1 Sum G, et al. BMJ Glob Health 2018;3:e000505. doi:10.1136/bmjgh-2017-000505 Multimorbidity and out-of-pocket expenditure on medicines: a systematic review Grace Sum, 1 Thomas Hone, 2 Rifat Atun, 3 Christopher Millett, 2 Marc Suhrcke, 4,5 Ajay Mahal, 6 Gerald Choon-Huat Koh, 1 John Tayu Lee 1,2,6 Research To cite: Sum G, Hone T, Atun R, et al. Multimorbidity and out-of-pocket expenditure on medicines: a systematic review. BMJ Glob Health 2018;3:e000505. doi:10.1136/ bmjgh-2017-000505 Handling editor Seye Abimbola ► Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ bmjgh-2017-000505). Received 28 July 2017 Revised 21 November 2017 Accepted 29 November 2017 1 Saw Swee Hock School of Public Health, National University of Singapore, Singapore 2 Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK 3 Harvard T.H Chan, School of Public Health, and Harvard Medical School, Harvard University, Boston, Massachusetts, USA 4 Centre for Health Economics, University of York, England, UK 5 Luxembourg Institute for Socio-economic Research, Luxembourg, Europe 6 Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia Correspondence to Dr Grace Sum; gracesum@u.nus.edu ABSTRACT Background Multimorbidity, the presence of two or more non-communicable diseases (NCD), is a costly and complex challenge for health systems globally. Patients with NCDs incur high levels of out-of-pocket expenditure (OOPE), often on medicines, but the literature on the association between OOPE on medicines and multimorbidity has not been examined systematically. Methods A systematic review was conducted via searching medical and economics databases including Ovid Medline, EMBASE, EconLit, Cochrane Library and the WHO Global Health Library from year 2000 to 2016. Study quality was assessed using Newcastle-Ottawa Scale. PROSPERO: CRD42016053538. Findings 14 articles met inclusion criteria. Findings indicated that multimorbidity was associated with higher OOPE on medicines. When number of NCDs increased from 0 to 1, 2 and ≥3, annual OOPE on medicines increased by an average of 2.7 times, 5.2 times and 10.1 times, respectively. When number of NCDs increased from 0 to 1, 2, ≥2 and ≥3, individuals spent a median of 0.36% (IQR 0.15%–0.51%), 1.15% (IQR 0.62%–1.64%), 1.41% (IQR 0.86%–2.15%), 2.42% (IQR 2.05%–2.64%) and 2.63% (IQR 1.56%–4.13%) of mean annual household net adjusted disposable income per capita, respectively, on annual OOPE on medicines. More multimorbidities were associated with higher OOPE on medicines as a proportion of total healthcare expenditures by patients. Some evidence suggested that the elderly and low-income groups were most vulnerable to higher OOPE on medicines. With the same number of NCDs, certain combinations of NCDs yielded higher medicine OOPE. Non-adherence to medicines was a coping strategy for OOPE on medicines. Conclusion Multimorbidity of NCDs is increasingly costly to healthcare systems and OOPE on medicines can severely compromise fnancial protection and universal health coverage. It is crucial to recognise the need for better equity and fnancial protection, and policymakers should consider health system fnancial options, cost sharing policies and service patterns for those with NCD multimorbidities. INTRODUCTION Non-communicable diseases (NCD) are the leading cause of morbidity and mortality globally. 1 The United Nations and the World Health Organization(WHO) have established coordinated responses to address NCDs worldwide. 2 3 A particular challenge with NCDs is multimorbidity, the presence of two or more NCDs. 4 Patients with multimorbidity are disproportionately burdened with illness, and economically, due to complex needs and high healthcare utilisation. 5 A study of six low-middle income countries (LMIC) found that the highest contribution to out-of-pocket expenditure (OOPE) in patients with multi- morbidity was on medicine. 6 Using nationally representative data, a study in the USA found that elderly patients with three or more NCDs Key questions What is already known about this topic? ► Patients with multimorbidity are disproportionately fnancially burdened due to complex health needs and high healthcare utilisation. ► Medicines constitute the largest proportion of out-of-pocket expenditure (OOPE) for patients with multimorbidity. ► Current health systems fail to provide suffcient fnancial protection for OOPE on medicines. What are the new fndings? ► There was an association between level of multimorbidity in patients and out-of-pocket expenditure (OOPE) on medicines. More multimorbidities were associated with higher OOPE on medicines as a proportion of total healthcare expenditures by patients. ► Even with the same number of non-communicable diseases (NCD), certain specifc combinations of chronic conditions yielded higher OOPE on medicines. ► The elderly were more vulnerable to higher OOPE on medicines, while some evidence suggested medicine OOPE accounted for a greater proportion of income for low-income groups. ► In patients with multimorbidity, non-adherence was a coping strategy for OOPE on medicines, with adverse health consequences. on 25 April 2018 by guest. Protected by copyright. http://gh.bmj.com/ BMJ Glob Health: first published as 10.1136/bmjgh-2017-000505 on 6 February 2018. Downloaded from