Understanding the CMAJ Study on Cost-Related Prescription Nonadherence

The Canadian Medical Association Journal (CMAJ) recently published a pivotal study examining disparities in cost-related prescription nonadherence between Black and White adults in Canada. Titled "Disparities in cost-related prescription nonadherence between Black and White adults in Canada," this research draws from five cycles of the Canadian Community Health Survey (CCHS) spanning 2015 to 2022. Researchers led by Bukola Salami from the University of Calgary analyzed data from adults aged 18 and older who self-identified as Black or White, providing national-level insights into how financial barriers affect medication adherence.

Cost-related prescription nonadherence, often abbreviated as CRNA, refers to behaviors such as not filling a prescription, delaying a refill, skipping doses, or taking smaller doses than prescribed because of out-of-pocket costs. This issue is particularly concerning in Canada, where while healthcare is universal through the Canada Health Act, prescription drugs are not covered nationally, leaving many to rely on private insurance, provincial plans, or personal funds.

Key Findings: 75% Higher Prevalence Among Black Adults

The study revealed stark disparities. In 2015, 15.3% of Black adults reported CRNA compared to 6% of White adults. By 2022, these rates had declined slightly to 9.5% for Black adults and 5.5% for White adults, yet the gap persisted. Overall, the prevalence of CRNA was 75% higher among Black adults than White adults, even after adjusting for factors like age, sex, education, household income, number of chronic conditions, self-perceived health, and having a regular healthcare provider.

Prescription drug coverage rates further highlight inequities: in 2015, 71.6% of Black adults had coverage versus 83% of White adults; by 2022, it was 72.5% versus 80%. Insurance significantly reduced CRNA for both groups, but Black adults remained at higher risk independently of coverage, suggesting deeper systemic issues such as employment discrimination affecting insurance access through employer plans.

Methodology and Data Robustness

The researchers used repeated cross-sectional data from Statistics Canada's CCHS, a nationally representative survey conducted every two years. Respondents were asked if, in the past 12 months, they did any of the following due to cost: did not fill a prescription, delayed filling or refilling, skipped doses, or took less medication. The sample included thousands of Black and White respondents across provinces, weighted for population representation.

Multivariable logistic regression models assessed crude and adjusted odds ratios (OR). Factors partially mediated the disparity, including lower income, fewer chronic conditions reported (possibly underdiagnosis), poorer self-perceived health, and lack of insurance. However, Black racial identity retained statistical significance (adjusted OR approximately 1.5-1.75 across models), indicating unmeasured factors like racism or mistrust in healthcare.

Broader Context of Racial Health Disparities in Canada

Black Canadians face disproportionate chronic disease burdens. They experience higher rates of diabetes, hypertension, cardiovascular disease, certain cancers, and HIV/AIDS mortality. Nonadherence exacerbates these, leading to poorer control, hospitalizations, and mortality. For instance, uncontrolled hypertension increases stroke risk by 4-6 times.

Systemic racism contributes: studies show Black patients receive fewer referrals, experience discrimination, and have less trust in providers. Geographic barriers in underserved neighborhoods and financial instability from wage gaps compound issues. A 2024 CMAJ study found overall CRNA at 4.9%, with racial minorities 20-67% more likely.

Photo by Andy Holmes on Unsplash

Trends Over Time and Insurance Gaps

• CRNA declined for both groups, possibly due to provincial expansions like Ontario's Trillium Drug Program or pandemic-era supports.
• Black coverage stagnated around 72%, while White dipped slightly, perhaps market shifts.
• Younger adults (18-34) and low-income households showed highest CRNA across races.

Employment-based insurance disadvantages precarious workers, overrepresented among Black communities due to discrimination.

Health Impacts of Nonadherence

CRNA leads to disease progression, emergency visits, and higher long-term costs. For Black Canadians with hypertension, skipping meds raises cardiovascular events by 30-50%. Diabetes nonadherence doubles complication risks like kidney failure. A prior study estimated free meds save $1641-$4465 per patient over 3 years via better outcomes.

Real-world example: In Toronto's Black communities, qualitative reports describe prioritizing rent/food over meds, leading to avoidable hospitalizations.

Policy Landscape: Pharmacare and Equity

Canada's Pharmacare Act (2024) aims for universal coverage starting with contraceptives/diabetes meds, bilateral deals with provinces. Yet, only 20% covered so far; full rollout uncertain post-2025 election. Experts like Salami urge equity: race-based data collection (e.g., PEI, NS), culturally safe dispensing, subsidies for uninsured.

Federal pharmacare updates highlight need for Black community input to avoid exacerbating gaps.

Solutions and Interventions

• Universal pharmacare without copays/deductibles.
• Expand provincial plans targeting racialized groups.
• Community pharmacies offering navigation, generics counseling.
• Anti-racism training for providers, trust-building initiatives.
• Race/ethnicity data in health records for targeted interventions.

U.S. studies show copay caps boost adherence 10-20% in minorities; adaptable to Canada. Patient-provider concordance improves adherence by 15%.

Photo by Donovan Dean Photography on Unsplash

Stakeholder Perspectives

Salami: "We need pharmacare based on need, not ability to pay." CMAJ editorial calls for urgent action amid rising drug costs. Black health advocates note employment racism limits coverage. Policymakers reference study in pharmacare debates.

Future Outlook and Research Needs

As pharmacare expands (target Jan 2026 for some), monitor impact on CRNA. Needed: longitudinal studies, intervention trials, qualitative Black voices. Higher ed role: train diverse pharmacists/public health experts. Universities like U Calgary lead equity research.

Optimistic: Declining trends suggest progress; equity-focused pharmacare could close gaps by 2030.