I serve as Professor of Family Medicine, Director of Japanese Family Health Program, and Co-Director of the Michigan Mixed Methods Research and Scholarship Program at the University of Michigan. In addition to being a family/general doctor fluent in Japanese, I have long been interested in the influence of culture on medical decision making and ethics, and have conducted numerous health research projects, and published numerous papers in English and Japanese.
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Reshma Jagsi, MD, DPhil, is Professor, Deputy Chair, and Residency Program Director in the Department of Radiation Oncology and Director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan.
She graduated first in her class from Harvard College and then pursued her medical training at Harvard Medical School. She also served as a fellow in the Center for Ethics at Harvard University and completed her doctorate in Social Policy at Oxford University as a Marshall Scholar.
Dr. Harris’ research examines issues at the intersection of clinical obstetrical and gynecological care and law, policy, politics, ethics, history, and sociology. She conducts interdisciplinary, mixed methods research on many issues along the reproductive justice continuum, including abortion, miscarriage, contraception, in vitro fertilization (IVF), infertility and birth, and racial, ethnic, and socioeconomic disparities in access to reproductive health resources.
Christian Vercler is a Clinical Associate Professor of Pediatric Plastic Surgery at the University of Michigan C.S. Mott Children’s Hospital. He is a service chief of the Clinical Ethics Service in the Center for Bioethics and Social Sciences in Medicine (CBSSM). Dr. Vercler has a special interest in ethics in surgery and he holds master's degrees in both Theology and Bioethics. He has a passion for teaching medical students and residents and has won teaching awards from Emory University Medical School, Harvard Medical School, and the University of Michigan.
Because of the high cost of many prescription drugs, some people take fewer pills than prescribed. What are the health implications?
Imagine that four months ago, you started getting chest pains whenever you exerted yourself physically, and at the time you decided this was serious enough to see a doctor. After your doctor examined you and ran some tests, you were told that you have angina, a kind of heart disease. This disease can develop when the coronary arteries become narrow and clogged from high cholesterol and the heart can't get the oxygen that it needs. Your doctor helped you plan some lifestyle changes to treat your condition. You have been very devoted to the new way of life, eating healthier and doing the proper kinds of exercise regularly. Also, part of your treatment involves regularly taking the medication that your doctor prescribed for you. You were told to take one pill each day.
- I would take the pill every day as prescribed.
- I would skip some days to save some money.
How do your answers compare?
You have to save money somehow, right? Perhaps you would just have to cut back on other expenses in your life, but apparently you felt the medication had to be taken as prescribed. Research has found, however, that especially among the elderly, a significant portion of the population reports restricting medications due to cost. An important question is whether this leads to adverse health outcomes. Policy debates have been largely divided on this issue.
Do those who restrict their medications due to cost experience adverse health outcomes?
A research team led by Dr. Michele Heisler and Dr. Kenneth Langa conducted a study to investigate this question. Prior to this study, no one had examined this question by studying the same individuals at different points in time to see if those who restricted medication due to cost were more likely to develop adverse health outcomes. The researchers obtained nationally representative data that was the result of nearly 8000 interviews. Each respondent was interviewed in 1995 or 1996 and then re-interviewed in 1998. At both times, individuals were asked about cost-related medication restriction and about their health. The health questions assessed overall health, angina and other cardiovascular diseases, diabetes, arthritis, and depression.
The researchers found that cost-related medication restriction was associated with almost twice the odds of experiencing a significant decline in overall health. The association between restricting medication due to cost and poor health outcomes was strongest for those who had cardiovascular disease. Of these individuals, those who restricted their medication had a 50% increased odds of suffering angina and a 51% increased odds of having a stroke. Aren't you glad on the previous page you said you wouldn't restrict your angina medication?
Those who had arthritis or diabetes and restricted their medication due to cost did not report worse disease-related outcomes at the second interview. For arthritis, this might have been because of equally effective over-the-counter pain medications, and for diabetes, higher rates of kidney disease would likely require a longer period of follow-up to detect. When looking at age as a factor, the results showed that older adults experienced significant declines in overall health, worse cardiovascular outcomes, and increased depression. The study showed that younger people who restrict are also at risk for a decline in their health.
One limitation of this study is the lack of data about how often individuals restricted medications. If an individual restricted only once or twice, it is not clinically plausible that this would have led to an adverse health outcome. Also, the data on health outcomes were self-reported, and thus subject to bias. Previous studies, however, have shown excellent agreement between medical records and self-reports for conditions such as hypertension, diabetes, and stroke.
Implications on policy
This study provides evidence that, contrary to some claims, adults with chronic illnesses who restrict medications due to cost experience adverse health outcomes. As drug costs continue to escalate and individuals continue to lack full prescription coverage from their health insurance, it will be increasingly important for healthcare systems and physicians to develop strategies to screen patients for cost-related underuse of medications and to provide assistance to these patients. Moreover, insurance companies will need to create benefit packages that provide appropriate coverage, taking into account the cost of prescription medications.
For more information see:
Michele Heisler, Kenneth M. Langa, Elizabeth L. Eby, A. Mark Fendrick, Mohammed U. Kabeto, John D. Piette. The Health Effects of Restricting Prescription Medication Use Because of Cost. Medical Care, 42(7). 2004.
Patients sometimes skip treatments because they just feel too busy. What should physicians do when their patients ignore their recommendations?
Imagine you are a businessperson who works long hours and you are on your way up to having a successful and lucrative career. You have a major business deal that will consume nearly all of your time over the upcoming month and your boss is relying on you to make sure the deal goes through. This is your chance to really make your mark and show your corporation that you are the kind of person that can handle deals as big as this one. Also suppose you have been smoking on and off for 25 years. You know it's a bad habit that could destroy your lungs, but you just can't quite kick it. Lately, you have been feeling tired, you have been experiencing chest pains when you are really busy at work and when you exercise, and you have had trouble breathing when climbing a flight of stairs. The chest pains are usually relieved by a little rest, but you decide it's time to get this examined by a doctor.
One day after work, you go to see Dr. Coral, who gives you a stress test and determines that you'll need an appointment for an angiogram to better evaluate your coronary arteries. Fortunately, you find one free day right before things get hectic at work, so you schedule the angiogram. Now imagine you have just had the angiogram and you are recovering in a paper gown waiting for Dr. Coral to come back with the results. Dr. Coral enters the room to speak with you and he has a serious look on his face. He says,
"I have both good and bad news for you. The angiogram shows that your 3 main coronary arteries are all severely blocked. The good news is that we caught this before you had a major heart attack."
"The bad news is that I am recommending you have triple bypass surgery as soon as possible. Your heart is working overtime, and it is just a matter of time until it gives out."
- I would put aside Dr. Coral's recommendation and instead take responsibility at work for the current deal. I'll wait to have surgery in about a month.
- I would follow Dr. Coral's recommendation by having surgery immediately, even though this forfeits the current opportunity at work.
A little feedback on what you chose.
- understand the information about the condition and the choices available;
- make a judgment about the information in keeping with his or her personal values and beliefs;
- understand the potential outcomes or consequences of different choices; and
- freely communicate his or her wishes
Joel D. Howell is a Professor at the University of Michigan in the departments of Internal Medicine (Medical School), Health Management and Policy (School of Public Health), and History (College of Literature, Science, and the Arts), as well as the Victor C. Vaughan Professor of the History of Medicine. He received his M.D. at the University of Chicago, and stayed at that institution for his internship and residency in internal medicine. At the University of Pennsylvania, he was a Robert Wood Johnson Clinical Scholar, and received his Ph.D. in the History and Sociology of Science.
Raymond De Vries PhD is Associate Director at the Center for Bioethics and Social Sciences in Medicine at the University of Michigan and is a Professor in the Department of Learning Health Sciences and the Department of Obstetrics and Gynecology. He is also visiting professor at CAPHRI School for Public Health and Primary Care, University of Maastricht, the Netherlands.