Full Coverage for Preventive Medications After Myocardial Infarction

Study Questions:

What is the effect of elimination of out-of-pocket costs for evidence-based therapies after myocardial infarction on adherence and clinical outcomes?

Methods:

The investigators enrolled patients discharged after myocardial infarction and randomly assigned their insurance-plan sponsors to full prescription coverage (1,494 plan sponsors with 2,845 patients) or usual prescription coverage (1,486 plan sponsors with 3,010 patients) for all statins, beta-blockers, angiotensin-converting enzyme [ACE] inhibitors, or angiotensin-receptor blockers [ARBs]). The primary outcome was the first major vascular event or revascularization. Secondary outcomes were rates of medication adherence, total major vascular events or revascularization, the first major vascular event, and health expenditures. Cox proportional-hazards models were used to estimate hazard ratios and 95% confidence intervals.

Results:

Rates of adherence ranged from 35.9% to 49.0% in the usual-coverage group and were 4-6 percentage points higher in the full-coverage group (p < 0.001 for all comparisons). There was no significant between-group difference in the primary outcome (17.6 per 100 person-years in the full-coverage group vs. 18.8 in the usual coverage group; hazard ratio, 0.93; 95% confidence interval [CI], 0.82-1.04; p = 0.21). The rates of total major vascular events or revascularization were significantly reduced in the full-coverage group (21.5 vs. 23.3; hazard ratio, 0.89; 95% CI, 0.90-0.99; p = 0.03), as was the rate of the first major vascular event (11.0 vs. 12.8; hazard ratio, 0.86; 95% CI, 0.74-0.99; p = 0.03). The elimination of copayments did not increase total spending ($66,008 for the full-coverage group and $71,778 for the usual-coverage group; relative spending, 0.89; 95% CI, 0.50-1.56; p = 0.68). Patient costs were reduced for drugs and other services (relative spending, 0.74; 95% CI, 0.68-0.80; p < 0.001).

Conclusions:

The authors concluded that enhanced prescription coverage improved medication adherence and rates of first major vascular events.

Perspective:

This study suggests that the elimination of copayments for statins, beta-blockers, ACE inhibitors, and ARBs did not significantly improve the primary outcome of the first major cardiovascular event or revascularization. The intervention, however, increased medication adherence and reduced the rates of prespecified secondary clinical outcomes (first major vascular event and total major vascular events or revascularization). Furthermore, the enhanced coverage reduced patients’ out-of-pocket spending for drug and nondrug services and did not significantly change total spending by insurers or overall costs. This strategy shows promise, may contribute significantly to ongoing efforts to improve the quality of care for patients after myocardial infarction, and may improve outcomes. The study also highlights the very poor adherence in both groups, and calls for the need for more effective ways to improve medication use to realize its benefits.

Clinical Topics: Dyslipidemia, Nonstatins, Novel Agents, Statins

Keywords: Medication Adherence, Angiotensin Receptor Antagonists, Myocardial Infarction, Proportional Hazards Models, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Health Expenditures


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