Durham, NC—Just as pharmacists suspected, cost matters when it comes to treatment adherence.

A new study presented at the American College of Cardiology annual scientific sessions meeting in Orlando tested whether removing financial barriers would increase the use of evidence-based therapies, improve patient adherence to those medications, and potentially save lives.

Although the first two outcomes were supported in the Duke Clinical Research Institute results, a question remained as to whether better adherence actually reduced mortality.

“This study provides some good insights into medication-taking behavior and tackling the adherence problem, a big problem in the U.S,” explained study chair Eric D. Peterson, executive director of the DCRI. “While financial issues are certainly part of the problem, a more complete answer will be needed to further improve adherence and patient outcomes.”

Background information in the report notes that higher-potency P2Y12 inhibitors are superior to clopidogrel in reducing major adverse cardiovascular events (MACE) for patients after myocardial infarction (MI). Yet, despite a class IIa guideline recommendation for the use of higher-potency P2Y12 inhibitors over clopidogrel, uptake has been low in the U.S.; this has primarily been attributed to higher out-of-pocket costs. In fact, the abstract notes, many MI patients do not complete the 1-year P2Y12-inhibitor course recommended by guidelines.

In the Affordability and Real-world Antiplatelet Treatment Effectiveness after Myocardial Infarction Study (ARTEMIS), which involved 301 U.S. hospitals with intervention and usual-care arms, 11,001 MI patients were enrolled prior to discharge from June 2015 to September 2016. While P2Y12-inhibitor choice was determined by clinicians, intervention-arm hospitals provided patients with vouchers that waived the copay for either clopidogrel or ticagrelor for 1 year after MI. One-year P2Y12-inhibitor persistence (continued use without a 30-day or more gap) and MACE (all-cause death, recurrent MI, or stroke were both endpoints.

Results indicate that clinicians were sensitive to their patients’ cost concerns and that, when patient copays were covered, doctors were more than 30% more likely to prescribe the drug with greater effectiveness even at greater cost.

At the same time, when patients were queried about their medication usage, 80% to 85% said that they filled all their prescriptions continuously, although the study’s analysis of pharmacy fill data indicated that only 55% had been fully compliant.

Still, the study confirms that more patients who got the pay vouchers adhered to their recommended drug regimens. Greater adherence did not appear to result in a reduced rate of
death, heart attacks, or strokes compared with patients who got usual care, however.

“This randomized trial tested the hypothesis that, when patient cost burden is lowered, clinicians are more likely to prescribe P2Y12 inhibitor per guideline recommendations, patients are more likely to persist with the guideline-recommended 1-year duration of P2Y12 inhibitor therapy, and patient outcomes are improved,” researchers concluded.

“Our study confirms some of our thoughts on how drug prices affect doctors’ and patients’ behaviors,” explained lead author Tracy Wang, MD, Associate Professor of Medicine at Duke University School of Medicine.

“But we still have a lot of work to do to understand how we can both measure and improve treatment adherence,” Wang added. “We should consider copayment reductions as part of broader initiatives to improve medication use and clinical outcomes.”

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