescriptions, or not filling prescriptions at all to reduce drug costs | 8.3% | Household food insecurity adjusted for sociodemographic factors, associated with CRN—RR 1.82 (95% CI 1.00 to 3.31), 3.83 (95% CI 2.44 to 6.03), and 5.05 (95% CI 3.27 to 7.81) for marginally, moderately, and severely food-insecure households, respectively, compared to those with no food insecurity | N/A |
Monagle 2018 [49] Phone survey of one anticoagulant clinic | N = 110 adult patients newly started on oral anticoagulants in Hamilton, ON | Leaving a prescription unfilled or delaying filling a prescription, or taking less of a medication, due to cost | Warfarin users were more likely to report CRN than NOAC users (40% vs. 13%, p = 0.02) | N/A | N/A |
Yao 2018 [50] Retrospective pre-post database study 2005–2009 pre- and post-Seniors’ Drug plan policy change (max. out-of-pocket $15 per prescription for patients ≥ 65 years) vs. concurrent control patients 40–64 years not affected by the policy | N = 188,109 observed patients in SK | CRNA assumed if adherence post-policy improved compared pre-period and to unaffected control | N/A | Odds of optimal medication adherence: post-SDP (compared to pre-SDP) (OR = 1.08, 95% CI 1.04 to 1.11), but only where OOP costs > $15 per prescription, for prevalent users, for some medication classes. Not compared directly to concurrent control | N/A |
Dormuth 2006 [51] Retrospective pre-post database study between June 1997 and 2004 with monthly time series pre- (full coverage) vs. post-policy (copayment) | N = 55,752 BC residents ≥ 65 years not in a nursing home, dispensed inhaled corticosteroids (ICS) in 2001 (mean age 75.5) | CRNA assumed if the use of respiratory inhalers declined after policy increasing out-of-pocket expenses | N/A | Initiation of ICS for a new diagnosis of asthma or COPD compared to pre-policy reduced by 25% (95% CI 14–31%); discontinuation of ICS was increased 47% (40–55%) in the copayment group | N/A |
Schneeweiss 2007 [52] Retrospective pre-post database study 2000–2004 with repeated measures design, monthly adherence measurement pre- (full coverage) vs. post-policy (copayment) | N = 41,561 seniors in BC who were new users of statin drugs | CRNA assumed if use of statins declined after policy increasing out-of-pocket expenses | N/A | Paying 100% out-of-pocket (compared to pre-policy) (OR = 1.94, 95% CI 1.82–2.08); patients post-myocardial infarction or post-revascularization (higher risk) (OR = 0.63, 95% CI 0.59–0.68) | N/A |
Schneeweiss 2007 [53] Retrospective pre-post database study 2000–2004 with repeated measures design, monthly adherence measurement pre- (full coverage) vs. post-policy (copayment) | N = 13,193 seniors from BC who were new users of β-blockers | CRNA assumed if the use of beta-blockers declined after policy increasing out-of-pocket expenses | N/A | Post-policy cohort (compared to pre-policy) associated with a 1.3% decline in adherence (95% CI 2.5–0.04) | N/A |
Goldsmith 2017 [54] Qualitative study with semi-structured interviews of CRNA experience from patients’ perspective 2014–2015 | N = 35 adults in BC and ON who reported CRNA | Patient self-report of skipping doses, splitting pills, or not filling their prescriptions due to out-of-pocket costs | N/A | Type of insurance; individual’s overall financial flexibility; the burden of drug cost on the individual’s budget; perceived importance of the drug | N/A |
Gupta 2019 [55] Qualitative study with semi-structured interviews of strategies used to deal with cost burden | N = 12 adult Canadians with spinal cord injuries who reported CRNA | N/A | N/A | Out-of-pocket cost of medication; perceived importance of the drug; lack of drug insurance; competing financial needs, e.g., food, housing; inability to discuss with physicians | N/A |
Tamblyn 2001 [56] Retrospective database study with interrupted monthly time series 1993–1997 pre (full coverage for welfare and low-income seniors; $2 copayment for all other seniors) vs. post-policy (25% coinsurance and deductible) | N = 70,801 elderly and 25,820 welfare recipients using “essential drugs” in QC | CRNA assumed if post-policy decrease in the use of essential drugs | N/A | Increase in cost sharing associated with a decrease in essential drug use by elderly by 9.1% (95% CI 8.7–9.6) and by welfare recipients by 14.4% (95% CI 13.3–15.6%) | Net increase in serious adverse events by 6.8 and 12.9 per 10,000/month; in ED visits by 14.2 and 54.2 per 10,000/month for elderly and for welfare recipients, respectively |
Pilote 2002 [57] Retrospective database study with time-series analysis 1994–1998 pre- (full coverage for welfare and low-income seniors and $2 copayment for all other seniors) vs. post-policy (25% coinsurance and deductible) | N = 22,066 patients ≥ 65 years admitted to a QC hospital for a first acute myocardial infarction and discharged alive | CRNA assumed if the proportion of patients who filled at least one prescription during the year after discharge declined post-policy change | N/A | N/A as no change in adherence pre- vs. post-policy | No differences in readmission for cardiac complications, mortality rate, or use of outpatient physician or ED services |
Randomized open-label trial 2016–2017 with free access including free delivery of prescribed essential medication, compared to usual care | N = 786 adults ≥ 18 years old in 9 primary care practices in ON who reported CRNA (mean age 51.7 years, 55.9% female) | Self-reported not filling a prescription or making a prescription last longer because of the cost within the previous 12 months | N/A | No variation in adherence by income | No difference in rates of hospitalization, serious adverse events, or deaths |