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Claims data have been used as a means to compare the impact of various benefit designs on the use of antihypertensive medication. Doubling copayments has been shown to reduce antihypertensive use by 26 percent, with less impact among those under regular care Goldman et al. Higher cost sharing has been associated with delayed initiation of hypertensive therapy. Solomon and colleagues found that doubling copays led to initiation of therapy in The authors concluded that the effect of cost sharing is greatest soon after diagnosis and then declines over time; however, in those without prior medication experience it declines more slowly.
Taira and colleagues found that medication compliance decreased substantially with increasing copayments. In a study examining the effect of a preferred drug list restricting 17 antihypertensive medications, 21 percent of individuals on antihypertensives were found to discontinue their medication Wilson et al.
Another study found that a percent increase in copayments led to a significant decrease in use of calcium channel blockers CCBs 4. There were also significantly higher discontinuance rates for ACE inhibitors In a prospective cohort study, Hsu et al. Cost sharing is not always consistent with decrease in utilization. In one study, the intervention group with the change in benefits was less likely than the control group to stop using ACE inhibitors Huskamp et al. In another study, the introduction of a new cost sharing led to a significant decrease in antihypertensive medication use at three months, but only a 1.
A RAND randomized controlled trial found that cost sharing had little impact on compliance with medication, but that those under free care were more likely to be taking medication due to improved case finding, prescription of medication, and more frequent follow-up Keeler et al. Studies focusing on chronically ill patients have consistently shown greater use of inpatient and ER services with higher cost sharing; however, studies across broader ranges of drugs showed mixed results as to whether cost sharing leads to adverse health outcomes or increased costs Goldman et al.
In a large study restricted to persons using medication for which a reduction in use might be expected to have an adverse affect on health, a 25 percent cost-sharing policy for prescription drugs up to an income-dependent deductible was associated with reductions in essential drug use and an increase in serious adverse events and emergency room visits among the elderly and welfare recipients.
In contrast, reductions in use of less essential drugs were not associated with an increase in risk of adverse events or ER visits Tamblyn et al. Capped individuals also had an increase in ER visits, increase in nonelective hospitalizations, and higher death rates. The rates of elective hospitalization were not significantly different between the two groups. In an older randomized controlled trial that was representative of the U. The impact was greater for those of lower socioeconomic status SES. The authors estimated a percent difference in the probability of death in the next year as a result of poorer hypertension control in the cost-sharing plan Brook et al.
Hypertensive individuals in the cost-sharing plans were less likely to be diagnosed with hypertension despite having a blood pressure 4 mm Hg higher than those with free care who had also seen a physician This failure to diagnose and treat resulted in most of the overall difference in blood pressure control between plans at the end of the study Keeler et al. Not all research has demonstrated adverse health outcomes associated with cost sharing. For example, Johnson et al.
In comparing members switched from a two-tier to a three-tier plan with those retained in the two-tier plan, Fairman and colleagues found that the two groups did not differ significantly with respect to the number of office visits, emergency department visits, or inpatient hospitalizations. Another study assessing the impact of moving from a two-tier to a three-tier system also found no significant difference in emergency room visits or hospitalizations Motheral and Fairman, A study comparing patients whose ACE inhibitors were put on reference pricing with those switched to an ACE inhibitor that was not subject to the price increase found a transient 2-month increase in physician visits and hospitalization through the emergency room for those who were switched to reference pricing, but no evidence that reference pricing resulted in increased long-term health care utilization Schneeweiss et al.
In a prospective cohort study, Hsu and colleagues reported that those whose prescriptions were capped had lower pharmacy and outpatient visit costs, but higher hospitalization costs and higher ER costs than individuals not subject to a cap. Total medical costs were comparable in the two groups. In a study of individuals who were switched to a no-cost ACE inhibitor compared with those who had cost sharing for ACE inhibitors, overall health care costs decreased a slight increase in costs of physician visits but large decreases in medication costs Schneeweiss et al.
Traditional worksite health promotion programs strive to maintain worker health, improve work productivity, lower health care costs, and enhance organizational image and future interests Goetzel and Ozminkowski, Typically these programs provide a number of workforce-based initiatives that may include health promotion services, disease management, and other efforts to improve employee productivity by improving employee health Goetzel et al. Healthy People further describes workplace health promotion to include not only health education that focuses on skill development and lifestyle behavior change but also programs that help employees assess health risks and link to health plan benefits to provide appropriate medical follow-up and treatment.
Key to these programs is their integration within the organizational structure and a supportive environment in which organizational values, norms, policies, and initiatives reinforce and support a healthy work culture Partnership for Prevention, The evidence supporting worksite prevention interventions is addressed in the Guide to Community Preventive Services Of the studies reviewed, significant changes were seen in systolic and diastolic blood pressure.
The median decrease in systolic blood pressure was 2. A decrease of 4. The Task Force concluded that there is strong evidence of effectiveness to support worksite interventions that include the assessment of health risks with feedback plus health education with or without other interventions. Worksite prevention programs may be attractive to employers if they can yield a return on investment ROI. Of the 12 studies reviewed to assess the financial impact of health promotion programs on health care costs, 7 studies had a positive ROI and 4 studies reported no effects of the programs on health care costs.
Benefit- or value-based insurance design refers to programs that provide a reduction in costs to targeted patients for targeted interventions that are deemed from the medical evidence to be highly beneficial. For example, a program might provide lower copayments for hyperten sion patients for blood pressure medications that are known to be effective Chernew et al.
Data available on diabetes care indicated that ER use decreased by 26 percent and pharmacy costs decreased by 7 percent. Total direct health care costs per plan participant with diabetes decreased by 6 percent. The hotel chain Marriott also began waiving employee copayments on generic drugs and reducing copayments by half for brand name drugs for diabetes, asthma, and heart disease Capozza, ; health outcomes and other results are still pending.
The guide provides advice to employers to assist them in purchasing health services that have the greatest impact on health improvement and are cost-effective. Hypertension screening, counseling, and treatment are identified among the top 25 high-value preventive services identified in the guide.
The document ranked hypertension screening, counseling, and treatment with the highest score of clinical preventive burden of disease on a scale of 1 to 5 where 5 is the highest score and a medium score of 3 for cost-effectiveness on the 5-point scale. Overall, hypertension screening, counseling, and treatment was ranked sixth out of the top 25 high-value preventive services CDC, ; Maciosek et al.
The toolkit includes a check list to help employers choose and negotiate health benefit packages that fit the needs of their employees. It provides a compilation of research, evidence, and practice information that supports worksite health promotion as a means to enhance productivity management, health promotion, and chronic disease management American College of Sports Medicine, Previous sections have addressed a number of system factors that influence the control of hypertension. Individual factors such as motivation to take prescribed medication and healthy lifestyle choices also play a role.
Community health workers CHWs have been studied as a strategy to help improve hypertension control Brownstein et al. They serve as lay educators, coaches, navigators, advocates, and liaisons to the health care system Brownstein et al. Highlights from the review include positive behavioral changes in 9 of 10 studies: Among the 5 studies that addressed adherence to medications, 2 RCTs saw significant improvement in the intervention groups that included CHWs compared to the control group. A time-series study and a before-and-after study also noted improvement with CHW interventions. With respect to blood pressure control, 9 of 10 studies reported positive improvements.
Improvement in blood pressure control ranged from 4 to 46 percent over different time periods 6 to 24 months. One study did not find differences between CHW and control groups.
Impact of a cost-sharing drug insurance plan on drug utilization among older people. In a study of individuals who were switched to a no-cost ACE inhibitor compared with those who had cost sharing for ACE inhibitors, overall health care costs decreased a slight increase in costs of physician visits but large decreases in medication costs Schneeweiss et al. Strategies range from those that offer access to health care providers who screen and treat individuals with high blood pressure, reduce the cost of medications for those in treatment insurance coverage, benefit design, cost sharing , support hypertension control e. Use of antihypertensive drugs by Medicare enrollees: Later it was determined that the etiologic agent of Q fever was Coxiella burnetii, a rickettsial bacterium. Capitalizing on life-saving, cost-effective preven tive services.
The roles and duties of CHWs tend to be similar across studies and reflect the common objective of improving blood pressure control through a range of physician- or nurse-supervised behavioral and social support interventions. The latter typically include measuring and monitoring blood pressure; providing health education to patients and families about behavioral risk factors for hypertension; recommending changes in diet and physical activity; explaining treatment protocols, health insurance matters, and the importance of adhering to medication regimens; providing help with obtaining transportation to medical appointments; serving as mediators between patients and health care and social service systems; arranging for translation services; and finally, listening to patients and their family members, motivating them, reducing their isolation, and leading self-help groups.
Some of the roles and the successes achieved appear to be similar to those of nurses who have provided educational interventions aimed at hypertension control and suggest an efficient strategy for bringing about enhanced treatment and sustained blood pressure control for targeted racially or ethnically diverse, high-risk populations. Although trained laypeople cannot perform in the same capacity as professional nurses and health educators, with appropriate training and supervision they can successfully contribute to the care of community members with hypertension Bosworth et al.
Community health workers may also play an important role in linking diverse communities to the health care system HRSA, ; IOM, e. Federal agencies, including the CDC and the National Heart, Lung, and Blood Institute, recognize the potential contributions of CHWs in the prevention and control of cardiovascular disease, including hypertension. Training manuals for community health workers and lay health educators have been developed and disseminated by these agencies CDC, a; NHLBI, a,b, , a,b.
Access to health care and the quality of health care have been areas of serious review and analysis at the Institute of Medicine. In the early s, the IOM produced a series of reports on the general benefits of having health insurance and the adverse health consequences when insurance is lacking IOM, a, a,b, b,d, The IOM also published landmark reports on the poor state of quality in the health care delivery system and on a comprehensive vision for how the health care system might be transformed to be safe, effective, patient-centered, timely, efficient, and equitable IOM, b, c.
These reports do not specifically address access to hypertension care or providers. One report, Priority Areas for National Action: Transforming Health Care Quality IOM, c , however, identified hypertension with a focus on appropriate management of early disease as one of 20 priority areas for improvement in health care quality. The committee, in its review of the evidence related to hypertension control and access to care and providers, found that although lack of health insurance is associated with poorer screening rates, poorer compliance with medication, and poorer blood pressure control; the vast majority of individuals with uncontrolled hypertension in the United States are insured.
In fact, the committee found that lack of health insurance or lack of access to health care accounts for a relatively low proportion of poor awareness or poor control of hypertension. Based on the review of the literature, there is strong evidence that physicians are not paying adequate attention to treating and controlling systolic hypertension. For example, under the National Heart Disease and Stroke Prevention Program, Virginia, Georgia, and South Carolina have programs to support professional education and training to promote quality health care.
This is especially salient among the elderly, given the aging of the U. While a number of studies have documented the problem, little information is available to understand clearly why providers do not adhere to JNC guidelines related to screening and treating or intensifying treatment for mild to moderate systolic hypertension.
As one study reported, some physicians were satisfied with blood pressure levels above mm Hg and 90 mm Hg, and some physicians attributed higher risk to elevated diastolic pressure than to elevated systolic pressure, especially in the elderly Oliveria et al. Once these factors are better understood, strategies should be developed to increase the likelihood that primary provid ers will screen for and treat hypertension appropriately, especially in elderly patients. Educating clinicians about the importance of treating and controlling systolic hypertension may be one important strategy but is not expected to be the only one.
Furthermore, high levels of uncontrolled hypertension are indicative of poor-quality care.
The committee agrees with the IOM recommendation that identified hypertension with a special focus on appropriate management of early disease as one of the top 20 priorities for improvement in health care quality IOM, c. The evidence reviewed indicates that although physicians screen for blood pressure, screening does not always lead to treatment or to intensified treatment when appropriate. Out-of-pocket cost of medication has been identified in the literature as a significant barrier to patient adherence with hypertension treatment.
It is estimated that for every 10 percent increase in cost sharing, overall prescription drug spending decreases by percent Goldman et al. Goldman and colleagues compared the impact of reducing cost barriers with other interventions designed to improve adherence with medications for chronic conditions and noted that even the most successful interventions designed to increase patient adherence to medication did not result in larger improvements in adherence than reducing the costs, and generally relied on complicated, labor-intensive regimens Goldman et al. The committee finds the evidence convincing that reducing costs of antihypertensive medication is an important and efficient way to increase medication adherence.
The committee also recommends that the DHDSP work with the pharmaceutical industry and its trade organizations to standardize and simplify applications for patient assistance programs that provide reduced-cost or free antihypertensive medications for low- income, underinsured, or uninsured individuals. The committee notes that the DHDSP is also well positioned to educate the private sector that eliminating or reducing the costs of antihypertensive medications is an important and efficient way to increase medication adherence.
Through collaborations with the National Forum for Heart Disease and Stroke Prevention Chapter 3 and cooperative agreements and partnerships with the private sector, the division provides support and guidance to the employer community on hypertension and cardiovascular disease prevention and control. The private sector is already experimenting with reducing the copayments associated with drugs commonly prescribed for diabetes, asthma, and hypertension Pitney Bowes, Marriott, others.
The results of these experiments should be shared broadly with the business community. The DHDSP might also consider working with the business community to evaluate and disseminate broadly the research on the health impacts of efforts to reduce financial burdens associated with the treatment of hypertension. The use of community health workers to support the care of individuals with hypertension has been identified as a promising strategy.
Community health workers have contributed to greater medication adherence among individuals with hypertension and have been shown to play an important role in linking diverse communities to the health care system and navigating that system. In the absence of such programs, the division should work with state partners to de velop programs of community health workers who would be deployed in high-risk communities to help support healthy living strategies that include a focus on hypertension.
The Georgia Cardiovascular Health Initiative, along with its partner, the International Society on Hypertension in Blacks, conducts a series of continuing medical education for community-based health center staff and other providers.
Turn recording back on. National Center for Biotechnology Information , U. Physician Adherence to Guideline Recommendations and Hypertension Control Although patient compliance with treatment is one reason for lack of hypertension control, it is also clear that lack of physician adherence to hypertensive guidelines is a major problem and a significant reason for the lack of awareness, lack of pharmacologic treatment, and lack of hypertension control in the United States Chiong, ; Pavlik et al.
FIGURE The proportion of patients over a month period that was not diagnosed with hypertension, separated by average diastolic and systolic blood pressure. FIGURE The diastolic and systolic blood pressure ranges at which physicians would start drug treatment in patients with uncomplicated hypertension. Patient Nonadherence to Treatment of Hypertension Patient noncompliance with prescribed antihypertensive medications is also a problem that contributes to suboptimal rates of blood pressure control. Cost of Medication and Hypertension One reason for patient nonadherence with treatment is out-of-pocket costs for medication Chockalingam et al.
Insurance Coverage and Control of Hypertension One way of reducing patient costs of treatment is through insurance coverage. Hypertension Control and Cost Sharing Among Those with Insurance Cost sharing is described by AHRQ as the contribution consumers make toward the cost of their health care as defined in their health insurance policy. Studies Assessing Impact of Cost Sharing on Antihypertensive Medication Utilization The impact of cost sharing specifically related to the use of antihypertensive medication has been assessed Adams et al.
The case for a Medicare drug coverage benefit: A critical review of the empirical evidence. Annual Review of Public Health Use of antihypertensive drugs by Medicare enrollees: Does type of drug coverage matter? Health Affairs 20 1: Correlates of controlled hypertension in indigent, inner-city hypertensive patients. Journal of General Internal Medicine 12 1: PMC ] [ PubMed: Closing the quality gap: A criti cal analysis of hypertension care strategies. Financial impact of health promotion programs: A comprehensive review of the literature. American Journal of Health Promotion 15 5: Algorithm for measures calculation—EHRS.
American College of Sports Medicine. A guide to building healthy and productive companies. When patients have to pay a share of drug costs: Effects on frequency of physician visits, hospital admissions and filling of prescriptions. Canadian Medical Association Journal Impact of generosity level of out-patient prescription drug coverage on prescription drug events and expenditure among older persons.
American Journal of Public Health 92 8: Effects of cap and co-payment on rational drug use. Cochrane Database of Systematic Reviews 1. Unmet health needs of uninsured adults in the United States. Journal of the American Medical Association Inadequate management of blood pressure in a hypertensive population. New England Journal of Medicine Impact of a cost-sharing drug insurance plan on drug utilization among older people. Journal of the American Geriatrics Society 49 4: Drug coverage and drug purchases by Medicare beneficiaries with hypertension. Health Affairs 19 2: How do providers assess antihypertensive medication adherence in medical encounters?
Journal of General Internal Medicine 21 6: Nurse administered telephone intervention for blood pressure control: A patient-tailored multifactorial intervention. Patient Education and Counseling 57 1: A further subgroup analysis of the effects of the DASH diet and three dietary sodium levels on blood pressure: Results of the DASH-sodium trial. American Journal of Cardiology 94 2: Does free care improve adults health—results from a randomized controlled trial. Community health workers as interventionists in the prevention and control of heart disease and stroke.
American Journal of Preventive Medicine 29 5 Suppl 1: Effectiveness of community health workers in the care of people with hypertension. American Journal of Preventive Medicine 32 5: First-dollar coverage for chronic disease care: Can it save money and im prove patient outcomes? UC Berkeley Labor Center. Health objectives for the nation: Adults taking action to control their blood pressure—United States, Morbidity and Mortality Weekly Report 43 A training manual for pre venting heart disease and stroke.
Division for Heart Disease and Stroke Prevention. Successful business strategies to prevent heart disease and stroke. Centers for Disease Control and Prevention. The National Business Group on Health. Moving Science into Coverage. National Business Group on Health. Health Affairs 26 2: Controlling hypertension from a public health perspective. International Journal of Cardiology 2: Adherence to management of high blood pressure: Recommendations of the Canadian coalition for high blood pressure prevention and control.
Improving compliance and increasing control of hypertension: Needs of special hypertensive populations. American Heart Journal 2 Pt 2: The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Archives of Internal Medicine 4: Medical Care 39 3: Health Affairs 27 5: Isolated systolic hypertension in the elderly: Optimizing medication adherence in older persons with hypertension.
International Urology and Nephrology 35 4: Retrospective, long-term follow-up study of the effect of a three-tier prescription drug copayment system on pharmaceutical and other medical utilization and costs. Clinical Therapeutics 25 Withdrawing routine outpatient medical services: Effects on access and health.
Journal of General Internal Medicine 3 4: Predominance of isolated systolic hypertension among middle-aged and elderly US hypertensives: Preferences and practices of Americans and their physicians in antihypertensive therapy. American Journal of Medicine 81 6C: The health and cost benefits of work site health-promotion programs. Promising practices in employer health and productivity management efforts: Findings from a benchmarking study.
Journal of Occupational and Environmental Medicine 49 2: Pharmacy benefits and the use of drugs by the chronically ill. Prescription drug cost sharing: Associations with medication and medical utilization and spending and health. Journal of the Ameri can Medical Association 1: High blood pressure and cardiovascular disease mortality risk among U.
Annals of Epidemiology 18 4: Guide to Community Preventive Services. Physical activity recommendation for hypertension management: Does healthcare provider advice make a difference? Ethnicity and Disease 18 3: The role of providers in improving patient adhereence to antihypertensive medications. Current Opinion in Cardiology 21 4: The effect of drug co-payments on utilization and cost of pharmaceuticals in a health maintenance organization.
Medical Care 28 Factors associated with hypertension control in the general population of the United States. Archives of Internal Medicine 9: Community health worker national workforce study: Department of Health and Human Services. Unintended consequences of caps on Medicare drug benefits. The effect of incentive-based formularies on prescription-drug utilization and spending. Self-reported hypertension treatment practices among primary care physicians—blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine. Archives of Internal Medicine Characteristics of patients with uncontrolled hypertension in the United States.
New England Journal of Medicine 7: Physician role in lack of awareness and control of hypertension. Journal of Clinical Hypertension Greenwich 2 5: IOM Institute of Medicine. To err is human: Building a safer health system.
Insurance and health care. Crossing the quality chasm: A new health system for the 21st century. Too little, too late. The National Academies Press. Health insurance is a family matter. The future of public health in the 21st century. Hidden costs, value lost: Priority areas for national action: Transforming health care quality.
Community effects of uninsurance. Confronting racial and ethnic disparities in health care. Importance of systolic blood pressure in older Americans. The effect of increased prescription drug cost-sharing on medical care utilization and expenses of elderly health maintenance organization members. Medical Care 35 The impact of increasing patient prescription drug cost sharing on therapeutic classes of drugs received and on the health status of elderly HMO members.
Health Services Research 32 1: How do incentive-based formularies influence drug selection and spending for hypertension? Health Affairs 23 1: How free care reduced hypertension in the Health Insurance Experiment. Journal of the Ameri can Medical Association Effects of cost sharing on physiological health, health practices, and worry. Health Services Research 22 3: Reducing the risk of heart disease and stroke: A six-step guide for employers.
Centers for Disease Control and Prevention, U. Effects of regular exercise on blood-pressure and left-ventricular hypertrophy in African-American men with severe hypertension. Hypertension control and access to medical care in the inner city. American Journal of Public Health 88 Methods to improve medication adherence in patients with hypertension: Current status and future directions.
Current Opinion in Cardiology 20 4: Impact of 3-tier pharmacy benefit design and increased consumer cost-sharing on drug utilization. American Journal of Managed Care 11 Effects of prescription drug user fees on drug and health services use and on health status in vulnerable populations: A systematic review of the evidence. International Journal of Health Services 34 1: Differential control of systolic and diastolic blood pressure: Livestock and other animals are the primary hosts and therefore the source for cross-infection of humans living in close proximity to these animals, or having direct contact with the animals.
Although Q fever is found worldwide, its exact incidence is difficult to establish because so many Use this site remotely Bookmark your favorite content Track your self-assessment progress and more! Otherwise it is hidden from view. About MyAccess If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. Sign in via OpenAthens. Sign in via Shibboleth.
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