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Adopting simple strategies to lower out-of-pocket medication costs for Canadians with peripheral arterial disease (PAD) may help improve adherence and ultimately health outcomes, according to a new study.

Writing prescriptions for 90 days or longer, choosing the lowest-cost generic drugs, and finding pharmacies with the lowest dispensing fees are strategies prescribers can use to reduce barriers to care for many of their patients with PAD. These strategies could save patients as much as several hundred dollars per month.

"There are simple, basic changes primary care providers can make that drastically impact the cost of basic medications for patients with peripheral vascular disease," study author Graham R. McClure, MD, a vascular surgeon at Halton Healthcare and researcher at the Population Health Research Institute of McMaster University in Hamilton, Ontario, Canada, told Medscape Medical News.

The findings were published on January 3, 2024, in the Canadian Journal of Surgery.

Cost Reductions Possible

"Patients with PAD are known to be financially disadvantaged, with some literature showing that it disproprtionately affects people of lower socioeconomic status," said McClure. "So, medication costs can be real barrier to care. Only a third of people with PAD are on the medication that they should be on, and when you talk to patients, you find out that they can't afford their medication. The point of this study was to figure out how to fix that."

The researchers compared the costs of drug therapies for PAD to identify prescribing approaches that minimize out-of-pocket expenses for these medications. Between March and June 2019, they contacted outpatient pharmacies in Ontario to evaluate the pricing of pharmacologic therapies for PAD at dosages included in the 2016 American College of Cardiology/American Heart Association guideline for the management of lower extremity PAD.

In addition, they gathered pricing information for supplementary charges, including delivery, pill splitting, and blister packaging. They calculated prescription prices with and without dispensing fees for 30-day brand-name and generic prescriptions and for 90-day generic prescriptions.

Among the 24 pharmacies contacted, four were hospital-based, 16 were chain-based, and four were independently owned. The average annual household income where the pharmacies were located ranged from $41,396 to $190,813.

The researchers observed substantial variations in cost for each drug, as well as variation between drugs in the same class. They also saw variation between brand-name drugs and the corresponding generic versions.

Differences in cost for 90-day supplies of the same drug sold at different pharmacies or produced by different companies ranged from $11.55 to $57.23 for generic medications and from $45.51 to $650.07 for brand-name drugs.

Dispensing fees also varied, ranging from $3.89 to $13.00, and were charged per medication fill and refill. This factor resulted in tripled fees for 30-day vs 90-day prescriptions.

Most pharmacies (20 of 24 or 83%) offered delivery, and 16 of them offered free delivery. Pill splitting and blister packaging were also offered by all but one pharmacy at no additional cost.

By selecting the least expensive option, prescribers could reduce the cost of PAD medicine by as much as $1377.26 every 90 days.

Generic Formulations

Costs were affected by the choice of agent within a drug class, generic vs brand-name drug, quantity dispensed, dispensing fee, and delivery cost, if any.

Regarding concerns about the interchangeability of generic and brand-name medications, the researchers noted that a systematic review and meta-analysis found no significant difference in efficacy between these two groups.

"In light of this and the substantial cost disparity observed in the present study, it is difficult to justify continued prescription of brand-name agents, particularly in populations of low socioeconomic status," they wrote.

A generic formulation of rivaroxaban has recently become available in Canada, and it should help patients with PAD and lower incomes gain needed access to therapy, said McClure.

"It was a very expensive drug, and now people can get it for $30 per month, vs $120. There may be a huge uptake in the use of rivaroxaban, now that it is available in Canada. Doctors would prescribe it, but they know that some of their patients are not able to afford it, but hopefully, this will start breaking down barriers to care," he said.

Patient Education Needed

Commenting on the findings for Medscape Medical News, Mohammad Qadura, MD, assistant professor of vascular surgery at the University of Toronto and surgeon-scientist in the division of vascular surgery at St. Michael's Hospital in Toronto, Ontario, Canada, said that reducing out-of-pocket medication costs may improve compliance to medication but will not be enough solve the issue. Qadura did not participate in the study.

"It's part of the solution but not the whole solution. For example, we start all our patients with PAD on aspirin. A year's supply of aspirin costs $19. You would be surprised at how many of my patients choose not to take aspirin but instead choose to smoke a pack of cigarettes a day, which costs about $15. So, in addition to making medications more affordable, we need to educate these patients," said Qadura.

Patients often lie about taking their medication, he added. "I did a very small study on about 150 patients, all with PAD. When I asked them if they were taking their aspirin, they all looked me in the eye and said yes, they take their aspirin every day. But when we tested a urine sample as part of our study, we found that almost 40% of those who said they were taking aspirin had no metabolites in their urine, so they were not taking the medication. We need to really educate our patients about the disease itself and the consequences of not taking their medicine as prescribed."

No funding for the study was reported. McClure and Qadura reported no relevant financial relationships.