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)
2002-03 Joint Canada-US Survey of Health
|
N=3,505 Canadian adults > 18 yrs.
|
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=2,980 Canadian adults > 18 yrs.
|
Not filling a prescription or skipping doses of medication due to cost during the previous 12 months
|
8.0%
|
Younger (< 65 yrs.), 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=2,183 Canadian adults > 18 yrs. (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=5,732 community-dwelling Canadians > 12 yrs. who received a prescription in 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-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 Jan.-Dec. 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 Feb. 2011-Mar. 2012
|
N=1,849 > 40 yr 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=4,690 community-dwelling Canadians > 55 yrs.
|
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 > 65y): 55-64 yrs. 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=4,696 community-dwelling Canadians > 55 yrs.
|
Not filling a prescription or skipped doses within the last 12 months because of out-of-pocket costs
|
8.3%
|
Canadians (compared to 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=4,547 Canadian adults > 18 yrs.
|
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 yrs.
|
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 yrs.
|
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(54)
2016 CCHS phone survey
|
N = 8420 community-dwelling Canadians > 12 yrs 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, eg, BC OR 4.20, 95%CI 2.55, 6.91.
|
N/A
|
Men 2019(55)
2016 CCHS phone survey
|
N = 11,172 community-dwelling Canadians with a prescription within previous year and answering a food security questionnaire
|
Skipping or reducing dosages, or 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(56)
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(47)
Retrospective pre-post database study 2005-09 pre- and post-Seniors’ Drug plan policy change (max. out-of-pocket $15 per prescription for patients > 65 yrs.) vs concurrent control patients 40-64 yr not affected by 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(48)
Retrospective pre-post database study between Jun. 1997-04 with monthly time series pre- (full coverage) vs. post-policy (copayment)
|
N=55,752 BC residents > 65 yrs. not in a nursing home, dispensed inhaled corticosteroids (ICS) in 2001 (mean age 75.5)
|
CRNA assumed if use of respiratory inhalers declined after policy increasing out-of-pocket expenses
|
N/A
|
Initiation of ICS for 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 copayment group
|
N/A
|
Schneeweiss 2007(49)
Retrospective pre-post database study 2000-04 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(50)
Retrospective pre-post database study 2000-04 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 use of beta-blockers declined after policy increasing out-of-pocket expenses
|
N/A
|
Post-policy cohort (compared to pre-policy) associated with 1.3% decline in adherence (95% CI 2.5 - 0.04)
|
N/A
|
Goldsmith 2017(51)
Qualitative study with semi-structured interviews of CRNA experience from patients’ perspective 2014-15
|
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 importance of the drug
|
N/A
|
Gupta 2019(57)
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, eg, food, housing; inability to discuss with physicians.
|
N/A
|
Tamblyn 2001(52)
Retrospective database study with interrupted monthly time-series 1993-97 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 use of essential drugs
|
N/A
|
Increase in cost sharing associated with 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/mo; in ED visits by 14.2 and 54.2 per 10,000/mo for elderly and for welfare recipients respectively
|
Pilote 2002(53)
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 yrs. admitted to a QC hospital for a first acute myo-cardial infarction and discharged alive
|
CRNA assumed if 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
|
Persaud 2019(58, 65)
Randomized open label trial 2016-2017 with free access including free delivery of prescribed essential medication, compared to usual care
|
N = 786 adults > 18 yr old in 9 primary care practices in ON who reported CRNA (mean age 51.7 yr, 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.
|