Coping Strategies Used by Patients Infected with Hepatitis C Virus Who Are Facing Medication Costs

Coping Strategies Used by Patients Infected with Hepatitis C Virus Who Are Facing Medication Costs

Chiranjeev Sanyal, Ethel Langille Ingram, Ingrid S Sketris, Kevork M Peltekian, Susan Kirkland



The prevalence of infection with hepatitis C virus (HCV) is increasing worldwide. Antiviral therapy, prescription and nonprescription medications, and nondrug therapies to treat HCV infection and to manage associated adverse effects are costly.


To determine whether individuals infected with HCV attending a hepatology clinic were negatively affected by the costs of prescription medications, and if so, to determine coping strategies they adopted.


Patients infected with HCV attending Hepatology Services, a clinic within the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, were interviewed as part of an exploratory study (April 2 to July 8, 2008). The interview was based on a validated survey adapted for Nova Scotia. Information collected included demographic characteristics; types of prescription, nonprescription, and complementary medications used by patients; and strategies patients adopted to pay their medication costs.


Fifty patients (age 33–64 years) participated in the interviewer-administered survey, including 35 (70%) men and 19 people (38%) with household income less than $30 000. Frequently used medications were antidepressants (19 patients [38%]), antihypertensive agents (12 [24%]), anxiolytics (10 [20%]), and nonsteroidal anti-inflammatory drugs (10 [20%]). More than half (29 [58%]) were concerned about having sufficient money to pay for their medications. Coping strategies adopted in response to costs of prescription medications were either self-initiated or undertaken in consultation with physicians and/or other health care professionals. Sixteen (32%) of the respondents expressed the belief that physicians usually do not consider patients’ concerns about affordability when prescribing medications. Seven (14%) indicated they would seek help from a pharmacist to buy low-cost substitutes for their medications.


This study highlighted a range of coping strategies adopted by patients infected with HCV in response to medication costs. It underscores that cost may limit access to essential medications within this patient population, even in a publicly funded health care system. Some of the coping strategies adopted might reduce patients’ persistence and adherence with medication therapy, which could lead to adverse health outcomes. Hospital and community pharmacists need to be aware of the challenges faced by patients in terms of paying for medications and should consider possible proactive responses to address potentially detrimental coping strategies.

KEYWORDS: hepatitis C virus, treatment, cost of medications, chronic disease, coping strategies, pharmacists


Contexte :

La prévalence de l’infection par le virus de l’hépatite C (VHC) augmente à l’échelle planétaire. Les traitements antiviraux, les médicaments d’ordonnance et en vente libre, ainsi que les traitements non médicamenteux contre l’infection par le VHC et pour prendre en charge les effets indésirables connexes coûtent cher.

Objectif :

Évaluer si les personnes infectées par le VHC qui fréquentaient une clinique d’hépatologie étaient touchées négativement par le coût des médicaments d’ordonnance et, le cas échéant, déterminer les stratégies d’adaptation qu’ils ont adoptées.

Méthodes :

Des patients infectés par le VHC qui fréquentaient les services d’hépatologie, une clinique au sein du Queen Elizabeth II Health Sciences Centre à Halifax, en Nouvelle-Écosse, ont été interviewés dans le cadre d’une étude préliminaire (du 2 avril au 8 juillet 2008). L’entrevue était fondée sur un sondage validé qui avait été adapté pour la Nouvelle-Écosse. Les données collectées comprenaient les caractéristiques démographiques; les types de médicaments d’ordonnance, en vente libre et complémentaires consommés par les patients; et les stratégies utilisées par ceux-ci pour payer leurs médicaments.

Résultats :

Un total de 50 patients (âgés de 33 à 64 ans) ont participé à l’entrevue-sondage. De ces participants, 35 (70 %) étaient des hommes et 19 (38 %) avaient un revenu familial inférieur à 30 000 $. Les médicaments couramment utilisés étaient les antidépresseurs (19 patients [38 %]), les antihypertenseurs (12 [24 %]), anxiolytiques (10 [20 %]) et les antiinflammatoires non stéroïdiens (10 [20 %]). Plus de la moitié des participants (29 [58 %]) étaient inquiets de ne pas avoir suffisamment d’argent pour payer leurs médicaments. Les stratégies utilisées pour s’adapter aux coûts des médicaments d’ordonnance étaient entreprises par les patients eux-mêmes ou en collaboration avec les médecins ou d’autres professionnels de la santé. Des répondants, 16 (32 %) ont dit croire que les médecins ne tenaient généralement pas compte des préoccupations des patients à propos de l’abordabilité lorsqu’ils leur prescrivaient des médicaments. Sept patients (14 %) ont mentionné qu’ils demanderaient l’aide d’un pharmacien pour acheter des substituts à prix inférieurs.

Conclusion :

Cette étude met en lumière des stratégies d’adaptation qui ont été adoptées par des patients infectés par le VHC en réponse au coût des médicaments. Elle souligne la possibilité que le coût limite l’accès à des médicaments essentiels dans cette population de patients, même dans un système de soins de santé universel. Certaines des stratégies d’adaptation utilisées pourraient nuire à la poursuite et à l’observance du traitement, ce qui pourrait entraîner des résultats cliniques indésirables. Les pharmaciens communautaires et hospitaliers doivent être conscients des difficultés auxquelles se heurtent les patients pour payer leurs médicaments et envisager des réponses proactives éventuelles pour redresser des stratégies d’adaptation potentiellement préjudiciables.

MOTS CLÉS: virus de l’hépatite C, traitement, coût des médicaments, maladie chronique, stratégies d’adaptation, pharmaciens

[Traduction par l’éditeur]


About 5000 Canadians become infected with the hepatitis C virus (HCV) annually, and the average lifetime cost (i.e., medical costs and economic losses) for an affected patient, from the time of diagnosis to death, has been estimated at $1 million.1 In 2005, HCV infections cost the Canadian health care system about $500 million, an amount that was expected to double by 2010.1 These trends are similar to those in the United States, where models from the year 2010 through 2019 project more than 190 000 deaths due to HCV, 165 900 deaths from chronic liver disease and 27 200 deaths from hepatocellular carcinoma, with direct medical and societal costs estimated at US$10.7 billion and US$54.2 billion, respectively.2 Medication costs incurred by patients with HCV infections may include costs for prescription, non-prescription, and complementary medications (including natural health products, such as vitamins and minerals, herbal remedies, and homeopathic medicines) related to their antiviral treatment, to the management of adverse effects (i.e., drug-related morbidity from the antiviral treatment), and to any comorbid conditions.

In 2007, the prevalence of HCV infection in Atlantic Canada was estimated at 7961 cases, including 4252 cases in Nova Scotia.3 Furthermore, 46% of affected Nova Scotians were unaware of their infection.35 The current treatment for HCV infection combines pegylated interferon and ribavirin in a regimen lasting either 24 or 48 weeks, depending on viral genotype.6 This treatment combination costs, on average, $1748 per month per patient.7 The adverse effects of HCV treatment can be substantial,8 and patients with HCV infection may also have comorbidities. Patients may require prescription, nonprescription, and complementary medications to manage the adverse effects of antiviral drug treatment and to manage comorbidities,9 which, depending on their drug coverage plan, may lead to additional out-of-pocket costs. Coverage for prescription drugs in Canada is not universal and varies from province to province.10 As a result, these medication costs may be “catastrophic” for a certain proportion of patients. In 2002, both the report of the Commission on the Future of Health Care in Canada (the Romanow Commission)11 and the report of the Standing Senate Committee on Social Affairs, Science and Technology (the Kirby report)12 recommended federal funding for catastrophic drug coverage. The Romanow Commission defined “catastrophic” to mean expenditures of $1500 or more annually on drugs,11 whereas the Kirby report used a definition of 3% of family income.12 In a 2009 document, the Canadian Parliamentary Information and Research Service13 reported that about 17% of Canadian adults with a chronic illness had out-of-pocket expenses of more than $1000 for prescription drugs each year. Similar concerns were identified in a 2009 study of US households with Medicaid coverage.14

Faced with financial constraints, patients may adopt a range of coping strategies to deal with the out-of-pocket expenses required to access essential medications.1518 Such coping strategies might lead to a lack of persistence and adherence with medication use, poor health outcomes, and higher overall health care costs.19,20 The unintended effects of patients’ coping strategies arising from cost-sharing policies might exacerbate the burden of the disease. Studies have suggested that the burden of out-of-pocket expenses for prescription and non-prescription drugs might be profound for certain patients with chronic disease, in spite of current drug coverage plans with low copayments and/or deductibles.14,16,21 Among patients with HCV, the effects of prescription, nonprescription, and complementary medication costs to manage comorbid conditions and the adverse effects of antiviral treatment have not been reported.

The objectives of this study were to examine the types of prescription, nonprescription, and complementary medications (including natural health products) used to treat comorbidities and medication-related adverse effects related to antiviral treatment for HCV infection, to identify the coping strategies adopted by affected patients to meet the costs of these concomitant medications and complementary remedies, and to determine patients’ inclination to discuss medication cost issues with their physicians or pharmacists.


Study Population

In Nova Scotia, more than 90% of patients with HCV infection receive care through Hepatology Services, located at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, within the Capital District Health Authority. This collaborative practice team, including 2 nurse practitioners and a hepatologist (K.M.P.), responds to the health needs of more than 4000 patients with chronic liver diseases. Hepatology Services receives about 1400 outpatient clinic visits annually for the management of HCV infection (G. Hirsh, Nurse Practitioner, Hepatology Services, Queen Elizabeth II Health Sciences Centre, Capital District Health Authority, Halifax, Nova Scotia; personal communication, July 16, 2010). There is no dedicated clinical pharmacy service for the hepatitis C outpatient clinic, and patients fill their prescriptions at their own community pharmacies. Given their regional focus, the 2 nurse practitioners are able to negotiate the health care system on behalf of their patients to ensure access to HCV medications through private drug insurance, publicly funded Nova Scotia Community Services Pharmacare22 (for those on social assistance), and through reimbursement programs supported by pharmaceutical manufacturers (i.e., Peg-Care and Pegassist).23 The study population was drawn from patients with HCV infection who received care through Hepatology Services. Patients were eligible for inclusion if they were living in Nova Scotia, were 19 years of age or older, were eligible to receive treatment for HCV infection, and were able to understand English sufficiently to answer the survey questionnaire. The exclusion criteria were based on contraindications for antiviral drug treatment for HCV infection, including serious social, mental, or medical conditions that would impede the patient’s ability to tolerate therapy or being pregnant.


A questionnaire developed by Schafheutle and others24 in the United Kingdom was adapted for the Nova Scotia setting by a group of 4 experts in HCV and epidemiology survey methods (including K.M.P. and S.K.). The adapted survey was pilot-tested with 2 patient volunteers from the Hepatology Services outpatient clinic. The structured questionnaire (entitled “A Nova Scotia Survey of Health and Health Care Costs for Hepatitis C”) had questions about the patient’s general health status, his or her experience with HCV infection, specific medications taken (e.g., prescription, nonprescription, and complementary medications, including natural health products such as vitamins and minerals, herbal remedies, and homeopathic medicines), personal knowledge about HCV, knowledge about and attitudes toward prescription medication costs, and reflections on health care providers’ sensitivity to costs. The survey also included questions about current drug insurance coverage and background demographic information. The complete survey is available from the authors upon request.

After receipt of ethics approval from the Capital District Health Authority Research Ethics Board (approval CDHA-RS/2007-358), the 2 nurse practitioners identified potential participants who either were currently attending or had previously attended Hepatology Services clinics and who met the inclusion criteria and were not excluded by the exclusion criteria. Once the nurse practitioners had initiated communication, an independent researcher (E.L.I.) contacted each person to request their participation in the survey. Written informed consent was obtained before each interview. All interviews were conducted in person at the Queen Elizabeth II Health Sciences Centre, between April 2 and July 8, 2008, with the exception of one interview conducted by telephone (after written consent had been received).

Urban/Rural and Income Characteristics

Each participant’s location of residence, in terms of urban or rural setting, was determined from the first 3 alphanumeric characters of the person’s postal code, which was collected during the interview. Participants were also asked to identify 1 of 11 categories of total gross household income from all sources during the past 12 months. These categories were collapsed into 3 categories, with cut points based on maintaining equivalent cell sizes (for statistical purposes) while capturing meaningful income brackets: less than $30 000, between $30 000 and $69 999, and $70 000 or more. This categorization was guided by Statistics Canada’s low-income cut-offs for 200825: in urban areas, $22 171 for a single individual and $41 198 for a household of 4 people; in rural areas, $15 262 for a single individual and $28 361 for a household of 4 people.

Medications Used

Data about medications identified by the participants were based on responses to the question “Below, please list the name(s) of the drugs for hepatitis C (HCV) that you get on prescription from your doctor and, if possible, the strength of the medicine, other prescription drugs, nonprescription drugs and complementary medicines, including natural health products and herbal remedies.” The prescription medications were classified into therapeutic categories according to the 2010 World Health Organization Anatomical Therapeutic Chemical (WHO/ATC) system. Only those therapeutic categories reported by 5 or more respondents are reported here.

Statistical Analysis

The cross-sectional survey data were assessed, and responses were collapsed as appropriate (i.e., groupings of “always”, “often”, and “sometimes”; “strongly agree” and “agree”; and “disagree” and “strongly disagree”) to describe the study population and address the objectives. Descriptive statistics were generated with SPSS statistical software (version 17.0.1, SPSS Inc, Chicago, Illinois).


Of the 87 potential participants initially identified, 50 (57%) completed the survey. Nonparticipants included people who could not be contacted, those who declined to participate, and “no shows”.

Patient Characteristics

The majority of the participants were male (n = 35 [70%]) and were living in an urban area (n = 44 [88%]) (Table 1). Participants ranged in age from 33 to 64 years. Nineteen (38%) of the respondents had household income less than $30 000. Five participants (10%) reported that their general health status was “bad/very bad”, and 10 participants (20%) had 5 or more comorbid conditions (Table 1).

Table 1. Characteristics of 50 Survey Respondents with Hepatitis C Virus, Seen by Hepatology Services, Capital District Health Authority, Halifax, Nova Scotia, Canada, 2008


Respondents reported taking a range of prescription medications, with antidepressants being the most frequent therapeutic class (Table 2). Two-thirds of the study participants (n = 33 [66%]) had a private drug insurance plan, and a further 13 (26%) had coverage through Nova Scotia Community Services Pharmacare. Respondents also reported taking a range of nonprescription and complementary medications, such as antiemetics, antihistamine, calcium, eye care products, laxatives, pain relievers, skin care products, vitamins, and milk thistle (Table 2). At the time of the survey, 35 (70%) of the study participants had completed their antiviral HCV treatment; hence they did not identify current use of antiviral medications.

Table 2. Use of Concomitant Medications and Drug Insurance Reported by 50 Survey Respondents with Hepatitis C Virus, Seen by Hepatology Services, Capital District Health Authority, Halifax, Nova Scotia, Canada, 2008


Coping Strategies

Strategies to Meet Prescription Medication Costs

More than half of the respondents (n = 29 [58%]) indicated that they were thoughtful about how much money they had available to spend when they were obtaining medications (Table 3). The most common strategies were borrowing money to pay for prescriptions (n = 15 [30%]), staggering the filling of prescriptions for multiple medications listed on a single prescription form (n = 10 [20%]), and waiting until they got paid before filling a prescription (n = 9 [18%]).

Table 3. Perceptions about Affordability of and Access to Medications, as Reported by Survey Respondents with Hepatitis C Virus in Halifax, 2008


Table 4 illustrates the concerns related to medication costs of the 19 patients with household income below $30 000: 14 (74%) would consider the price of a nonprescription medication before purchasing it without a prescription; 12 (63%) would request a prescribed medication if it was covered (by insurance, etc.) because nonprescription and over-the-counter medications were too expensive; and 11 (58%) would request a low-cost substitute (e.g., a natural health product) at the pharmacy as an alternative to an expensive nonprescription health product.

Table 4. Strategies to Ensure Access to Prescribed Medications, as Reported by Survey Respondents with Hepatitis C Virus in Halifax, 2008


Strategies Involving Health Care Professionals

Many respondents (n = 15 [30%]) reported asking the doctor or a nurse practitioner to provide free samples of medications to save the prescription charge (Table 4). Others asked the doctor or a nurse practitioner to recommend low-cost substitutes that could be purchased without a prescription (n = 12 [24%]) or requested a longer-duration supply (n = 9 [18%]), to reduce the costs of pharmacists’ professional fees for processing prescriptions.

Self-initiated Practices for Nonprescription Medications

Several of the strategies reported by respondents highlighted self-initiated medication practices (Table 4). A common strategy adopted by patients concerned about medication costs was to request low-cost substitutes at the pharmacy when they were not able to afford nonprescription medications (n = 17 [34%]).

Patient–Physician Communication about Medication Costs

Forty (80%) of the respondents indicated that they knew the total cost (i.e., market price) of their prescription medications relative to what they actually paid (e.g., through a copayment) (Table 5). Other data suggest that respondents were not always keen to discuss issues related to the cost of medications and their affordability with their physicians (n = 28 [56%]). More than half of the respondents (n = 33 [66%]) felt that physicians should not be aware of their patients’ concerns about affordability, yet a similar number (n = 31 [62%]) thought it was the physician’s job to ask patients if they could pay for their medications. Ten (20%) of the respondents were concerned that prescription charges, including copayments, were too high.

Table 5. Views about Prescription Medication Costs and Inclination to Discuss Cost-Related Issues with a Physician, as Identified by Survey Respondents with Hepatitis C Virus in Halifax, 2008



To the authors’ knowledge, this is the first published study to delineate the coping strategies adopted by patients with HCV infection who are faced with medication costs, including the costs of prescription, nonprescription, and complementary medications, such as natural health products (e.g., vitamins and minerals, herbal remedies, and homeopathic medicines), for the adverse effects of antiviral medications and/or comorbid conditions. This study, which enabled patients with HCV infection to share their experiences with managing their condition, used a survey instrument that was designed to examine chronic diseases associated with high drug costs. The survey was originally developed in the United Kingdom24 and was adapted for use in Nova Scotia. This study highlights decision-making by patients, on their own or in consultation with physicians and/or other health care professionals (e.g., nurse practitioners), to modify their therapeutic regimens by a range of strategies when faced with out-of-pocket medication costs. About 10% of Canadians lack drug insurance coverage, and for an additional 10%, the drug insurance coverage they have is inadequate.26 In a nation with universal health coverage, as specified in the Canada Health Act,27 about 2% of citizens have no drug insurance, and 9% are only partially covered.12 In the province of Nova Scotia, 22% of the population had no drug insurance coverage before introduction of the Nova Scotia Family Pharmacare Program.28 This Pharmacare program29 is a drug insurance coverage program that provides reimbursement to eligible Nova Scotians who do not have a drug insurance coverage plan. It also provides some coverage for high-priced drugs that are not reimbursed by private drug plans. Eligible residents who are enrolled in the program pay an annual family deductible and copayment.

In Canada, employed individuals may have drug coverage under private drug insurance plans or through their provincial, territorial, or federal government plans. More specifically, some provinces and territories have plans that cover all eligible residents, whereas others cover only residents over 65 years of age and those who are clients of community services or social assistance.13,30 There are also federal plans, such as the plan available through Veterans Affairs,13 to provide coverage to specific clientele. Because both drug utilization and drug costs have increased, Canadian public and private drug insurance plans have implemented measures for sharing costs with patients.10,31

These cost-sharing policies, such as copayments, aid the health care system to offset overall drug expenditures; however, the out-of-pocket costs may discourage patients from using medications as suggested by their physicians. Previous studies have suggested that out-of-pocket costs of medications, including copayments, may have an inverse relationship with drug utilization, which could lead to adverse health outcomes.24,3137 Moreover, physicians often lack awareness about price differentials across drugs, about patients’ out of-pocket costs, and about the formulary status of medications.3841 Furthermore, lack of communication about drug prices between physicians and patients39,40 might contribute to physicians not selecting the most cost-effective medications.

At Capital District Health Authority Hepatology Services, the majority of health care is provided by nurse practitioners using a holistic approach in an outpatient setting of chronic liver disease clinics.42 This approach allows provision of acute and chronic care, primary and secondary prevention, health promotion, advocacy, education, coordination of services, referrals, and community development (Capital District Health Authority, Department of Medicine, Division of Gastroenterology: Annual Report, April 1, 2008, to March 31, 2009). This model facilitates communication and feedback within the system to improve delivery of care and support to this population. The ability of the nurse practitioners to negotiate the health care delivery system on behalf of their patients, and the insights they gain from this role, may help in identifying ways to improve the health of individuals with HCV infection, especially in terms of their ability to access treatment. The benefits of this type of collaborative health care delivery model have been reported previously.43

Almost 60% of the study population were concerned about having sufficient financial resources to afford their medications, a proportion lower than those reported in previous studies (using a similar approach) for patients with hypertension and dyspepsia in the United Kingdom (70%)16,24 and Italy (66%).16 This difference might arise because of differences in the health care systems and the chronic diseases examined; differences in study design, sample size, or patient characteristics; price elasticity across therapeutic classes; and variable reimbursement strategies.16

Coping strategies identified in this study suggest that out-of-pocket medication costs could have a profound effect on medication use. Thirty percent of survey participants reported borrowing money to pay for their prescription medications, a finding similar to that reported in a previous study from the United Kingdom.24 Other self-initiated strategies identified in this study that were similar to strategies reported in the literature were not obtaining all medications listed on a single prescription form at one time and not getting prescription medications dispensed at all.17,4446 Self-initiated strategies such as not filling prescriptions or taking fewer doses to make a medication last longer might result in adverse health outcomes through lack of persistence and/or adherence. As reported in the literature,18,47,48 the common strategies involving assistance from physicians were seeking free samples, substituting prescription medications with lower-cost nonprescription products, and requesting a longer-duration supply to reduce the cost associated with filling individual prescriptions. The coping strategies identified in this study suggest that barriers to accessing medications for the management of adverse effects associated with HCV treatment or comorbid conditions (which are not always paid for within the public health system) should be recognized and addressed. For example, out-of-pocket copayments for concomitant prescription medications and payments for the costs of nonprescription medications and complementary remedies for treating comorbidities and the treatment-emergent adverse effects of antiviral therapy might lead the patient to either discontinue treatment or respond to the cost burden in a manner that is detrimental to treatment effectiveness. The extent of use of complementary medications, including natural health products, by patients with HCV infection in this study was similar to that documented in previous reports.9,49

Previous studies3841 have concluded that there is a lack of awareness among some physicians about price differentials across medications, which might prevent them from prescribing low-cost substitutes without compromising therapeutic benefit. Participants in the current study indicated that physicians were not always sensitive to affordability issues when prescribing medications, a finding similar to those of previous studies.3841 However, about a third of the study participants felt that physicians should be sensitive to these issues. Nearly half (42%) of the study population reported that physicians sometimes recommended substituting nonprescription medications for prescription medications, which suggests that price was sometimes taken into consideration. Furthermore, this study revealed that many respondents were not keen to discuss affordability of medications with their physicians, as reported elsewhere.15,20,24,50,51 Some respondents sought advice from pharmacists to obtain low-cost substitutes, a finding consistent with the literature.24

Although the nurse practitioners at Hepatology Services can arrange resources to cover the costs associated with HCV treatment, they are unable to provide resources or access funds to cover out-of-pocket copayments for prescriptions to treat comorbid conditions or nonprescription and complementary medications, including natural health products. Study participants expressed concern about the costs of concomitant prescription medications, nonprescription medications, and complementary therapies. For many of these patients, it is critical that they use medications to manage the adverse effects of antiviral treatment and treatments for comorbid conditions in order to realize the overall therapeutic benefit of the HCV disease management strategy. As part of a chronic disease management strategy, integrated care by physicians and other health care professionals, such as nurse practitioners and pharmacists, has the potential to enhance access to essential medications, leading to better medication adherence and better health outcomes.52,53

A study at a Canadian children’s hospital suggested that pharmacists’ involvement in discharge planning led to decreased drug costs and avoidance of drug complications and readmissions.54 It has also been suggested that with sufficient infrastructure at the community pharmacy level, pharmacists’ identification and resolution of drug-related problems could lead to improved patient outcomes and could also reduce health care costs,55,56 with recognition that there are incentives and barriers to implementation of such activities.57 However, even with the availability of clinical pharmacists at the community level for chronic disease management, there remains the issue of whether the patient can afford the medications.

These study findings should be interpreted in light of the following limitations. First, generalizability of the findings might be affected by selection bias, in that those who attended the Hepatology Services outpatient clinic and agreed to participate in the study may have been systematically different from the larger population of individuals infected with HCV. Second, the self-reporting of medication use, as presented in this study, might have led to under- or over-reporting, which might in turn have influenced the study findings. Similarly, reported incomes may not be a true reflection of actual incomes because of poor recall or because of unreported or undocumented income. Finally, the Nova Scotia Family Pharmacare Program was implemented soon after the initial study interviews were conducted. Hence, the responses of patients who had already completed HCV treatment would not reflect the potential benefits of the new, more comprehensive program.


In the Canadian province of Nova Scotia, Hepatology Services, Queen Elizabeth II Health Sciences Centre, Capital District Health Authority, helped patients with HCV infection obtain their antiviral medications, but many patients experienced hardship in paying for concomitant medications. These patients employed various coping strategies, including borrowing money, asking their health care practitioners for free samples, not getting all of their prescriptions filled at the same time, and/or waiting to fill their prescriptions until they got paid (or received their social assistance cheques). Many patients felt that, when prescribing medications, physicians should take into account patients’ ability to pay for the drugs.

Furthermore, health care professionals need to be sensitive to patients’ ability to pay and should use strategies to help them. Pharmacists could play a key role in recognizing the various coping strategies used by patients with HCV infection and could help to develop proactive responses in conjunction with other health professionals.

Future studies should examine which medications provide the greatest cost burden, explore the cost-effectiveness of medications, and determine the impact of cost-sharing policies on patients with HCV infection and other chronic conditions.


1. Responding to the epidemic: recommendations for a Canadian hepatitis C strategy. Hepatitis C Collaboration; 2005 Sep [cited 2010 Aug 27]. Available from:$file/Responding_e.pdf

2. Wong JB, McQuillan GM, McHutchison JG, Poynard T. Estimating future hepatitis C morbidity, mortality, and costs in the United States. Am J Public Health 2000;90(10):1562–1569.

3. Remis RS. Modelling the incidence and prevalence of hepatitis C and its sequelae in Canada, 2007. Final report. Ottawa (ON): Public Health Agency of Canada, Infectious Disease and Emergency Preparedness Branch, Centre for Communicable Diseases and Infection Control, Community Acquired Infections Division; 2007.

4. Peltekian K. A collaborative model for viral hepatitis service [abstract]. In: New Knowledge, New Hope: Proceedings of the 2nd Canadian Conference on Hepatitis C; 2004 Mar 27–30; Vancouver (BC).

5. Nova Scotia Department of Health, Office of the Chief Medical Officer of Health. Hepatitis C surveillance report 2004. Halifax (NS): Nova Scotia Department of Health; 2005 Jun.

6. Wilkins T, Malcolm J, Raina D, Schade R. Hepatitis C: diagnosis and treatment. Am Fam Physician 2010;81(11):1351–1357.

7. Brady B, Siebert U, Sroczynski G, Murphy G, Husereau D, Sherman M, et al. Pegylated interferon combined with ribavirin for chronic hepatitis C virus infection: an economic evaluation. Technol Rep 82. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2007.

8. Seeff LB, Hoofnagle JH. Appendix: The National Institutes of Health Consensus Development Conference Management of Hepatitis C 2002. Clin Liver Dis 2003;7(1):261–287.
cross-ref  pubmed  

9. White CP, Hirsch G, Patel S, Adams F, Peltekian K. Complementary and alternative medicine use by patients chronically infected with hepatitis C virus. Can J Gastroenterol 2007;21(9):589–595.

10. Grootendorst P. Beneficiary cost sharing under Canadian provincial prescription drug benefit programs: history and assessment. Can J Clin Pharmacol 2002;9(2):79–99.

11. Romanow RJ, chair. Building on values: the future of health care in Canada. Final report. Saskatoon (SK): Commission on the Future of Health Care in Canada; 2002.

12. Kirby M, chair. The health of Canadians—the federal role. Ottawa (ON): Standing Senate Committee on Social Affairs, Science and Technology; 2002.

13. Phillips K. Catastrophic drug coverage in Canada. Report PRB 09-06E. Ottawa (ON): Library of Parliament, Parliamentary Information and Research Service; 2009 Sep 1.

14. Briesacher B, Ross-Degnan D, Adams A, Wagner A, Gurwitz J, Soumerai SB. A new measure of medication affordability. Soc Work Public Health 2009;24(6):600–612.
cross-ref  pubmed  

15. Schafheutle E, Hassell K, Noyce PR, Weiss MC. Access to medicines: cost as an influence on the views and behaviour of patients. Health Soc Care Community 2002;10(3):187–195.
cross-ref  pubmed  

16. Atella V, Schafheutle E, Noyce P, Hassell K. Affordability of medicines and patients’ cost-reducing behaviour: empirical evidence based on SUR estimates from Italy and the UK. Appl Health Econ Health Policy 2005;4(1):23–35.
cross-ref  pubmed  

17. Cronk A, Humphries TL, Delate T, Clark D, Morris B. Medication strategies used by Medicare beneficiaries who reach the Part D standard drug-benefit threshold. Am J Health Syst Pharm 2008;65(11):1062–1070.
cross-ref  pubmed  

18. Tseng CW, Brook RH, Keeler E, Steers WN, Mangione CM. Cost-lowering strategies used by Medicare beneficiaries who exceed drug benefit caps and have a gap in drug coverage. JAMA 2004;292(8):952–960.
cross-ref  pubmed  

19. Kennedy J, Morgan S. A cross-national study of prescription nonadherence due to cost: data from the Joint Canada–United States Survey of Health. Clin Ther 2006;28(8):1217–1224.
cross-ref  pubmed  

20. Schafheutle E. The impact of prescription charges on asthma patients is uneven and unpredictable: evidence from qualitative interviews. Prim Care Respir J 2009;18(4):266–272.
cross-ref  pubmed  

21. Brixner DI. The case against excessive cost sharing. Am J Manag Care 2006;12(6 Suppl):S162,S164; discussion S167–S172; quiz S173–S176.

22. Prescription drug coverage. Halifax (NS): Province of Nova Scotia, Community Services; 2011 [cited 2011 Apr 14]. Available from:

23. Treatment coverage in your region [website]. Canadian AIDS Treatment Information Exchange; [cited 2010 Aug 9]. Available from:

24. Schafheutle E, Hassell H, Noyce PR. Coping with prescription charges in the UK. Int J Pharm Pract 2004;12:239–246.

25. Low income cut-offs for 2007 and low income measures 2006. Income Res Pap Ser. Cat. no. 75F0002M No.004. Ottawa (ON): Statistics Canada; 2009 Jun.

26. Flood CM, Thomas B. Blurring of the public/private divide: the Canadian chapter. Eur J Health Law 2010;17(2):257–278.
cross-ref  pubmed  

27. Canada Health Act, RSC 1985, c. C-6. Available from: [current to 2010 Jun 16; cited 2010 Aug 27].

28. Kapur V, Basu K. Drug coverage in Canada: who is at risk? Health Policy 2005;71(2):181–193.

29. Nova Scotia Family Pharmacare. Halifax (NS): Government of Nova Scotia; 2011 [cited 2011 Apr 14]. Available from:

30. Coombes ME, Morgan SG, Barer ML, Pagliccia N. Who’s the fairest of them all? Which provincial pharmacare model would best protect Canadians against catastrophic drug costs? Healthc Q 2004;7(4 Suppl): 13–19.

31. Kephart G, Skedgel C, Sketris I, Grootendorst P, Hoar J. Effect of copayments on drug use in the presence of annual payment limits. Am J Manag Care 2007;13(6 Pt 2):328–334.

32. Anis AH, Guh DP, Lacaille D, Marra CA, Rashidi AA, Li X, et al. When patients have to pay a share of drug costs: effects on frequency of physician visits, hospital admissions and filling of prescriptions. CMAJ 2005;173(11):1335–1340.

33. Tamblyn R, Laprise R, Hanley JA, Abrahamowicz M, Scott S, Mayo N, et al. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. JAMA 2001;285(4):421–429.
cross-ref  pubmed  

34. Soumerai SB, Avorn J, Ross-Degnan D, Gortmaker S. Payment restrictions for prescription drugs under Medicaid: effects on therapy, cost, and equity. N Engl J Med 1987;317(9):550–556.
cross-ref  pubmed  

35. Gemmill MC, Thomson S, Mossialos E. What impact do prescription drug charges have on efficiency and equity? Evidence from high-income countries. Int J Equity Health 2008;7(12):1–22.

36. Hsu J, Price M, Huang J, Brand R, Fung V, Hui R, et al. Unintended consequences of caps on Medicare drug benefits. N Engl J Med 2006;354(22):2349–2359.
cross-ref  pubmed  

37. Reed M, Brand R, Newhouse JP, Selby JV, Hsu J. Coping with prescription drug cost sharing: knowledge, adherence, and financial burden. Health Serv Res 2008;43(2):785–797.
cross-ref  pubmed  

38. Pham HH, Alexander GC, O’Malley AS. Physician consideration of patients’ out-of-pocket costs in making common clinical decisions. Arch Intern Med 2007;167(7):663–668.
cross-ref  pubmed  

39. Alexander GC, Casalino LP, Meltzer DO. Physician strategies to reduce patients’ out-of-pocket prescription costs. Arch Intern Med 2005;165(6): 633–636.
cross-ref  pubmed  

40. Alexander GC, Casalino LP, Tseng CW, McFadden D, Meltzer DO. Barriers to patient–physician communication about out-of-pocket costs. J Gen Intern Med 2004;19(8):856–860.
cross-ref  pubmed  

41. Khan S, Sylvester R, Scott D, Pitts B. Physicians’ opinions about responsibility for patient out-of-pocket costs and formulary prescribing in two Midwestern states. J Manag Care Pharm 2008;14(8):780–789.

42. Desai S, Chen G, Hirsch G, Quinn A, Peltekian K. Referral patterns of Hepatology Services outpatient clinic: wait time from referral to visit by rule of sevens [abstract]. Can J Gastroenterol 2004;18 Suppl A:S140.

43. Kontorinis N, Garas G, Young J, Speers D, Chester BP, MacQuillan GC, et al. Outcome, tolerability and compliance of compassionate use interferon and ribavirin for hepatitis C infection in a shared care hospital clinic. Intern Med J 2003;33(11):500–504.
cross-ref  pubmed  

44. Beardon PH, McGilchrist MM, McKendrick AD, McDevitt DG, MacDonald TM. Primary non-compliance with prescribed medication in primary care. BMJ 1993;307(6908):846–848
cross-ref  pubmed  

45. Jones I, Britten N. Why do some patients not cash their prescriptions? Br J Gen Pract 1998;48(426):903–905.

46. Schafheutle EI, Hassell K, Seston EM, Noyce PR. Non-dispensing of NHS prescriptions in community pharmacies. J Pharm Pract 2002; 10(1):11–15.

47. Groves KE, Sketris I, Tett SE. Prescription drug samples — does this marketing strategy counteract policies for quality use of medicines? J Clin Pharm Ther 2003;28(4):259–271.
cross-ref  pubmed  

48. Piette J, Heisler M, Wagner TH. Problems paying out-of-pocket medication costs among older adults with diabetes. Diabetes Care 2004; 27(2):384–391.
cross-ref  pubmed  

49. Ferrucci LM, Bell BP, Dhotre KB, Manos MM, Terrault NA, Zaman A, et al. Complementary and alternative medicine use in chronic liver disease patients. J Clin Gastroenterol 2010;44(2):e40–e45.

50. Alexander GC, Casalino LP, Meltzer DO. Patient–physician communication about out-of-pocket costs. JAMA 2003;290(7):953–958.
cross-ref  pubmed  

51. Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients’ unvoiced agendas in general practice consultations: qualitative study. BMJ 2000;320(7244):1246–1250.
cross-ref  pubmed  

52. Piette JD, Heisler M, Horne R, Caleb Alexander G. A conceptually based approach to understanding chronically ill patients' responses to medication cost pressures. Soc Sci Med 2006;62(4):846–857.

53. Nichols-English GJ, Poirier S. Adherence to pharmaceutical care. In: DiPiro JT, editor. Encyclopedia of clinical pharmacy. New York (NY): Marcel Dekker, Inc; 2003. p. 10–22.

54. Cameron B. The impact of pharmacy discharge planning on continuity of care. Can J Hosp Pharm 1994;47(3):101–109.

55. Layson-Wolf C, Morgan JA. Pharmacy continuity of care: what do community pharmacists need from an acute care hospital to improve continuity of pharmaceutical care? Dis Manag Health Outcomes 2008;16(4):199–203.

56. Nkansah N, Mostovetsky O, Yu C, Chheng T, Beney J, Bond C, et al. Effect of outpatient pharmacists’ non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database Syst Rev 2010;(7): CD000336.

57. Lehnbom EC, Brien JA. Challenges in chronic illness management: a qualitative study of Australian pharmacists’ perspectives. Pharm World Sci 2010;32(5):631–636.
cross-ref  pubmed  

Chiranjeev Sanyal, MSc, is with the College of Pharmacy and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia
Ethel Langille Ingram, MA, is with the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia Canada
Ingrid S Sketris, PharmD, MPA(HSA), is with the College of Pharmacy and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia
Kevork M Peltekian, MD, FRCPC, is with the Departments of Medicine and Surgery, Dalhousie University, and Hepatology Services, Queen Elizabeth II Health Sciences Centre, Capital District Health Authority, Halifax, Nova Scotia
Susan Kirkland, PhD, is with the Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia


This project was supported in part by a nondirected grant from Green Shield Foundation Canada and a Chair in Health Services Research from the Canadian Health Services Research Foundation/Canadian Institutes of Health Research, cosponsored by the Nova Scotia Health Research Foundation, held by Ingrid S Sketris. The opinions expressed in this paper are those of the authors and do not represent the opinions of Green Shield Foundation Canada, the Canadian Health Services Research Foundation, the Canadian Institutes of Health Research, or the Nova Scotia Health Research Foundation.

We acknowledge the work of the 2 hepatology nurse practitioners, Geri Hirsch and Carla Burgess. We also acknowledge the contributions of Tressie Dutchyn, who coordinated the project, and Lindsay Wallace, who performed data entry. We thank Dr Ellen I Schafheutle, University of Manchester, Manchester, United Kingdom, for kindly allowing us to adopt and adapt the survey instrument that she and her colleagues developed to evaluate access to medications in the United Kingdom. We also thank the patients from Hepatology Services at Queen Elizabeth II Health Sciences Centre for participating in the survey.

Address correspondence to: Dr Ingrid S Sketris, College of Pharmacy, 5968 College Street, Halifax NS B3H 2J5, e-mail:

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Canadian Journal of Hospital Pharmacy, VOLUME 64, NUMBER 2, 2011

ISSN 1920-2903 (Online)
Copyright © 2019 Canadian Society of Hospital Pharmacists