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Cardiovascular Disease: Reducing Out-of-Pocket Costs for Cardiovascular Disease Preventive Services for Patients with High Blood Pressure and High Cholesterol

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What the Task Force Found

About The Systematic Review

The Task Force finding is based on evidence from a systematic review of 31 studies with 35 study arms (search period: beginning of database – July 2013). The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to cardiovascular disease prevention.

Context

Reducing out-of-pocket costs (ROPC) for patients with high blood pressure and high cholesterol involves program and policy changes that make cardiovascular disease preventive services more affordable. These services include medications, behavioral counseling (e.g., nutrition counseling), and behavioral support (e.g., community-based weight management programs, gym membership). Costs for these services can be reduced by providing new or expanded treatment coverage and lowering or eliminating patient out-of-pocket expenses (e.g., copayments, coinsurances, deductibles).

ROPC is coordinated through the health care system and preventive services may be delivered in clinical or non-clinical settings (e.g., worksite, community). ROPC can be implemented alone or in combination with additional interventions to enhance patient-provider interaction such as team-based care, medication counseling, and patient education. Program and policy changes may be communicated to patients and providers using targeted messages to increase awareness and use of covered services.

Summary of Results

  • Eighteen included studies were stratified based on suitability of study designs, as defined by the Task Force (Briss et al., 2000). Reducing out-of-pocket costs for patients was associated with improvements in medication adherence, and blood pressure and cholesterol outcomes.
  • 12 studies used designs considered to be of greatest/moderate suitability: individual randomized controlled trial (3 studies), other designs that have a concurrent comparison group (6 studies), retrospective cohort (2 studies), post only with concurrent comparison (1).
  • 6 studies used a design considered to be least suitable: before-after without a comparison group.

Summary of Economic Evidence

The economic review included nine studies, seven of which evaluated reducing out-of-pocket costs within a value-based insurance design. Two of the nine studies combined reduced cost for medications with team-based care and three combined VBID with support for disease or lifestyle management, with only one study providing separate estimates for the cost to implement the component interventions. Monetary values are reported in 2014 U.S. dollars.

  • Three studies of VBID reported net benefits, with 2 showing the cost of intervention exceeded averted health care costs by $337 and $90 per patient per year, and the third showing the intervention was cost-neutral.
  • No studies reported cost-effectiveness results.
  • The median intervention cost per person per year was $172 (IQI: $70 to $529, n = 10), 9 studies.
    • The higher estimates included blood pressure-lowering and diabetes medications.
  • Median change in health care cost was –$127 (IQI: –$632 to –$18, n = 8), 7 studies.
    • Estimates from all but two studies were the result of ROPC combined with other interventions.

An overall economic conclusion cannot be reached because the net benefit evidence is small and inconsistent and no studies reported cost-effectiveness.

Applicability

Results from included studies are applicable to various groups with access to health care, including:

  • Adults (18-64 years old)
  • Women and men
  • Hispanic, white, and African-American patients
  • Low income patients

Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified Evidence Gaps

  • None of the included studies examined effectiveness of reducing out-of-pocket costs (ROPC) for behavioral counseling or behavioral support interventions independent of ROPC for medications. Additional studies could examine ROPC programs and policies for these preventive services, especially when coordinated with ROPC for medications to control high blood pressure and high cholesterol.
  • The majority of included studies eliminated patients' costs for medication but only a few studies reported the actual dollar amount saved by patients. Studies that eliminated the cost for generic medications and lowered the cost for brand name drugs did not report how often patients chose generic vs. brand name medications. Additional research could describe and examine effectiveness of ROPC by total medication cost, proportional cost-reduction, patient income, or drug patent type.
  • In general, policy studies that examined the impact of ROPC for medications for an entire patient population only measured changes in medication adherence. Conversely, studies of multicomponent programs that included ROPC for medications examined clinical outcomes for patients in the program, but did not report on changes in medication adherence. Both outcomes provide useful information to those implementing programs and should be reported.
  • To increase awareness and use of ROPC-covered services, it is important to promote benefits among patients and providers. Only three of the included studies described such communications to patients. Information about effective strategies to promote covered benefits to patients and providers would be useful to implementers.
  • Several economic evaluations of multicomponent interventions that included ROPC only provided the cost for some of the components. More information is needed about the overall costs of these interventions.
  • Frequently, cost-effectiveness could not be calculated because studies did not report clinical outcomes.

Study Characteristics

  • Eighteen included studies were stratified based on suitability of study designs, as defined by the Task Force (Briss et al., 2000). Reducing out-of-pocket costs for patients was associated with improvements in medication adherence, and blood pressure and cholesterol outcomes.
  • 12 studies used designs considered to be of greatest/moderate suitability: individual randomized controlled trial (3 studies), other designs that have a concurrent comparison group (6 studies), retrospective cohort (2 studies), post only with concurrent comparison (1).
  • 6 studies used a design considered to be least suitable: before-after without a comparison group.
Medication Adherence
  • Patients' adherence to blood pressure and cholesterol-lowering medications
    • Greatest/moderate suitability studies: median increase of 3.0 percentage points (interquartile interval [IQI]: 2.3 to 4.5; 6 studies, 15 arms).
  • Proportion of patients achieving 80% adherence
    • Greatest/moderate suitability studies: increase of 5.1 pct pts (1 study)
Blood Pressure
  • Patients' systolic blood pressure
    • Greatest/moderate suitability studies: median decrease of 5.9 mmHg (range: -10.7 to 3.8; 4 studies)
    • Least suitability studies: decrease of 8.7 mmHg (IQI: -14.5 to -5.5 mmHg; 6 studies)
  • Patients' diastolic blood pressure
    • Greatest/moderate suitability studies: median decrease of 3.8 mmHg (range: -6.1 to -2.1 mmHg; 4 studies)
    • Least suitability studies: median decrease of 4.5 mmHg (IQI: -7.8 to -3.8 mmHg; 6 studies)
  • Proportion of patients achieving blood pressure goal (<140 mmHg/90 mmHg; ≤130/80 mmHg for people with diabetes)
    • Greatest/moderate: median increase of 6.0 pct pts (range: -8.2 to 17.0 pct pts; 3 studies)
    • Least suitability studies: median increase of 30.1 pct pts (IQI: 20.3 to 46.5 pct pts; 4 studies)
Cholesterol
  • Patients' total cholesterol
    • Greatest/moderate suitability design: decrease of 15.0 mg/DL; 1 study
    • Least suitability design: decrease of 25.0 mg/dL; 1 study
  • Patients' low-density lipoprotein (LDL)
    • Greatest suitability design: median decrease of 14 mg/dL (range: -16.0 to -6.9 mg/dL; 3 studies)
    • Least suitability of design: median decrease of 14 mg.dL IQI: -18.9 to 10.9 mg/dL; 3 studies, 6 study arms)
  • Patients LDL level at goal (<100mg/dL for most patients)
    • Greatest suitability studies: increases of 13.0 and 24.0 pct pts; 2 studies
    • Least suitability studies: increase of 10 pct pts; 1 study
  • Patients' triglycerides
    • Greatest suitability studies: decreases of 13.0 and 9.8 mg/dL; 2 studies
    • Lest suitability studies: decreases of 38.4 and 25.0 mg/dL; 2 studies

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