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Am J Manag Care. 2009 Nov;15(11):833-40.

Cost-sharing and adherence to antihypertensives for low and high adherers.

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  • 1Health Economics Resource Ctr, Palo Alto VA Healthcare System, Menlo Park, CA 94025, USA.



To examine how the influence of cost-sharing on adherence to antihypertensive drugs varies across adherence levels.


Cross-sectional study using medical and pharmacy claims and benefits data on 83,893 commercially insured patients with hypertension from the 2000-2001 Medstat MarketScan Database.


We measured drug adherence using the medication possession ratio (MPR) for antihypertensive drugs over 9 months. Drug cost-sharing was measured as either copayments or coinsurance. Other patient characteristics included age, sex, comorbidity, health plan type, and county-level sociodemographics. We compared adherence for different cost-sharing categories with a bivariate test of equal medians and simultaneous quantile regressions predicting different percentiles of drug adherence.


Median MPR was high (>80%) across all cost-sharing categories. Among the poorest adherers, the regression-adjusted MPR was 8 to 9 points lower among patients with the highest drug cost-sharing compared with patients with the lowest cost-sharing (copayment $5 or less). The effects of cost-sharing were smaller at the median (2-3 points lower) and nonsignificant at higher levels of adherence. Other significant factors influencing adherence at low adherence levels were drug class and comorbidity.


Cost-sharing had a substantial negative association with adherence among low adherers and little association at higher adherence levels. At a clinical level, physicians should closely monitor adherence to antihypertensive drugs, particularly for patients with multiple comorbidities and those taking multiple drugs. At a health system level, current benefit designs should encourage adherence while limiting the cost burden of drugs for patients with multiple chronic conditions taking multiple drugs.

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