2. 1- Study Aims 2- Problem Statement 3- Methods 4- Results 5- Conclusions2

3. To Identify cost-reducing strategies, including Cost related non adherence (CRN). 1 To Understand how are these strategies employed by chronically-ill patients presenting to Alexandria University Hospitals. To Examine factors affecting prevalence of CRN. 3 3 To Explore impact of better Doctor Patient Interaction (DPI) on CRN. 1 2 3 5 4 To Pinpoint the best DPI methods that minimized CRN.

4. 4 1. Heisler M, Wagner TH, Piette JD. Clinician identification of chronically ill patients who have problems paying for prescription medications. Am J Med. 2004 Jun 1;116(11):753-8 2. 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. 3. Wilson IB, Schoen C, Neuman P, Strollo MK, Rogers WH, Chang H, Safran DG. Physician-patient communication about prescription medication nonadherence: a 50- state study of America's seniors. J Gen Intern Med. 2007 Jan;22(1):6-12.

5. 5 4. World Health Organization Statistical Information System (WHOSIS). World Health Statistics 2010. [Online]. 2010 Apr;(1):130-3. [cited 2010 Aug 18]. Available from: http://www.who.int/entity/whosis/whostat/EN_WHS10_Full.pdf 5. Arab Republic of Egypt Central Agency for public mobilization and statistics health status report 2010. [Online]. 6. Tamblyn R, Laprise R, Hanley JA, Abrahamowicz M, Scott S, Mayo N, Hurley J, Grad R, Latimer E, Perreault R, McLeod P, Huang A, Larochelle P, Mallet L. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. JAMA. 2001 Jan 24-31;285(4):421-9.

6. 6. Piette JD, Heisler M, Krein S, Kerr EA. The role of patient-physician trust in moderating medication nonadherence due to cost pressures. Arch Intern Med. 2005 Aug 8-22;165(15):1749-55. 6

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8. Income Ratio : Income Ratio :Drug cost to monthly income ratio,P=.003 Education: Education: (P=.028) (University 14.2% - High School 23.8% - Elementary 26.7% - No Education certificate 35.3%). Marital status: Marital status: widowed were 4 times liable than married to develop CRN (P=.044). Number of medications Number of medications currently prescribed (per month) : against higher rates of CRN (p=.003). Patients adopt multiple strategies in CRN to adopt with drug costs (given a score according to number of methods used).8 Insurance Coverage: (P <. 001) Insurance Coverage: (P <. 001) (Non Insured 75.9%, Public 22.4%, Private 1.7%) Better DPI regarding drug costs (p =.004)

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14. Encouraging patients to ask for cheaper alternatives Ensuring patient education on drug costs, showing strong emotional support and reducing poly pharmacy can significantly lower CRN Clinicians can pay an important role with patients who face problems paying for prescription drugs Patient-physician communication can be an important determinant of self- management behavior and health outcomes 14

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