Miriam E. Tucker

November 03, 2013

WASHINGTON — One in 6 liver transplant recipients say they make trade-offs between buying food and their medication or they space out doses because they cannot afford them and try to make them last longer, a new study finds.

"Transplantations are not immune from these cost barriers," Marina Serper, MD, a transplant hepatology fellow at the University of Pennsylvania in Philadelphia, told Medscape Medical News. "Financial situations change. These things are important in the chronic disease population, and they're important in the transplant population as well."

Dr. Serper presented the results here at the Liver Meeting 2013: American Association for the Study of Liver Diseases (AASLD).

Session comoderator David Reich, MD, said, "When I started transplant surgery, I perceived the surgical hurdles, the immunosuppressive hurdles, and the organ shortage hurdles as the real challenges, but what you find is it's the simple things."

Dr. Reich, from Drexel University College of Medicine in Philadelphia, said during an interview that even relatively affluent patients can become financially challenged with the huge burden of medications and sometimes the inability to work. "Noncompliance is a big problem. It's not usually a problem of attitude; it's basically the realities of life."

Patients are embarrassed to ask. They feel proud and don't want to display vulnerability. Dr. David Reich

And although there are resources available ― including compassionate-use drug availability by most pharmaceutical companies ― people might not bring the issue up. "Patients are embarrassed to ask. They feel proud and don't want to display vulnerability," Dr. Reich explained. "It's definitely a problem."

Dr. Serper told Medscape Medical News, "I think we may want to check in once in a while and see how people are doing and if they're having issues. We need to give them more social support and to have our social workers get them help covering their meds. We're able to do that if we know about the problem," she pointed out. "We do a really good job of helping people cover medications, but sometimes if we don't ask, we don't know."

Previous studies have shown that the rate of nonadherence among patients with chronic conditions is about 50%. In the transplant world, approximately 30% of patients are nonadherent overall, with about 20% attributed to cost. About 50% of late transplant rejections and 15% to 35% of graft losses are due to nonadherence, Dr. Serper said.

In this new cross-sectional pilot study, a total of 105 liver transplant patients were interviewed at 2 US transplant centers, Northwestern in Chicago and Emory in Atlanta.

The mean age of the patients was 57.5 years; 41.8% were women, 80.6% were white, and 13.6% were black. A quarter did not complete high school, and 15.8% had annual household incomes of less than $20,000.

The interview included 4 questions about medication trade-offs that have been previously validated for the diabetes population:

  1. During the past 12 months, was there any time when you needed prescription meds but didn't get them because you couldn't afford it?

  2. Did you ever put off paying for meds so that you'd have money to buy food?

  3. Did you ever space out the frequency of taking your meds because you couldn't afford to buy more?

  4. Have you ever had to make a choice between buying medication and buying food?

Overall, 16.9% reported having made 1 or more medication trade-offs, with 9.7% answering yes to question 1, 4.9% to question 2, 5.8% to question 3, and 8.8% to question 4, Dr. Serper reported.

The patients reporting trade-offs did not differ by age, sex, or race compared with those without trade-offs. However, the trade-off group did have significantly lower household income (P = .001) and lower educational level (P = .06).

Patients with trade-offs were more than twice as likely to have limited literacy (34.9 vs 76.5%, P = .001). They also had more chronic comorbid conditions (1.1 vs. 1.9, P < .01), were taking more medications (10.0 vs. 12.6, P = .02), and had slightly higher readmission rates (0.8 vs. 1.0, P = .06).

When queried, nearly a quarter of the patients did not know what the majority of their medications were for, 26.9% were nonadherent by self-report, and 41.9% were unable to demonstrate proper dosing. In multivariate analysis, trade-offs were independently associated were inadequate knowledge, nonadherence by self-report, and readmission rate, Dr. Serper reported.

"We should think about multifaceted trials to look at interventions to improve adherence, additional patient and caregiver education, use of regimen monitoring and feedback, and improved coordination of care," she concluded in her presentation.

Dr. Serper told Medscape Medical News that one limitation of the study was that the questions did not ask all of the things that patients were trading for medications, nor did they assess whether it was antirejection medications, other chronic disease medications, or both that were being skipped.

But regardless, the solution lies in improved communication, the session's other comoderator, David Mulligan, MD, from Yale University and Yale–New Haven Transplantation Center in Connecticut, told Medscape Medical News.

"The message is always about better communication. We need to continue to educate patients of the need to let caregivers know if they're having financial difficulties. If they're running into problems, before they start cutting back on medications, they need to engage and get medications from other sources. There are a lot of sources out there to provide compassionate use of meds. If patients don't know about those resources and don't talk to their transplant providers, they won't have access."

Dr. Serper, Dr. Reich, and Dr. Mulligan report no relevant financial relationships.

The Liver Meeting 2013: American Association for the Study of Liver Diseases (AASLD): Abstract 5. Presented November 3, 2013.


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