Affordability and Real-World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study - ARTEMIS

Contribution To Literature:

The ARTEMIS trial showed that, while copayment reduction significantly affected clinician’s choice of P2Y12 inhibitor use post-ACS presentation and improved patient persistence with treatment, it did not impact clinical outcomes at 1 year.

Description:

The goal of the trial was to compare the efficacy of copayment intervention on P2Y12 inhibitor use among acute coronary syndrome (ACS) patients and outcomes at 1 year.

Study Design

Patients presenting with ACS underwent 1:1 cluster randomization to either copay intervention (n = 131 sites, 6,135 patients) or usual care (n = 166 sites, 3,967 patients). P2Y12 inhibitor choice and duration of therapy were determined by the treating physicians. Enrolled patients could be treated with any P2Y12 inhibitor. Intervention site patients provided a copayment voucher card for either a generic (clopidogrel) or brand (ticagrelor) P2Y12 inhibitor. No other interventions to improve adherence were given.

Inclusion criteria:

  • ST-segment elevation myocardial infarction (STEMI) or NSTEMI patients on P2Y12 inhibitor therapy
  • Enrolled before discharge
  • US-based health insurance (commercial or government)
  • Total number of enrollees: 10,102
  • Duration of follow-up: 1 year
  • Mean patient age: 62 years
  • Percentage female: 32%

Other salient features/characteristics:

  • STEMI: 46%
  • Diabetes: 32%
  • Home aspirin use: 43%, home P2Y12 inhibitor use: 14%
  • Percutaneous coronary intervention (PCI) during index MI: 89%
  • Discharge P2Y12 inhibitor use among copay intervention vs. usual care arm: clopidogel 36.0% vs. 54.7%, ticagrelor 59.6% vs. 32.4%, p < 0.001

Principal Findings:

The primary outcome, patient-reported nonpersistence (≥30-day gap) in P2Y12 inhibitor use, for copay intervention vs. usual care, was 13.0% vs. 16.2%, p < 0.0001; adjusted odds ratio 0.84 (95% confidence interval 0.72-0.98).

  • Based on pharmacy fills: 44.8% vs. 53.7%, p < 0.0001
  • Major adverse cardiac events (MACE): 10.2% vs. 10.6%, p = 0.65

Secondary outcomes:

  • Death: 3.9% vs. 3.9%, p = 0.98
  • Recurrent MI: 6.9% vs. 7.3%, p = 0.64

Among patients in the intervention arm who actually used the voucher (72% of total), MACE was 10% vs. 16.2%, p < 0.001.

Interpretation:

The results of this trial indicate that while copayment reduction significantly affected clinician’s choice of P2Y12 inhibitor use post-ACS presentation and improved patient persistence with treatment, it did not impact clinical outcomes at 1 year. Further, even among patients who were in the intervention arm, nearly one in three did not use their vouchers.

These results are similar to the MI FREEE trial, where providing medication free (no copayment) for statins, beta-blockers, and angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker to patients recently discharged with a MI improved medication adherence and lowered patient costs, but did not improve patient outcomes. This further reinforces that copayment reduction/elimination should part of a multi-pronged strategy to enhance medication persistence and outcomes, rather than as a solution set in itself.

References:

Presented by Dr. Tracy Wang at the American College of Cardiology Annual Scientific Session (ACC 2018), Orlando, FL, March 11, 2018.

Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Nonstatins, Novel Agents, Statins, Interventions and ACS

Keywords: ACC18, ACC Annual Scientific Session, Acute Coronary Syndrome, Adenosine, Dyslipidemias, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Insurance, Health, Medication Adherence, Myocardial Infarction, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Treatment Outcome


< Back to Listings