Transcript First-dollar coverage for secondary preventative therapies

FULL COVERAGE FOR PREVENTIVE
MEDICATIONS AFTER MYOCARDIAL
INFARCTION
NEW ENGLAND JOURNAL OF MEDICINE 2011; DOI: 10.1056/NEJMSA1107913
Niteesh K. Choudhry, MD, PhD,1 Jerry Avorn, MD,1 Robert J. Glynn, ScD, PhD,1,2
Elliott M. Antman, MD,3 Sebastian Schneeweiss, MD, ScD1, Michele Toscano, MS,4
Lonny Reisman, MD,4 Joaquim Fernandes, MS,4 Claire Spettell, PhD,4
Joy L. Lee, MS,1 Raisa Levin, MS,1 Troyen Brennan, MD, JD, MPH,5
and William H. Shrank, MD, MSHS,1 for the Post-Myocardial Infarction Free Rx
Event and Economic Evaluation (MI FREEE) Trial
Divisions of 1Pharmacoepidemiology and Pharmacoeconomics and 2Preventive Medicine, and
the 3Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and
Harvard Medical School; 4Aetna and 5CVS Caremark
Background

Adherence to evidence-based medications prescribed after
myocardial infarction (MI) remains poor
■ Within 2 years of initiating therapy, only half of patients are adherent to their
prescribed statins, beta-blockers, or ACEI/ARBs

Drug costs appear to be a central reason for medication
underuse
■ Even among patients with insurance, utilization varies according to the
comprehensiveness of coverage

Eliminating out-of-pocket costs for evidence-based therapies
may promote adherence and improve outcomes
■ Referred to as “value-based insurance design” or “evidence-based plan design”
■ Observational studies support the ability of this strategy to increase adherence but
its impact on health outcomes and spending has not been rigorously evaluated
Post-Myocardial Infarction Free Rx Event
and Economic Evaluation (MI FREEE) Trial
OBJECTIVE:
To evaluate the impact of eliminating copayments for
statins, beta-blockers and ACEI/ARB prescribed to post-MI
patients on rates of major vascular events and health
spending
clinicaltrials.gov NCT00566774
Overall Design
MI FREEE
AETNA BENEFICIARIES DISCHARGED AFTER ACUTE MI
Based on discharge claims submitted by hospitals (specificity 99%)
study group
assignment
occurred a mean
of 49 days post-MI
EXCLUSIONS:
Age > 65, didn’t have both
drug and medical coverage,
enrolled in ineligible plan
cluster randomized
by plan sponsor
FULL COVERAGE
CONTROL
all beta-blockers, ACEI/ARBs
usual levels of prescription
insurance coverage
and statins
Both groups contacted to tell them that taking their prescribed medications is
important +/- inform them of their benefit change
SOURCE: Choudhry et al. Am Heart J 2008; 156: 31
Outcomes and analysis
MI FREEE
Primary
First major vascular event* or revascularization
Secondary Total major vascular events and revascularization
First major vascular event
Medication adherence (proportion of days covered)
Pharmacy and medical spending
*Fatal

or non-fatal acute MI, unstable angina, stroke, congestive heart failure
Outcomes assessed using validated health services claims
and based on intention to treat principles
■ Included only verifiable (in hospital) fatal events

Clinical events evaluated using time-to-event (Cox) modeling;
adherence and spending evaluated using generalized
estimating equations
■ Analyses adjusted for the cluster and block randomized design
Enrollment and Randomization
MI FREEE
6,768 patients (3,983 plan sponsors) potentially eligible
913 covered by plan sponsors
who declined to participate
5,855 patients (2,980 plan sponsors) randomized
FULL COVERAGE
2,845 patients (1,494 plan sponsors)
USUAL COVERAGE
3,010 patients (1,486 plan sponsors)
133 (4.7%) patients lost insurance
eligibility before randomization
151 (5.0%) patients lost insurance
eligibility before randomization
Median follow-up: 394 days (interquartile range: 201 to 663 days)
Baseline characteristics (selected)*
MI FREEE
CHARACTERISTIC
Age, mean
Male sex, %
Comorbidities, %
Congestive heart failure
Diabetes
Hypertension
Prior MI
Stroke
Procedures on index hospitalization, %
Angiography
PCI
CABG
Monthly baseline copayment, mean
ACEI/ARB
Beta-blocker
Statin
FULL
COVERAGE
(N=2845)
53.6
75.6
USUAL
COVERAGE
(N=3010)
53.7
74.7
27.0
34.3
71.2
15.6
5.8
29.1
34.8
72.4
17.4
6.7
94.7
67.3
17.9
93.7
66.0
18.1
$13.48
$12.64
$24.98
$13.35
$12.83
$24.92
*There was no significant between-group difference in any category
Medication adherence
Full coverage
MI FREEE
% of days covered
60
ACEI/ARBs
Beta-blockers
Statins
5.6%
4.4%
6.2%
50
40
Usual coverage
All 3 classes
5.4%
55.1
49.3
41.1
30
49.0
45.0
43.9
35.9
38.9
20
10
0
P<0.001 for all comparisons
% fully adherent
31%
32%
37%
41%
40
38.6
30
20
10
0
31.6
30.7
27.7
22.9
25.2
12.1
8.9
Major vascular event or revascularization
MI FREEE
Full
coverage
Rate per 100
person years
Usual
coverage
Usual coverage
17.6
18.8
Full coverage
Hazard ratio (95% CI): 0.93 (0.82-1.04)
P-value: 0.21
No. at Risk
Usual coverage
Full coverage
3010
2845
2361
2295
1652
1572
1099
1013
662
625
379
340
131
135
Major vascular events (Fatal or nonfatal MI, unstable angina, CHF, stroke)
MI FREEE
Rate per 100
person years
Full
coverage
Usual
coverage
11.0
12.8
Usual coverage
Full coverage
Hazard ratio (95% CI): 0.86 (0.74-0.99)
P-value: 0.03
No. at Risk
Usual coverage
Full coverage
3010
2845
2361
2295
1652
1572
1099
1013
662
625
379
340
131
135
Total major vascular events or revascularization*
MI FREEE
Hazard ratio (95% CI) 0.89 (0.80-0.99)
Rate per 100 person year
25
P=0.03
23.3
20
21.5
15
10
5
0
Full Coverage
*Considers
all events experienced by each patient
Usual Coverage
Health spending
Full coverage
Usual coverage
MI FREEE
Patient Spending
$2,000
Pharmacy
Medical
Total
30%
18%
26%
P<0.001
P=0.005
P<0.001
$1,781
$1,500
$1,000
$500
$1,282
$1,164
$802
$618
$480
$0
Total spending
$75,000
17%
10%
11%
P=0.02
P=0.72
P=0.68
$60,358
$50,000
$25,000
$5,649
$0
$5,085
$66,693
$66,008
$71,778
Cardiovascular spending
Full coverage
Usual coverage
MI FREEE
Patient Spending
$1,000
Pharmacy
Medical
Total
51%
9%
40%
P<0.001
P=0.05
P<0.001
$900
$800
$600
$665
$526
$400
$200
$235
$203
$323
$0
Total spending
$25,000
8%
14%
11%
P=0.02
P=0.06
P=0.08
$20,000
$15,000
$15,661
$10,000
$5,000
$0
$2,594
$2,488
$17,750
$18,254
$20,238
Summary
MI FREEE

Eliminating copayments for post-MI secondary prevention:
 Improved adherence
 Reduced rates of major vascular events*
 Reduced patient out-of-pocket spending for drugs and other nondrug services
 Did not increase insurer or total spending
 Did not significantly reduce the composite outcome of major
vascular events plus revascularization
*Fatal
or non-fatal acute MI, unstable angina, stroke, congestive heart failure
Implications
MI FREEE

This quality-improvement strategy could contribute to ongoing
efforts to improve post-MI outcomes
■ Probably cost-effective
■ Could be easily scaled

Adherence was improved but remained poor even for patients
who received full coverage
■ Average adherence to all 3 of the study medication classes remained < 50%

Our results highlight the need for other interventions to promote
adherence
■ Should target other causes of non-adherence: complex treatment regimens,
difficulties accessing medications, knowledge gaps, adverse effects, forgetfulness
Choudhry NK et al. New England Journal of Medicine 2011;
DOI: 10.1056/NEJMsa1107913