Kennedy Jae, Morgan Steve
Department of Health Policy and Administration, Washington State University, Spokane, Washington, USA.
Clin Ther. 2009 Jan;31(1):213-9. doi: 10.1016/j.clinthera.2009.01.006.
Prior research indicates that residents of the United States are nearly twice as likely as Canadian residents to report cost-related nonadherence (CRNA) (ie, being unable to fill > or =1 prescription due to cost). However, these kinds of national comparisons obscure important within-country differences in insurance coverage.
This study was designed to compare rates of CRNA across major financing systems for prescription drugs in the United States and Canada.
This study used the 2007 International Health Policy Survey in Seven Countries (supported by the US Commonwealth Fund) to estimate rates of CRNA in the following health systems: Canadian compulsory coverage (Quebec), Canadian senior and social assistance coverage (Ontario), Canadian income-based coverage (British Columbia, Manitoba, and Saskatchewan), Canadian mixed coverage (all other provinces), US private coverage (employer-based or individual insurance), US senior and social assistance coverage (Medicare and/or Medicaid), and US no coverage (uninsured).
Adults in the United States were far more likely than adults in Canada to report CRNA (23.1% vs 8.0%; chi(2) = 147.4; P < 0.001). Seniors (> or =65 years of age) were less likely than younger adults (<65 years) to report CRNA in both the United States (9.2% vs 25.8%; chi(2) = 64.3; P < 0.001) and Canada (4.6% vs 8.7%; chi(2) = 14.9; P < 0.001), presumably due to categorical eligibility for prescription drug insurance. Comparative analyses therefore focused on working-age adults (<65 years). Adults in Quebec (who have compulsory drug coverage) were only half as likely as those in Ontario to report CRNA (odds ratio [OR] = 0.5; 95% CI, 0.3-0.8). Uninsured adults in the United States were >7 times as likely to report CRNA (OR =7.2; 95% CI, 5.0-10.5), and adults with public insurance (OR = 2.2; 95% CI, 1.4-3.5) and private insurance (OR = 2.2; 95% CI, 1.6-3.0) were >2 times as likely to report CRNA.
After stratifying by age and simultaneously adjusting for sex, household income, and chronic illness, large differences in CRNA were found between and within countries. Even in a compulsory prescription insurance system like that in Quebec, 4.4% of working-age adults reported CRNA. However, these rates were low compared with CRNA rates for working-age adults in the United States who lack any health insurance (43.3%).
先前的研究表明，美国居民报告与费用相关的不依从（CRNA，即因费用问题无法填写≥1张处方）的可能性几乎是加拿大居民的两倍。然而，这类全国性比较掩盖了各国国内保险覆盖情况的重要差异。
本研究旨在比较美国和加拿大主要处方药筹资系统中的CRNA发生率。
本研究使用了2007年七国国际卫生政策调查（由美国联邦基金支持）来估计以下卫生系统中的CRNA发生率：加拿大强制保险覆盖（魁北克省）、加拿大老年人和社会救助覆盖（安大略省）、加拿大基于收入的保险覆盖（不列颠哥伦比亚省、曼尼托巴省和萨斯喀彻温省）、加拿大混合保险覆盖（所有其他省份）、美国私人保险覆盖（雇主提供或个人保险）、美国老年人和社会救助覆盖（医疗保险和/或医疗补助）以及美国无保险覆盖（未参保）。
美国成年人报告CRNA的可能性远高于加拿大成年人（23.1%对8.0%；χ² = 147.4；P < 0.001）。在美国（9.2%对25.8%；χ² = 64.3；P < 0.001）和加拿大（4.6%对8.7%；χ² = 14.9；P < 0.001），老年人（≥65岁）报告CRNA的可能性均低于年轻人（<65岁），这可能是由于处方药保险的分类资格。因此，比较分析集中在工作年龄成年人（<65岁）。魁北克省（拥有强制药品保险）的成年人报告CRNA的可能性仅为安大略省成年人的一半（优势比[OR] = 0.5；95%置信区间，0.3 - 0.8）。美国未参保成年人报告CRNA的可能性超过7倍（OR = 7.2；95%置信区间，5.0 - 10.5），而有公共保险（OR = 2.2；95%置信区间，1.4 - 3.5）和私人保险（OR = 2.2；95%置信区间，1.6 - 3.0）的成年人报告CRNA的可能性超过2倍。
在按年龄分层并同时调整性别、家庭收入和慢性病因素后，发现各国之间以及各国国内CRNA存在巨大差异。即使在魁北克省这样的强制处方药保险系统中，4.4%的工作年龄成年人报告了CRNA。然而，与美国缺乏任何医疗保险的工作年龄成年人的CRNA发生率（43.3%）相比，这些发生率较低。
