The finding that relatively young stroke survivors have less access to care and more difficulty affording medications than their older counterparts reflects the more widespread problem of lack of medical insurance in the United States, which has “staggering ramifications,” according to Dr. Steven Levine, professor of neurology and director of the cerebrovascular education program at The Mount Sinai Stroke Center and School of Medicine, New York, speaking in an interview.

“We can no longer assume that younger stroke survivors have better access to care than their older counterparts,” he said, commenting on findings from research by Dr. Deborah A. Levine of the University of Alabama, Birmingham and her colleagues. The Drs. Levine are not related.

Dr. Deborah A. Levine reported that between 1997 and 2004, the number of stroke survivors aged 45–64 years in the United States who were unable to afford prescribed medications increased significantly from 8% to 13% (Stroke 2007;38:1557–64).

The findings, based on the responses of 5,840 individuals who participated in the National Health Interview Survey—an in-person household survey conducted annually by the National Center for Health Statistics—suggest that in 2004, about 76,000 stroke survivors in the United States were unable to afford prescribed medications. Those under age 65—along with blacks, women, and those with high comorbidity or low health status—had the lowest rates being able to afford their medications. A number of barriers to care and medications were identified among those with reduced ability to afford medication, suggesting these are particularly vulnerable populations.

For example, compared with stroke survivors who were able to afford medications, those who could not more often had a lack of transportation (15% vs. 3%), no health insurance (16% vs. 3%), annual income below $20,000 (66% vs. 40%), no usual place of care (6% vs. 2%), and out of pocket medical expenses of $2,000 or more.

These barriers to care likely equate to the barriers to secondary stroke prevention—and thus to an increased risk of subsequent cardiovascular event, according to Dr. Deborah A. Levine and her associates, who noted that medication access is an essential component of secondary stroke prevention.

Ischemic stroke survivors have up to a 14% annual risk of recurrent stroke, and also are at risk for other cardiovascular events that can adversely affect health, quality of life, and finances; younger patients often are in the most productive years of life, and thus may be hit the hardest by these effects. Stroke tops the list of disabling diseases among adults, with only 1 in 5 returning to work, 1 in 11 returning to work full time, and 1 in 30 becoming institutionalized, according to one study that looked at stroke survivors 3 months following the event (Arch. Phys. Med. Rehab. 2000;81:205–9).

Dr. Deborah A. Levine's findings expand on those from an earlier study in which she and her colleagues found that younger age among stroke survivors was associated with no general doctor visit (odds ratio 1.4), no medical specialist visit (odds ratio 1.69), and an inability to afford medications (odds ratio 2.94) in the previous 12 months after adjusting for sex, race, income, neurologic disability, health status, and comorbidity. Lack of health insurance explained the lack of access to medical care—which is particularly problematic when it comes to primary care visits since the majority of secondary prevention measures are prescribed by primary care physicians—but did not explain the lack of ability to afford medications. After adjusting for health insurance, younger age remained independently associated with reduced medication affordability, perhaps because of competing expenses or lack of prescription drug coverage, Dr. Deborah A. Levine said in an interview.

For the earlier study, Dr. Deborah A. Levine and her colleagues used 1998–2002 data from the National Health Interview Survey, including responses from 3,681 stroke survivors, representing about 4 million U.S. stroke survivors, nearly a third of whom are aged 45–64 years. The implications of the findings of these studies are numerous and alarming, according to the investigators (Arch. Neurol. 2007;64:37–42).

For example, reduced medication access, specifically patient self-reduction in prescription use, has been associated with increased serious adverse event rates and emergency department visits, a number of adverse health conditions and outcomes in diabetics, and high rates of angina and nonfatal stroke or myocardial infarction in those with cardiovascular disease.

And given that stroke survivors are discharged from rehabilitation with an average of 11 medications totaling about $750 per month (based on 2004 monthly average wholesale price), according to one study, and given that stroke survival is improving while age-specific stroke incidence is remaining constant and the size of the 65 and older population is increasing—as is the number of uninsured nonelderly in the United States—the the long-term care of stroke survivors will prove costly, Dr. Deborah A. Levine said.

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