INTRODUCTION
In the USA, it is estimated that 30–50% of medications are not taken as prescribed, accounting for approximately 10% of hospitalizations, $100 billion in expenditures, and 125,000 preventable deaths annually.1 Though medication adherence is related to multiple factors, one of the most important hurdles patients must overcome is affordability.1,2 Further, racial/ethnic disparities in medication adherence are largely driven by cost concerns.2 In this study, we evaluate variation by race and ethnicity in asking doctors for lower-cost options in those who have difficulty affording prescription medication.
METHODS
We obtained data from the NIH All of Us (AoU) Research Program, a large nationwide database.3 Participants provided written informed consent during enrollment. Data used were de-identified and considered non-human subjects research by the University of California San Diego IRB. Racial/ethnic categories studied include non-Hispanic (NH) White, NH Black, NH Asian, and Hispanics of all races. A total of 115,742 individuals over age 18 completed the Health Care Access and Utilization Survey between June 2016 and March 2021. Observations with missing values for covariates used in our analysis were excluded, yielding 81,942 individuals. Only those who answered yes to the question “during the past 12 months, was there any time when you could not afford prescription medicines” (12%) were included in the final dataset (N=9860).
We used logistic regression to generate odds ratios (ORs) and 95% confidence intervals (CIs) to characterize responses for the question “during the past 12 months, was there any time when you asked your doctor for a lower cost medication to save money” between different race/ethnicities, with NH White persons as the reference group. We calculated univariable and multivariable models adjusting for age, gender, insurance status, education, and income. Statistical tests were two-sided, and p-values<0.05 were considered statistically significant. Analyses were conducted on the AoU Researcher Workbench using R version 4.1.0. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for observational studies.
RESULTS
Of the 9860 individuals in our study population, 68.3% were NH White, 15.2% were NH Black, 2.4% were NH Asian, and 14.1% were Hispanic (any race). Overall, 56.2% asked for lower cost medication to save money in the past 12 months (Table 1). In univariable models, NH Black (OR: 0.64; 95% CI: 0.57–0.72), NH Asian (OR: 0.75; 95% CI: 0.58–0.98), and Hispanic (any race) (OR: 0.63; 95% CI: 0.56–0.71) persons were significantly less likely than NH White individuals to ask for lower cost medications. In multivariable models adjusting for age, gender, insurance status, education, and income, NH Black (OR: 0.72; 95% CI: 0.64–0.81) and Hispanic (any race) (OR: 0.73; 95% CI: 0.64–0.82) respondents were significantly less likely than NH White respondents to ask for lower cost medications, while NH Asian respondents were not less likely to ask for lower cost medication (OR: 0.80; 95% CI: 0.61–1.05).
Table 1.
Distribution of Selected Characteristics for Patients with Glaucoma Who Report Difficulty Affording Medications in the NIH All of Us Research Program by Race/Ethnicitya
| Characteristics | NH White individuals | NH Black individuals | NH Asian individuals | Hispanic (any race) Individuals |
|---|---|---|---|---|
| Total, No. (%) | 6732 (68.3) | 1501 (15.2) | 232 (2.4) | 1395 (14.1) |
| Median age (IQR) | 54 (40–66) | 51 (40–60) | 40 (31–55) | 44 (33–56) |
| Age category, No. (%) | ||||
| <40 | 1588 (23.6) | 371 (24.7) | 108 (46.6) | 559 (40.1) |
| 40–64 | 3273 (48.6) | 907 (60.4) | 95 (40.9) | 689 (49.4) |
| 65–74 | 1333 (19.8) | 178 (11.9) | <20 | 132 (9.5) |
| 75-84 | 502 (7.5) | 42 (2.8) | <20 | <20 |
| ≥85 | 36 (0.5) | <20 | <20 | <20 |
| Gender, No. (%) | ||||
| Female | 4900 (72.8) | 1175 (78.3) | 134 (57.8) | 1032 (74.0) |
| Male | 1638 (24.3) | 313 (20.9) | 88 (37.9) | 312 (22.4) |
| Other/skipped | 194 (2.9) | <20 | <20 | 51 (3.7) |
| Income, No. (%) | ||||
| 0–25k | 1886 (28.0) | 802 (53.4) | 58 (25.0) | 578 (41.4) |
| 25k–50k | 1842 (27.4) | 393 (26.2) | 42 (18.1) | 420 (30.1) |
| 50k–100k | 1795 (26.7) | 233 (15.5) | 58 (25.0) | 284 (20.4) |
| 100k–200k | 995 (14.8) | 65 (4.3) | 56 (24.1) | 96 (6.9) |
| >200k | 214 (3.2) | <20 | <20 | <20 |
| Health insurance, No. (%) | ||||
| Medicaid | 1351 (20.1) | 548 (36.5) | 37 (15.9) | 486 (34.8) |
| Other insured | 5360 (79.6) | 934 (62.2) | 192 (82.8) | 895 (64.2) |
| None | 21 (0.3) | <20 | <20 | <20 |
| Education, No. (%) | ||||
| No HS diploma | 138 (2.0) | 97 (6.5) | <20 | 144 (10.3) |
| HS diploma/GED | 806 (12.0) | 305 (20.3) | <20 | 239 (17.1) |
| Some college | 2412 (35.8) | 626 (41.7) | 35 (15.1) | 525 (37.6) |
| College and above | 3376 (50.1) | 473 (31.5) | 186 (80.2) | 487 (34.9) |
| Asked for lower cost medication, No. (%) | ||||
| Yes | 4017 (59.7) | 732 (48.8) | 122 (52.6) | 674 (48.3) |
| No | 2715 (40.3) | 769 (51.2) | 110 (47.4) | 721 (51.7) |
aPer the All of Us Research Program data sharing policies, cells with less than 20 respondents are suppressed
DISCUSSION
In this large nationwide study, we found that NH Black and Hispanic (any race) individuals who have trouble affording medication were less likely to ask their doctors for lower cost medications than NH White individuals, even after adjusting for socioeconomic factors. This is important since medication costs are not routinely discussed during patient encounters, and more affordable alternatives are often underutilized.4 While the source survey referred only to “doctors” rather than a broader group of clinicians and was also limited by the potential exclusion of individuals who could not afford a doctor’s visit to ask for lower cost medication, the findings suggest an important health disparity that Black and Hispanic individuals may be less likely to engage with their doctors to discuss these problems than NH White individuals.
There is evidence that racial/ethnic minority populations are less likely to advocate for themselves in healthcare settings.5 Reasons are multifactorial, including differences in role expectations, disengagement due to feeling stereotyped, and lack of opportunities to participate—which may devolve from doctors’ conscious or unconscious biases.5,6 It is essential therefore that doctors are proactive and initiate discussions about costs themselves. This may be accomplished with relatively simple interventions. One study of a 60-min training session for primary care doctors significantly increased medication cost discussions with patients.4 Open discussion of medication costs with all patients may ultimately promote health equity in the USA.
Author Contribution
Arash Delavar: data curation, formal analysis, investigation, methodology, software, visualization, writing—original draft, writing—review and editing. Bharanidharan Radha Saseendrakumar: data curation, formal analysis, methodology, software, writing—review and editing. Robert N. Weinreb, MD: funding support, investigation, methodology, project administration, supervision, writing—review and editing. Sally L. Baxter: funding support, conceptualization, data curation, formal analysis, investigation, methodology, project administration, supervision, writing—review and editing.
Funding
Author Arash Delavar is a recipient of the Research to Prevent Blindness (New York, NY) Medical Student Eye Research Fellowship. This study was supported by the National Institutes of Health Grants R01MD0148500, P30EY022589, and DP5OD029610 (Bethesda, MD, USA) and an unrestricted departmental grant from Research to Prevent Blindness. The All of Us Research Program is supported (or funded) by grants through the National Institutes of Health, Office of the Director: Regional Medical Centers: 1 OT2 OD026549; 1 OT2 OD026554; 1 OT2 OD026557; 1 OT2 OD026556; 1 OT2 OD026550; 1 OT2 OD 026552; 1 OT2 OD026553; 1 OT2 OD026548; 1 OT2 OD026551; 1 OT2 OD026555; IAA #: AOD 16037; Federally Qualified Health Centers: HHSN 263201600085U; Data and Research Center: 5 U2C OD023196; Biobank: 1 U24 OD023121; The Participant Center: U24 OD023176; Participant Technology Systems Center: 1 U24 OD023163; Communications and Engagement: 3 OT2 OD023205; 3 OT2 OD023206; and Community Partners: 1 OT2 OD025277; 3 OT2 OD025315; 1 OT2 OD025337; 1 OT2 OD025276. In addition to the funded partners, the All of Us Research Program would not be possible without the contributions made by its participants.
Declarations
Conflict of interest
Robert N. Weinreb: financial support (research instruments)—Heidelberg Engineering, Carl Zeiss Meditec, Konan Medical, Optovue, Centervue Consultant–Aerie Pharmaceuticals, Allergan, Equinox, Eyenovia, Nicox; patent—Toromedes, Carl Zeiss Meditec.
Footnotes
Publisher’s Note
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Change history
3/7/2023
A Correction to this paper has been published: 10.1007/s11606-023-08110-w
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