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First Study The effect of drug co-payment policy on the purchase of prescription drugs for children with infections in the community Haim Reuveni, MD Health Policy 62 (2002) 1–13 Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel 1 Introduction • Co-payment (CP) policy - patients cover part of treatment cost • CP policy reduces expenditures of the insurance carrier and unnecessary use of services • CP reduce consumption of the medical care, prescribed drugs mainly among low SES people • CP cause deterioration in health state. • Each 10% increase in CP is associated with an 8.7% decrease in total per-episode expenditure 2 Aims To examine the effect CP on the purchase of prescribe drugs in children with acute infectious diseases. This was preformed in community settings (Pediatric Health Center in the city of Kiryat-Gat) 3 Objectives 1. To calculate the rates of partial or non-purchase of antibiotics (WHO classification). 2. To assess the association between the number & cost of prescribe drugs and the non or partial purchase of the drugs. 3. To identify factors that can predict non or partial purchase of prescribe drugs due to cost considerations. 4 Methods Design: Cross-sectional study. Setting: The Pediatric Health Center in the city of Kiryat-Gat one of Israel’s poorest cities (high unemployment rate). The pediatric clinic has: a registry of 6500 children an average of 200 visits per day. 5 pediatricians. Data collection was for 6-weeks in May to June 1999. 5 Study population • Included: Children and adolescents aged 0–18 years, diagnosed by a pediatrician with an acute infectious disease for which drugs, including antibiotics, were prescribed. • Excluded: children and adolescents that: (1) already taking antibiotic drugs (2) diagnosed for an acute infectious disease, but did not receive a prescription (3) received a prescription which did not include antibiotics. 6 Data sources 1) The computerized patient visit reports (I.e. demographics, type of drug, dosage, date of prescription). 2) The computerized drug dispensing reports from the clinic’s pharmacy. 7 Three study groups were defined: Full purchase- All drugs prescribed were issued by the pharmacy. Partial purchase- Some of the drugs and/or amounts were issued. Non-purchase- None of the prescribed drugs were issued within 7 days of prescription date. 8 Study protocol 9 Results During the 6-week study period, antibiotics were prescribed for the following acute infections 10 11 12 13 Conclusions: • CP is a serious barrier for purchasing the prescribed medication for children with acute infections. • The policy has a particularly deleterious effect in under-privileged populations. • CP policy is in contradiction with the proclaimed principles of justice and equality underlying the obligatory Israeli National Health Insurance Law. 14 The incomplete purchase (partial treatment) of antibiotics may: • lead to an extended period of symptoms. • Development of long-term complications such as meningitis and rheumatic fever. The role of partial antibiotic treatment in the development of antibiotic resistance is not clear. 15 More questions……. • What are the drug purchasing patterns when several family members are concurrently ill. • What is the long-term clinical outcome for these children? • What is the consequent extent of medical care utilization by these children? • How can we define a “reasonable level ” of CP ? for essential drugs or other treatments…….. Zero CP? for different layers of income……….. Partial/Full CP? Further studies are required………. 16 More research 17 2nd Study Determinants affecting initiation of continuous positive airway pressure treatment. Brin YS, Reuveni H, Greenberg S, Tal A, Tarasiuk A. Isr Med Assoc J. 2005 Jan;7(1):13-8. 18 PSG study Diagnosis Titration study CPAP adaptation Purchasing Purchased Adaptation Acceptance OSAS (+) (N=128, 32%) (N=183, 46%) (N=324, 81%) (N=400, 100%) OSAS (-) Declined Declined Declined (N=76, 19%) (N=141, 35%) (N=55, 14%) 19 Refused adaptation 70 Number of Patients (%) 60 Declined purchasing Purchased CPAP 50 40 30 20 10 0 very low low mean high very high Monthly income Brin et al Figure 2 20 3d Study The effects of co-payment policy on compliance with medical technologies: The case of chronic CPAP treatment in patients with OSAS requiring continuous positive airway pressure (CPAP) therapy Haim Reuveni1, Ariel Tarasiuk2 Supported by Grant from the Israeli Institute for Health Policy and Health Services Research, award no. A/147/2003. 21 Introduction • CPAP device is provided free of charge in countries such as Germany, the United Kingdom, several parts of Canada and by some health care providers in the USA. • In these countries, treatment initiation and long-term compliance were found to be more than 70%. • In Israel, results strongly suggest that sharing the cost of CPAP is a potential barrier to purchase CPAP. 22 Main Objective To develop a model for decision-makers to determine CP policy for CPAP 23 Specifically 1) To compare compliance rates according to CP policy with that of other industrialized countries 2) To determine the cost-effectiveness of CPAP therapy. 3) To compare compliance rate to CPAP before (full CP) and after change (partial CP) in CP policy. 24 Group 1- Declining CPAP. 1a- CPAP will be re-offered CPAP with partial CP. 1b- CPAP will not re-offered Group 2- Commencing CPAP. Group 3- New patients, minimal CP. followed-up for 12 m 25 LOW SOCIOECONOMIC STATUS IS A RISK FACTOR FOR CPAP ACCEPTANCE AMONG ADULT OSAS PATIENTS REQUIRING TREATMENT Submitted for publication Tzahit Simon-Tuval, Haim Reuveni, Sari Greenberg, Arie Oksenberg , Asher Tal, Ariel Tarasiuk 26 PSG study (n=278) Requiring CPAP treatment Not requiring CPAP treatment (n=162) (n=116) Commence CPAP treatment Decline CPAP treatment (n=65, 40%) (n=97, 60%) 27 Patients Recruitment PSG study Questioner 1 CPAP Titration CPAP Adaptation Patient decision Conclusion of Adaptation Accepting Questioner 2 Declining 28 Characteristics of OSAS Patients OSA patients OSA patients not requiring requiring CPAP CPAP p value n 116 162 Males (%) 55.2 74.7 0.001 Age (years) 49.7±13.2 54.9±12.0 0.0007 BMI (kg/m2) 30.3±7.3 32.3±5.4 0.01 HTN and/or CVD (prevalence) 37.9% 58.02 <0.0001 Income Low 30.4% 31.8% 0.562 Average 49.1% 43.1% High 20.5% 25.2% 29 Reasons for purchasing CPAP Reasons for purchasing CPAP device CPAP purchasing % patients (n=60) It solved my snoring problems 78% It reduced by daytime sleepiness 78% It improved my Sleep 59% My physician and sleep laboratory team to convinced me 53% Encouragement from partner 53% Will improve my associated morbidity 35% This is the best treatment available for me 33% 30 Reasons for declining CPAP Reasons for Declining CPAP device CPAP Declining % patients (n=102) I tried and could not adapt 38% I am Interested in other treatments 31% CPAP cost is too expensive 29% I have side effects 28% I feel better and don’t need this treatment 13% Not encouraged by my partner 10% Not encouraged by my physician 6% 31 Determinants of OSAS Patients Requiring and Accepting CPAP Treatment (n=162) Variable Univariate analysis Multivariate analysis OR 95% CI OR 95% CI Income (low, medium, high) 2.03 1.3-3.2 2.4 1.2-4.6 Age (year +1) 1.05 1.02-1.1 1.07 1.01-1.1 BMI (+1 Kg/m2) 1.02 0.96-1.1 0.98 0.9-1.1 AHI (≥35 vs. <35 events/hr) 3.0 1.54-5.7 4.2 1.4-12.0 ESS (≥10 vs. <10 score) 0.66 0.35-1.3 0.9 0.3-2.3 Partner sleeps separately (yes vs. no) 2.4 1.1-5.1 4.3 1.4-13.3 Family and/or friends experience with CPAP (yes vs. no) 2.5 1.1-5.4 2.9 1.1-7.5 Income – individual income level; BMI body mass index; AHI – Apnea-Hypopnea Index; ESS – Epworth Sleepiness Scale score; CVD – Cardiovascular Disease; HTN – Hypertension; Area under the ROC 82% for patients living with partner. 32 Thank You ! 33