Estimating proportion of days covered (PDC) using real-world online medicine suppliers' datasets

Enhancing medication adherence in marginalized and minoritized communities: A brief training approach for pharmacy technicians and community health workers

Background

Medication non-adherence is a pervasive issue, with especially severe consequences for marginalized and minoritized populations. Engaging pharmacy technicians and community health workers (CHWs) to address medication adherence in collaboration with pharmacists could be an effective strategy since they may be better positioned to build trust and rapport with patients compared to pharmacists alone.

Objectives

This study aimed to evaluate and compare the effectiveness of a brief training program for pharmacy technicians and community health workers in improving medication adherence.

Methods

A hybrid model training program, including pre-recorded video lectures to be watched at home followed by an in-person session, was developed and delivered to 19 pharmacy technicians and 109 CHWs, focusing on key skills related to enhancing medication adherence. Participants' knowledge and self-efficacy were assessed using pre- and post-program questionnaires.

Results

The training program yielded significant improvements in participants' knowledge and confidence in performing activities to improve medication adherence. Notably, post-training scores did not differ significantly between pharmacy technicians and community health workers, indicating that both groups achieved similar levels of knowledge and self-efficacy. Furthermore, pharmacy technicians demonstrated significant gains in understanding cultural competence and health disparities.

Conclusion

A targeted, brief training program can significantly enhance the knowledge and self-efficacy of pharmacy technicians and community health workers in addressing medication adherence. Engaging these frontline healthcare workers could be a crucial strategy for improving medication adherence, particularly in marginalized communities. Future research is necessary to assess the impact of this training on patient adherence outcomes.

Real-world management of hypercholesterolemia in patients after acute coronary syndrome in Greece

Background

Prompt initiation of lipid-lowering therapy (LLT) following acute coronary syndrome (ACS) is crucial for preventing secondary cardiovascular events. However, there are gaps in clinical implementation of the 2019 ESC/EAS guideline-recommended low-density lipoprotein cholesterol (LDL-C) goal of <55 mg/dL in patients post-ACS.

Methods

This multicenter, real-world, retrospective, 12-month study of adult patients in Greece hospitalized for ACS from September 2019 to November 2022 assessed the attainment of target LDL-C (<55 mg/dL) during the first year post-ACS. Eligible patients had elevated LDL-C at hospitalization (>130 mg/dL if LLT naïve; >100 mg/dL if on statin monotherapy; >70 mg/dL if on a statin plus ezetimibe) and ≥1 LDL-C measurement within 12 months post-ACS.

Results

Overall, 212 eligible patients of mean (SD) age 59.9 (±11.1) years were enrolled. Type 2 diabetes and hypertension were reported in 19.8 % (42/212) and 50.9 % (108/212) of patients, respectively. Median (Q1, Q3) LDL-C was 138.0 (106.5, 158.0) mg/dL at hospitalization (n = 212). In patients with LDL-C availability at 12 months posthospitalization (n = 197), median (Q1, Q3) LDL-C was 64.0 (53.0, 76.0) mg/dL, with 27.9 % of patients (55/197) attaining LDL-C <55 mg/dL. Although 73.9 % of patients (199/212) were discharged from the hospital on statin monotherapy, 50 % of patients (106/212) were receiving statin-ezetimibe LLT and 1.4 % (3/212) were receiving statin-ezetimibe-PCSK9 inhibitor LLT 12 months posthospitalization.

Conclusion

LDL-C goal attainment is suboptimal in the first year after ACS hospitalization in Greece, indicating an unmet need to improve the treatment of patients with hypercholesterolemia during the post-ACS period by optimizing lipid management through earlier LLT intensification.

Adherence and Forgiveness of Two Modern ART Regimens: Lamivudine/Dolutegravir and Emtricitabine/Tenofovir Alafenamide/Rilpivirine

INTRODUCTION

Few data are available on the forgiveness of 2-drug (2DR) or low-barrier 3-drug antiretroviral regimens. The aim of this study is to evaluate the real-life forgiveness of lamivudine/dolutegravir (3TC/DTG) and emtricitabine/tenofovir alafenamide/rilpivirine (FTC/TAF/RPV).

METHODS

A 2-center retrospective observational study enrolled all people with HIV treated with 3TC/DTG or FTC/TAF/RPV. Adherence was measured as the proportion of days covered (PDC) by drug supply. Binary logistic regression was used to test the impact of baseline variables and adherence on the achievement of virological suppression.

RESULTS

In total, 1258 adult people with HIV were enrolled, 368 in 3TC/DTG and 890 in FTC/TAF/RPV. Most were men (71%), with a median age of 51 years (IQR 43-58 years) and a median CD4 nadir of 305 cells/mcL (IQR 132-485). Median cohort follow-up was 4558 persons/year. Median adherence, as calculated from PDC, was of 0.98 (IQR 0.93-1). Regardless of the treatment group, a PDC of 0.8 was sufficient to achieve HIV-RNA levels below 200 copies/mL in almost all study participants. With the same level of adherence, >90% of study participants achieved HIV-RNA below 50 copies/mL. PDC ( P < 0.0001), Italian origin ( P < 0.0001), and male sex ( P = 0.038) were significantly correlated with achieving <200 copies/mL.

CONCLUSIONS

In this study, we found a similar and high level of forgiveness with the INSTI-based 2-drug regimen 3TC/DTG and the NNRTI-based 3-drug regimen FTC/TAF/RPV.

Pharmacist interventions to improve medication adherence in patients with co-morbid hypertension and diabetes: a scoping review and bibliometric analysis

OBJECTIVES

To evaluate the characteristics, assessment methods and overall impact of pharmacist-led interventions on medication adherence (MA) and clinical outcomes in patients with co-morbid hypertension and diabetes.

METHODS

A predetermined search in four scientific databases (Scopus, Cochrane, Medline, and CINAHL) and a search engine (Google Scholar) was conducted between October 2023 and February 2024. This review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). A screening was conducted which considered the article type (original article), written in the English language and based on the study's relevance while conference proceedings, reviews, and meta-analyses were excluded. Bibliometric indicators and VOSviewer were utilized to analyse and visualize keyword networks.

KEY FINDINGS

Out of the 420 studies initially identified, 12 of them involving 3512 patients were analysed in this review. The majority (11) reported a significant effect of pharmacist interventions on MA to prescribe medications. Pharmacist-led interventions, including remote and in-person education, special monitoring, and medication simplification, significantly improved MA and clinical outcomes in patients with hypertension and diabetes. The inclusion of patient education in a pharmacist-led multimodal intervention achieved a 100% success rate in improving MA.

CONCLUSION

For patients with hypertension and diabetes co-morbidity, integrating pharmacist education in multifaceted interventions is more effective in improving MA and clinical outcomes.

Approach to Estimating Adherence to Heart Failure Medications Using Linked Electronic Health Record and Pharmacy Data

BACKGROUND

Medication non-adherence, which is common in chronic diseases such as heart failure, is often estimated using proportion of days covered (PDC). PDC is typically calculated using medication fill information from pharmacy or insurance claims data, which lack information on when medications are prescribed. Many electronic health records (EHRs) have prescription and pharmacy fill data available, enabling enhanced PDC assessment that can be utilized in routine clinical care.

OBJECTIVE

To describe our approach to calculating PDC using linked EHR-pharmacy data and to compare to PDC calculated using pharmacy-only data for patients with heart failure.

METHODS

We performed a retrospective cohort study of adult patients with heart failure who were prescribed guideline-directed medical therapy (GDMT) and seen in a large health system. Using linked EHR-pharmacy data, we estimated medication adherence by PDC as the percent of days in which a patient possessed GDMT based on medication pharmacy fills over the number of days the prescription order was active. We also calculated PDC using pharmacy-only data, calculated as medications possessed over days with continued medication fills. We compared these two approaches for days observed and PDC using a paired t-test.

RESULTS

Among 33,212 patients with heart failure who were prescribed GDMT, 2226 (6.7%) never filled their medications, making them unavailable in the assessment of PDC using pharmacy-only data (n = 30,995). Linked EHR-pharmacy data had slightly longer days observed for PDC assessment (164.7 vs. 163.4 days; p < 0.001) and lower PDC (78.5 vs. 90.6, p < 0.001) as compared to assessment using pharmacy-only data.

CONCLUSIONS

Linked EHR-pharmacy data can be used to identify patients who never fill their prescriptions. Estimating adherence using linked EHR-pharmacy data resulted in a lower mean PDC as compared to estimates using pharmacy-only data.

The association between polypharmacy and disease control in rheumatoid arthritis and systemic lupus erythematosus: a cohort study

Polypharmacy can be associated with poor outcomes in chronic diseases. Our objective is to determine the prevalence of polypharmacy and its association with disease control in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). An observational study was conducted using the SARD database of the CHU de Québec. Participants newly diagnosed with RA or SLE enrolled in the database after 24 months were included. Collected data included number and type of medications, Charlson Comorbidity Index, and medication adherence (proportion of days covered during the first 180 days). Polypharmacy was defined as the simultaneous use ≥5 medications. Multivariable logistic and linear regressions were used to determine the association between polypharmacy and disease control (DAS28CRP, SLEDAI-2 K). The study included 111 participants (RA = 81; SLE = 30). Medication count increased at two years in RA (mean ± SD): 4.6 ± 3.3 to 6.9 ± 3.6; and SLE: 6.5 ± 4.6 to 7.80 ± 4.82. Polypharmacy prevalence increased at two years: RA: from 43 to 74%; SLE: from 47 to 73%. Mean medication adherence exceeded 85%. For RA participants, polypharmacy was associated with a better DAS28CRP score at one year [adjusted odds ratio of achieving a poor outcome: 0.17 (95%CI 0.04-0.71)], but this association was lost at two years [2.88 (0.45-18.29)]. For SLE, polypharmacy was not associated with disease activity based on the SLEDAI-2 K at one year [7.36 (0.26-211.16)] or two years [0.32 (0.05-1.99)]. Overall, polypharmacy is very prevalent in RA and SLE and could be positively associated with the level of disease control in the year after a diagnosis of RA.

One-Year Compliance After Calcitonin Gene-Related Peptide Monoclonal Antibody Therapy for Migraine Patients in a Real-World Setting: A Multicenter Cross-Sectional Study

Background: Calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) are a breakthrough migraine treatment, but long-term compliance under limited public insurance coverage has not been well known. This study explores one-year treatment patterns and outcomes of CGRP mAbs using real-world data. Methods: This multicenter retrospective study included migraine patients treated with CGRP monoclonal antibodies (CGRP mAbs) from July 2022 to June 2023. Treatment discontinuation was defined as a gap of over 60 days between injections. Among patients with 12 months of follow-up, adherence was measured using the Proportion of Days Covered (PDC), calculated as the ratio of days covered to the follow-up duration, with PDC ≥ 80% indicating good adherence. Efficacy was also assessed, defined as a ≥50% reduction in monthly headache days and acute medication use. Results: The study included 140 patients (mean age 44.6 ± 12.1 years; 82.9% female). Migraine without aura was predominant (93.6%), and 65.0% had chronic migraine. CGRP mAbs discontinuation occurred in 71.4% of patients, primarily due to headache improvement (22.9%) or lack of efficacy (15.0%). Among 81 patients with 12 months of follow-up, good adherence was observed in 40.7% of patients. Among these patients, 60.6% achieved a ≥50% reduction in monthly headache days, and 51.9% showed a ≥50% reduction in monthly acute medication use. Conclusions: More than two-thirds of patients discontinued the CGRP mAb within 1 year, so these findings emphasize the need for strategies to improve adherence and optimize follow-up plans to enhance patient support.

Cost-effectiveness of a Low-cost Educational Messaging and Prescription-fill Reminder Intervention to Improve Medication Adherence Among Individuals With Intellectual and Developmental Disability and Hypertension

BACKGROUND

Adults with intellectual and developmental disabilities (IDDs) have a similar prevalence of hypertension as the general population, but a higher rate of medication nonadherence at 50% compared with the average of 30%.

OBJECTIVES

To assess the cost-effectiveness of educational messaging and prescription-fill reminders to adults with IDD and hypertension and their helpers among Medicaid members in a randomized control trial.

RESEARCH DESIGN

The authors calculated net cost savings by subtracting per-participant intervention costs from differences in spending between preintervention/postintervention cases versus controls. Using bootstrap samples, they assessed the probability of positive cost savings. They used quantile and logistic regression to examine which members contributed to the cost savings and to identify future high-cost members at baseline.

SUBJECTS

Four hundred twelve members with IDD and their helpers were recruited from the South Carolina Medicaid agency in 2018.

MEASURES

Intervention costs were determined using labor and communication costs. Health expenditures were obtained from South Carolina's all-payer claims database, using actual Medicaid expenditures and total all-payer expenditures estimated with cost-to-charge ratios.

RESULTS

The intervention, which cost $26.10 per member, saved $1008.02 in all-payer spending and $1126.42 in Medicaid payments per member, respectively, with 78% and 91% confidence. Cost savings occurred among members above the 85th percentile of spending, and those using the emergency department or inpatient services at least twice at baseline were predicted to be future high-cost members.

CONCLUSIONS

The intervention is cost-saving, and insurers can prospectively identify and target members who will likely benefit.

Real-world impact of Elexacaftor-Tezacaftor-Ivacaftor treatment in young people with Cystic Fibrosis: A longitudinal study

BACKGROUND

Elexacaftor, Tezacaftor, Ivacaftor (ETI) became available in the UK in August 2020 to treat people with Cystic Fibrosis (CF) aged >12 years. We report a real-world study of clinical outcomes in young people treated with ETI at our CF centre within the first two years of its availability.

METHODS

Participants aged 12-17 were identified within our clinic, with demographic data supplemented by the UK CF registry. Comprehensive outcome data spanning two years pre- and two years post-initiation of CFTR modulators were compiled from various local sources, including patient records, medication delivery logs, and clinical notes.

RESULTS

Of the 62 patients started on ETI (32 male, mean age 13.3 years), most (76 %) were homozygous for the F508del mutation. Three discontinuations occurred: one pregnancy, two related to side effects. Adherence was high (Proportion of Days covered >90 % both years). Following ETI initiation there was a significant increase in mean FEV1% (+11.7 units; 95 % CI 7.4-15.6), sustained throughout the two-year treatment period. There was no association between baseline lung function and the degree of improvement or rate of decline post-treatment. Improvements were similar for all treatable genotypes. BMI z-score increased by 0.25 units after four months of treatment, returning to baseline by 24 months. Intravenous antibiotic use decreased by 88 % (median IV days/year reduced from 32 to 4 days, p < 0.01).

CONCLUSIONS

ETI use in adolescents in a real-world setting led to sustained improvements in health outcomes, consistent with those seen in open trial extension studies.

Assessment of Phosphorodiamidate Morpholino Oligomer Treatment Patterns for Patients with Duchenne Muscular Dystrophy: A MarketScan Claims Analysis

INTRODUCTION

Phosphorodiamidate morpholino oligomers (PMOs), weight-based treatments administered weekly by intravenous infusion, are approved in the US for patients with Duchenne muscular dystrophy (DMD) amenable to certain exon skipping. Evidence regarding PMO treatment patterns in real-world settings is limited. This study used longitudinal administrative claims data to characterize PMO treatment patterns among US patients with DMD.

METHODS

MarketScan® commercial and Medicaid data (January 1, 2018-December 31, 2021) were used to identify claims for PMO treatments (eteplirsen, golodirsen, viltolarsen, casimersen). The proportion of days covered (PDC), proportion with continuous PMO claims coverage (no gaps in claims ≥ 30 days), and time to subsequent PMO claims after a ≥ 30-day gap in PMO claims were described.

RESULTS

One hundred thirty-three patients with ≥ 1 PMO claim were identified. Multiple codes were needed to identify PMO treatment coverage. Mean age was 14.1 years; all patients were male. Mean continuous follow-up duration was 669.3 days. Median PDC was 83.4%. Seventy-four (55.6%) patients had continuous PMO claims coverage (no ≥ 30-day gaps in claims). Of the 59 patients with ≥ 1 gap in PMO claims of ≥ 30 days, 39 had ≥ 1 subsequent PMO claim. Accounting for censoring via Kaplan-Meier analysis, 75.5% had a subsequent PMO claim within 1 year after a ≥ 30-day gap, with a median time of 64 days (including the qualifying 30 days).

CONCLUSION

Understanding treatment patterns is important for characterizing real-world utilization of precision genetic medicines. This study observed a high PDC for PMO treatments for DMD. Most patients had continuous PMO claims coverage, and most patients with a gap in PMO claims had a subsequent PMO claim. Nonetheless, the observed persistence may have been underestimated given shortcomings of claims data and payer coverage considerations. Caution should be exercised when inferring treatment effectiveness or tolerability based on observed treatment patterns from claims data alone for weight-based, infused PMO treatments.

Group-based trajectory modeling to identify adherence patterns for direct oral anticoagulants in Medicare beneficiaries with atrial fibrillation: a real-world study on medication adherence

BACKGROUND

Suboptimal adherence to direct oral anticoagulants (DOACs) among atrial fibrillation (AF) patients remains currently a major concern due to the increased risk of cardiac and thromboembolic events.

AIM

To identify longitudinal distinct trajectories of DOAC adherence and sociodemographic and clinical factors associated with each trajectory.

METHOD

Patients with AF who were prescribed with DOAC from July 2016-December 2017 were identified among patients enrolled in the Medicare Advantage Plan. Patients were followed up for a year after the index date to calculate the monthly proportion of days covered (PDC). The monthly PDC was incorporated into the logistic group-based trajectory model to evaluate distinct patterns of adherence. A multinomial regression model was carried out to assess various predictors associated with each trajectory. Sub-group analysis was conducted among incident DOAC users.

RESULTS

Total of 1969 patients with AF, four distinct trajectories of adherence were selected: adherent 36.8%, gaps in adherence 9.3%, gradual decline in adherence 29.7%, and rapid decline in adherence 24.2%. Significant predictors associated with suboptimal adherence trajectories were age (75 years or older), gender (male vs female), low-income subsidy health plan, prevalent users, and presence of comorbidities. Among 933 incident users, three adherence trajectories were identified: adherent trajectory (31.8%), rapid decline in adherence (32.5%), and gradual decline in adherence (35.6%). The significant predictors among incident users were gender (male vs female), low-income subsidy health plan, HAS-BLED score ≥ 2, and presence of coronary artery disease.

CONCLUSION

Adherence to DOACs was suboptimal among the total population and incident users.

Medication Management Initiatives Using Wearable Devices: Scoping Review

Background

Wearable devices (WDs) have evolved beyond simple fitness trackers to sophisticated health monitors capable of measuring vital signs, such as heart rate and blood oxygen levels. Their application in health care, particularly medication management, is an emerging field poised to significantly enhance patient adherence to treatment regimens. Despite their widespread use and increasing incorporation into clinical trials, a comprehensive review of WDs in terms of medication adherence has not been conducted.

Objective

This study aimed to conduct a comprehensive scoping review to evaluate the impact of WDs on medication adherence across a variety of diseases, summarizing key research findings, outcomes, and challenges encountered.

Methods

Adhering to PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines, a structured search was conducted across MEDLINE, Web of Science, and Embase databases, covering the literature from January 1, 2010, to September 30, 2022. The search strategy was based on terms related to WDs and medication adherence, specifically focusing on empirical studies to ensure the inclusion of original research findings. Studies were selected based on their relevance to medication adherence, usage of WDs in detecting medication-taking actions, and their role in integrated medication management systems.

Results

We screened 657 articles and identified 18 articles. The identified studies demonstrated the diverse applications of WDs in enhancing medication adherence across diseases such as Parkinson disease, diabetes, and cardiovascular conditions. The geographical distribution and publication years of these studies indicate a growing interest in this research area. The studies were divided into three types: (1) studies reporting a correlation between data from WDs or their usage and medication adherence or drug usage as outcomes, (2) studies using WDs to detect the act of medication-taking itself, and (3) studies proposing an integrated medication management system that uses WDs in managing medication.

Conclusions

WDs are increasingly being recognized for their potential to enhance medication management and adherence. This review underscores the need for further empirical research to validate the effectiveness of WDs in real-life settings and explore their use in predicting adherence based on activity rhythms and activities. Despite technological advancements, challenges remain regarding the integration of WDs into routine clinical practice. Future research should focus on leveraging the comprehensive data provided by WDs to develop personalized medication management strategies that can improve patient outcomes.

Long-term aspirin adherence following myocardial infarction and risk of cardiovascular events

AIMS

Aspirin is considered mandatory after myocardial infarction (MI). However, its long-term efficacy has been questioned. This study investigated the effectiveness of long-term aspirin after MI.

METHODS AND RESULTS

Patients ≥40 years with MI from 2004 to 2017 who were adherent to aspirin 1 year after MI were included from Danish nationwide registries. At 2, 4, 6, and 8 years after MI, continued adherence to aspirin was evaluated. Absolute and relative risks of MI, stroke, or death at 2 years from each time point were calculated using multivariable logistic regression analysis with average treatment effect modelling standardized for age, sex, and comorbidities. Subgroup analyses were stratified by sex and age > and ≤65 years. Among 40 116 individuals included, the risk of the composite endpoint was significantly higher for non-adherent patients at all time points. The absolute risk was highest at 2-4 years after MI for both adherent [8.34%, 95% confidence interval (CI): 8.05-8.64%] and non-adherent patients (10.72%, 95% CI: 9.78-11.66%). The relative risk associated with non-adherence decreased from 4 years after index-MI and onwards: 1.41 (95% CI: 1.27-1.55) at 4-6 years and 1.21 (95% CI: 1.06-1.36) at 8-10 years (Ptrend = 0.056). Aspirin non-adherence in women and individuals >65 years was not associated with increased risk. Pinteraction at each of the time points: Age - <0.001, <0.001, 0.002, 0.51; Sex - 0.25, 0.02, 0.02, 0.82.

CONCLUSION

Non-adherence to long-term aspirin was associated with increased risk of MI, stroke, or death, but not in women or individuals >65 years. The risk decreased from 4 years after MI with near statistical significance.

Impact of discontinuing disease-modifying therapies on health care utilization among midlife patients with multiple sclerosis in the United States

BACKGROUND

Multiple sclerosis (MS) is a lifelong progressive neurological disease treated primarily with disease-modifying therapies (DMTs). Disease activity tends to decline as patients age. Midlife represents a crossroads where the risks of DMT may outweigh the benefits, prompting providers to consider DMT discontinuation to reduce treatment burden. However, real-world evidence on the impact of DMT discontinuation among midlife patients is lacking.

OBJECTIVE

To evaluate the association between DMT discontinuation and health care utilization among midlife patients with MS.

METHODS

Midlife patients with MS who received an injectable or oral DMT between 2001 and 2018 were identified from the MarketScan commercial claims database. DMT discontinuation, defined as a treatment gap exceeding 90 days in days supply, was the independent variable. Patients who discontinued DMTs had their index date set as the last gap day, whereas index dates for those who continued DMTs were matched based on the time distribution of index dates of discontinuers. Inpatient hospitalizations (all-cause, MS-related, and non-MS-related), emergency department (ED) visits (all-cause, MS-related, and non-MS-related), and relapse-related hospitalizations and outpatient visits were independently evaluated during the 365-day follow-up. Patients were observed until the occurrence of an event (depending on the model), deviation from the treatment group, disenrollment, death, end of follow-up, or data unavailability. Stabilized inverse probability of treatment weighting (sIPTW) was employed to balance the 2 groups. The associations between DMT discontinuation and each utilization outcome were estimated using Cox proportional hazard regression models with sIPTW.

RESULTS

Of 149,721 midlife patients with MS, 22.8% discontinued DMTs and 77.2% continued DMTs. Patients who discontinued DMTs had a higher cumulative incidence for all utilization outcomes during the 365-day follow-up than those who continued DMTs. Cox regression showed that DMT discontinuation was associated with a 10.3% and 24.9% higher rate of all-cause and non-MS-related inpatient hospitalizations, respectively, with no significant association found for MS-related hospitalizations. Patients discontinuing DMTs exhibited higher utilization rates for ED visits, with an increase of 21.3% for all-cause, 23.0% for MS-related, and 20.9% for non-MS-related visits compared with those who continued DMTs. We also observed a 15.9% and 52.1% higher rate of relapse-related hospitalizations and outpatient visits associated with DMT discontinuation, respectively.

CONCLUSIONS

This study revealed that DMT discontinuation was associated with higher health care services utilization among midlife patients with MS, especially relapse-related outpatient visits. DMT discontinuation during midlife may be premature, and DMTs may still be necessary to reduce health care utilization.

Improvement of medication adherence for desmopressin by adjusting the prescription dosage in male patients with overactive bladder: A claims database analysis

OBJECTIVES

Desmopressin is widely used for nocturia in patients with nocturnal polyuria. We investigated the continuation rate and adherence for desmopressin in patients with overactive bladder and nocturia using a claims database and evaluated factors that improved adherence.

METHODS

Patients with nocturia in a Japanese claims database who started desmopressin between September 2019 and July 2021 were evaluated. Drug persistence was assessed using the Kaplan-Meier method for initial prescription of desmopressin. The proportion of days covered (PDC) was also evaluated among patients with prescription persistence. Multivariate analysis was performed using logistic regression analysis to identify factors predicting adherence to desmopressin.

RESULTS

The study included 72,888 patients entered into Japan Medical Data Center (JMDC) database between September 2019 and July 2021. For the 236 patients prescribed desmopressin formulations, mean prescription duration was 114 days. Among the total cases, 90 (38.1%) cases were prescribed only once, mean PDC was 0.60, and the number of high-adherence patients (PDC ≥ 0.80) was 108 (45.8%). Desmopressin prescription doses were fixed in 216 patients and adjusted in 20 patients. Multivariate analysis identified prescription dose adjustment for desmopressin as significantly associated with high PDC.

CONCLUSION

Desmopressin showed a 38% dropout rate after the first dose. However, high medication continuation and high medication adherence rates (PDC) could be maintained with prescription adjustments. Careful patient monitoring and appropriate adjustment of the desmopressin dosage appear to be important factors in improving nocturia.

Determinants of medication non-adherence among patients with chronic diseases at community pharmacy settings in South Gondar Zone, Northwest Ethiopia: a multicenter cross-sectional study

Background

Medication non-adherence is a significant public health concern in managing patients with chronic diseases, and community pharmacists are on the frontline in the management of chronic medications. Chronic diseases require lifelong pharmacotherapy and understanding the determinants of medication adherence has paramount importance to develop strategies that improve medication adherence and treatment outcomes. Thus, this study aimed to assess the magnitude of medication non-adherence and its contributing factors among patients with chronic diseases attending community pharmacies in South Gondar Zone, Northwest Ethiopia.

Methods

A multicenter cross-sectional study was conducted at community pharmacies in South Gondar Zone from September 01 to October 30, 2023. Medication adherence was assessed using a structured questionnaire using the Adherence in Chronic Diseases Scale (ACDS). Statistical Package for Social Sciences (SPSS) version 25 was used for analysis. Association between the outcome variable and independent variables was performed using binary logistic regression and a p-value of <0.05 was considered statistically significant.

Results

Among three hundred and eighty six (386) study participants recruited in this study, more than half of them 222 (57.51%, 95%CI: 52.4% - 62.5%) were low adherent to their medications. Concerning determinants of medication non-adherence; the presence of side effects (AOR =2.1, 95%CI=1.33-3.29), unable to get ever counseling from community pharmacists (AOR=2.3, 95%CI= 1.46-3.58), and poor about their medications (AOR=3.1, 95% CI= 1.96-4.82) were significantly associated with patients' non-adherence to medications.

Conclusion

The medication adherence level in this study was suboptimal, with a significant proportion of the patients being non-adherent to their medications. The presence of side effects, unable to get ever counseling, and poor knowledge about their medications were statistically significant factors of poorer medication adherence. Hence, healthcare professionals, especially community pharmacists, have a crucial role in designing the schedule for health education concerning the needs of these patients in community pharmacy settings.

Patterns of 12-Month Post-Myocardial Infarction Medication Use According to Revascularisation Strategy: Analysis of 15,339 Admissions in Victoria, Australia

AIM

Clinical guidelines recommend secondary prevention medications following myocardial infarction (MI) regardless of revascularisation strategy. Studies suggest that there is variation in post-MI medication use following percutaneous coronary intervention (PCI) and coronary artery bypass grafts (CABG). We investigated initial dispensing and 12-month patterns of medication use according to revascularisation strategy following non-ST-elevation MI (NSTEMI).

METHOD

We included all public and private hospital admissions for NSTEMI for patients aged ≥30 years in Victoria, Australia, between July 2012 and June 2017. We investigated initial dispensing of P2Y12 inhibitors (P2Y12i), statins (total and high intensity), angiotensin-converting-enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB), and beta blockers within 60 days after discharge. Twelve-month post-MI medication use was estimated as the proportion of days covered (PDC) over a 12-month period from the date of hospital discharge. Analyses were performed using adjusted regression models, stratified by revascularisation strategy.

RESULTS

There were 15,399 admissions for NSTEMI: 11,754 with PCI and 3,645 with CABG. Following adjustments, predicted probability of initial dispensing in the PCI and CABG groups, respectively, was 0.94 (95% confidence interval 0.93-0.95) vs 0.17 (0.13-0.21) for P2Y12i; 0.69 (0.66-0.71) vs 0.42 (0.37-0.48) for ACEi/ARB; 0.59 (0.57-0.62) vs 0.69 (0.64-0.74) for beta blockers; 0.89 (0.87-0.91) vs 0.89 (0.85-0.92) for statins; and 0.60 (0.57-0.62) vs 0.69 (0.63-0.73) for high intensity statins. The 12-month PDC in the PCI and CABG groups, respectively, was 0.82 (0.80-0.83) vs 0.12 (0.09-0.15) for P2Y12i; 0.62 (0.60-0.65) vs 0.43 (0.39-0.48) for ACEi/ARB; 0.53 (0.51-0.55) vs 0.632 (0.58-0.66) for beta blockers; 0.79 (0.78-0.81) vs 0.78 (0.74-0.81) for statins; and 0.49 (0.47-0.51) vs 0.55 (0.50-0.59) for high intensity statins.

CONCLUSIONS

Post-discharge dispensing of secondary prevention medications differed with respect to revascularisation strategy from 2012 to 2017, despite clear evidence of benefit during this period. Interventions may be needed to address possible clinician and patient uncertainty about the benefits of secondary prevention medications, regardless of revascularisation strategy.

Prescription Drug Utilization among Patients with Essential Tremor: A Cross-Sectional Study of More Than 36,000 Patients

BACKGROUND

Essential tremor (ET) is a chronic, progressive neurological disease that affects an estimated 7 million individuals in the United States (ie, 2.2% of the entire U.S. population). Despite its high prevalence, there are a few published studies on patterns of prescription medication use among patients.

OBJECTIVE

The aim was to examine prescription drug medication use among ET patients.

METHODS

This is a cross-sectional study of ET patients, age ≥40, with at least 1 prescription medication fill using the Optum's de-identified Clinformatics Data Mart Database from 2018 through 2019. We examined patterns of fills of key agents used to treat ET.

RESULTS

The final sample comprised 36,839 ET patients in the United States; 89% had at least 1 prescription drug claim over a 2-year period, indicating that 9 of 10 ET patients take a medication to treat their disease. For each of the 3 most frequently prescribed medications, only a modest fraction (1/5 to 1/4) of patients were taking that medication. Adherence to these agents was 52% to 61%. A high percentage of patients had fills for more than 1 of the main agents we studied.

CONCLUSION

These data illustrate a need for medication in the ET population. There is only 1 FDA-approved medication to treat ET, propranolol, and less than 25% of ET patients used this drug during our study period. At the same time, no single agent was utilized by more than one quarter of ET patients, adherence was low, and use of multiple agents was common. For such a common disease, the pharmacotherapeutic landscape is impoverished.

The impact of telemonitoring on correct drug use, complications and quality of life among patients with multiple myeloma (ITUMM): A study protocol for an open-label, parallel-group, randomized controlled trial

INTRODUCTION

Multiple myeloma (MM) is the second most common hematologic malignancy. MM is associated with significant morbidity due to its end-organ destruction and is a disease of the older population. Although survival rates for MM have improved over the last decade, due to an increase in treatment options, the disease remains incurable. Expensive (oral) agents are widely used in MM patients; however, tools for supporting patients in complex treatment regimens are scarce. To investigate if a tool will support MM patients and healthcare professionals, the MM e-coach was developed and tested. The aim of this study is to study the impact of telemonitoring on adherence, complications and quality of life in patients with MM (ITUMM study).

METHODS

A two-arm open-label parallel-group randomized controlled trial will be conducted between March 2021 and June 2024 to compare the telemonitoring (MM e-coach) with standard MM care. This study aimed to recruit 150 patients with recently diagnosed multiple myeloma (RDMM), starting first or second line of treatment. Blinded primary outcome is adherence by pill count after start of treatment at 1-3 months. Secondary outcomes are patient reported outcomes: GFI, EQ-5D-5L, EORTC-QLQ-C30, SDM-Q-9, MARS-5, single item questions, PREMs, adverse events, OS and PFS. Patient reported outcomes were developed and integrated in the e-coach MM to regularly measure digitized outcomes of MM patients from time of RDMM until 12 months post-diagnosis. Online measurements will be performed at baseline (0), 3, 6, 9 and 12 months.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Ethics Committee of the Isala klinieken in The Netherlands (No. 201111) at 25 February 2021. Study results will be disseminated to the relevant healthcare communities by publication in peer-reviewed journals, and at scientific and clinical conferences.

STUDY REGISTRATION NUMBER

ClinicalTrials.gov number: NCT05964270 and ABR number: NL75771.075.20.

Combination of low- or moderate-intensity statin and ezetimibe vs. high-intensity statin monotherapy on primary prevention of cardiovascular disease and all-cause death: a propensity-matched nationwide cohort study

AIMS

This study aims to compare the preventive effect of low- or moderate-statin with ezetimibe combination therapy and high-intensity statin monotherapy on cardiovascular disease (CVD) and all-cause death in a real-world setting.

METHODS AND RESULTS

Using the Korean National Health Insurance Service datasets, two cohorts comparing high-intensity statin monotherapy with low- or moderate-intensity statin and ezetimibe combination were constructed by 1:1 propensity score matching procedure. Primary outcome was a composite of myocardial infarction (MI), stroke, and all-cause death. Secondary outcome was an individual event. The study population was followed from baseline until the date of events, or the last health check-ups, whichever came first. Compared to high-intensity statin monotherapy, moderate-intensity statin with ezetimibe combination significantly reduced the risk of composite outcome [hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.77-0.92, P < 0.001] as well as individual MI (HR 0.81, 95% CI 0.71-0.94, P = 0.005) and stroke (HR 0.78, 95% CI 0.65-0.93, P = 0.005), but not all-cause death. Low-intensity statin with ezetimibe also significantly reduced the risk of the composite outcomes (HR 0.80, 95% CI 0.66-0.97, P = 0.024) compared to high-intensity statin monotherapy, but the risk of individual outcome did not differ between two groups. Statin and ezetimibe combination demonstrated consistent effect across various subgroups.

CONCLUSION

Among people without pre-existing CVD, moderate-intensity statin with ezetimibe combination was superior to high-intensity statin monotherapy in preventing composite outcomes as well as each of MI and stroke. In contrast, low-intensity statin with ezetimibe combination reduced the risk of composite but not individual outcomes.

Impact of Initial Treatment Policies on Long-term Complications and Costs in Japanese Patients with Type 2 Diabetes: A Real-World Database Study

INTRODUCTION

Type 2 diabetes (T2D) represents a remarkable disease burden in Japan, and the cost-effectiveness of pharmacotherapy is an important consideration. In this study, we compared the long-term effects of the type of initial medication, as well as the initial frequency of clinic visits, on the occurrence of T2D-related complications. Additionally, we compared the medical costs associated with each treatment pattern.

METHODS

We analyzed electronic health record data collected from multiple primary care clinics in Japan. Patients were selected based on being primarily prescribed either biguanides (BG) or DPP-4 inhibitors (DPP-4i) during a 3-month baseline period, both of which are commonly used as first-choice medications in Japan. We then followed the onset of T2D-related complications and conducted survival analyses. Additionally, we calculated the accumulated medical costs up to the onset of an event or loss to follow-up, and summarized the annual costs per patient for each treatment pattern.

RESULTS

A total of 416 Japanese patients with T2D who initiated treatment between January 2015 and September 2021 were included. The median follow-up period was 2.69 years. The survival analysis showed that the use of DPP-4is and frequent visits from the beginning of treatment did not offer a benefit in suppressing the onset of complications later on. On the other hand, it was found that the annual medical costs for the group using DPP-4i with frequent visits were about 1.9 times higher than for the group using BGs with less frequent visits.

CONCLUSIONS

The results suggest that for Japanese patients with T2D, the use of BGs along with relatively long follow-up intervals in the beginning of treatment can remarkably reduce medical costs while providing a level of complication suppression equivalent to that of the use of DPP-4is or frequent visits.

Medication Engagement, Determinants of Health, and A1C Levels Among Adults With Type 2 Diabetes within a Tribal Health System

PURPOSE

The purpose of this study was to examine the association between determinants of health, medication engagement, and A1C levels in adults with type 2 diabetes (T2DM) receiving Tribal health and pharmacy services.

METHODS

A retrospective analysis of 2020-2021 electronic health record data was conducted and included adult patients with T2DM using Choctaw Nation Health Services Authority prescribed ≥1 noninsulin glucose-lowering medication in 2020, had ≥1 A1C value in 2020 and 2021, and had a valid zip code in 2021. Patients receiving both insulin and other noninsulin glucose-lowering medication were included. The proportion of days covered (PDC) was used to calculate medication engagement. Statistical analyses included bivariate analysis and linear regression.

RESULTS

There were 3787 patients included in the analyses; 62.5% were considered engaged (PDC ≥ 0.8). The mean 2020 A1C level was 8.0 (64 mmol/mol) ± 1.8; 33% had an A1C of <7%, 42% had an A1C of 7% to 9%, and 25% had an A1C >9%. The mean A1C in 2021 was 7.9 (63 mmol/mol) ± 1.7; 34% had an A1C of <7%, 44% had an A1C of 7% to 9%, and 22% had an A1C >9%. Older age was weakly correlated with higher engagement; higher engagement was associated with lower A1C levels while adjusting for covariates.

CONCLUSIONS

Medication engagement was associated with lower A1C levels, and older age was weakly associated with higher engagement to noninsulin glucose-lowering medications, consistent with previous literature. No determinants of health were significantly associated with A1C levels while adjusting for covariates.

Development and Validation of a Tool to Explore Attitudes Towards meDication adHErence Using a Novel Self-Reported QuestionnairE (ADHERE-7)

Despite the availability of various tools for measuring medication adherence, efficiently identifying non-adherence levels and reasons at the point of care remains challenging. Existing tools often lack the ease of use needed for practical clinical application. This study aimed to develop and validate a user-friendly tool to provide healthcare professionals with a concise yet comprehensive means of identifying adherence behaviors. The methodology consisted of two phases: tool items were first developed using the nominal group technique with healthcare professionals, followed by a cross-sectional pilot study involving community-dwelling adults in Croatia. Validation analysis indicated acceptable face and content validity and satisfactory criterion validity, with Attitudes towards meDication adHErence self-Reported questionnairE (ADHERE-7) scores correlating with both the self-reported five-item Medication Adherence Report Scale (MARS-5 tool) (ρ = 0.765; p < 0.001) and an objective measure of the proportion of days covered (PDC) from pharmacy prescription claims data (G = 0.586; p = 0.015). Construct validity revealed three factors: Aversion, Comfort, and Practical Non-Adherence, with Cronbach's alpha values of 0.617 for Aversion and 0.714 for Comfort Non-Adherence. The mean total score for ADHERE-7 was 26.27 ± 2.41 (range 17 to 28). This robust validation process confirms the ADHERE-7 tool as a reliable instrument for assessing medication adherence, addressing aversion, comfort, practical issues, and both intentional and unintentional nonadherence.

Real world community-based HIV Rapid Start Antiretroviral with B/F/TAF versus prior models of antiretroviral therapy start - the RoCHaCHa study, a pilot study

BACKGROUND

The rapid start of antiretroviral therapy (RSA) model initiates antiretroviral therapy (ART) as soon as possible after a new or preliminary diagnosis of HIV, in advance of HIV-1 RNA and other baseline laboratory testing. This observational study aims to determine if RSA with a single tablet regimen of bictegravir, emtricitabine, and tenofovir alafenamide (B/F/TAF) is an effective regimen for achieving viral suppression and accepted by patients at the time of diagnosis.

METHODS

Adults newly or preliminarily diagnosed with HIV were enrolled from October 2018 through September 2021. Real world advantage, measured in days between clinical milestones and time to virologic suppression, associated with B/F/TAF RSA was compared to historical controls.

RESULTS

All Study RSA participants (n = 45) accepted treatment at their first visit and 43(95.6%) achieved virologic suppression by week 48. Study RSA participants had a significantly shorter time (median 32 days) from diagnosis to ART initiation and virologic suppression, in comparison to historical controls (median 181 days) (n = 42). Qualitative feedback from study RSA participants showed high acceptance positive response to RSA.

CONCLUSIONS

RSA is feasible and well accepted by patients in a real-world community-based clinic setting. Promoting RSA in community-based clinics is an important tool in ending the HIV epidemic.

Extemporaneous combination therapy with nebivolol/ramipril for the treatment of hypertension: a real-world evidence study in Europe

OBJECTIVES

To describe the clinical characteristics and treatment adherence in European adult hypertensive patients starting treatment with the extemporaneous combination of nebivolol and ramipril (NR-EXC).

METHODS

Retrospective database analysis of patients receiving NR-EXC treatment across five European countries (Italy, Germany, France, Poland, Hungary) over a period ranging from 3 to 9 years (until 30 June 2020) according to data availability for the different data sources. Patient demographics, comorbidities, and treatment adherence were evaluated.

RESULTS

We identified 592,472 patients starting NR-EXC. Most of them were over 60 years of age, with ramipril most commonly prescribed at 5 mg (from 30.0 to 57.2% of patients across the databases). Notable comorbidities included diabetes (19.2%) and dyslipidemia (18.2%). The study population was also highly subjected to polytherapy with antithrombotics, lipid-lowering agents, and other lowering blood pressure agents as the most co-prescribed medications, as resulted from Italian database. Up to 59% of the patients did not request a cardiologic visit during the study period. Adherence to therapy was low in 56.3% of the patients, and it was high only in 11.1% of them.

CONCLUSIONS

The combination of nebivolol and ramipril is frequently prescribed in Europe, but adherence to treatment is suboptimal. The transition to a single pill combination could enhance treatment adherence and streamline regimens, potentially leading to significant benefits. Improved adherence not only correlates with better blood pressure control but also reduces the risk of cardiovascular events, underscoring the importance of this development.

Medication adherence, related factors and outcomes among patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension: a systematic review

INTRODUCTION

Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are life-threatening conditions that can progress to death without treatment. Although strong medication adherence (MA) is known to enhance outcomes in chronic illnesses, its association with PAH and CTEPH was sporadically explored. This study aims to examine the MA of patients with PAH or CTEPH, identify factors associated with low adherence and explore the resulting outcomes.

METHODS

A systematic review was conducted by searching multiple databases (Medline, Embase, Cochrane Central, ClinicalTrials.gov, Scopus, Web of Science and Google Scholar) from 6 March 1998 to 6 July 2023. We included studies reporting MA as primary or secondary end-points. Study selection, data extraction and methodological quality assessment were performed in duplicate.

RESULTS

20 studies involving 22 675 patients met the inclusion criteria. Heterogeneity was observed, particularly in the methods employed. MA means ranged from 0.62 to 0.96, with the proportion of patients exhibiting high MA varying from 40% (95% CI 35-45%) to 94% (95% CI 88-97%). Factors associated with low adherence included increased treatment frequency, time since diagnosis and co-payment. High MA seems to be associated with reduced hospitalisation rates, inpatient stays, outpatient visits and healthcare costs.

CONCLUSIONS

This systematic review underscores the heterogeneity of MA across studies. Nevertheless, the findings suggest that high MA could improve patients' clinical outcomes and alleviate the economic burden. Identifying factors consistently associated with poor MA could strengthen educational efforts for these patients, ultimately contributing to improved outcomes.

Treatment adherence in forensic patients with schizophrenia spectrum disorders discharged on long-acting injectable antipsychotics: a comparative 3-year mirror-image study

In this retrospective 3-year mirror-image study, 81 patients with schizophrenia spectrum disorders (SSD) were categorized according to whether they were prescribed long-acting injectable antipsychotics (LAI) or not upon discharge from the inpatient forensic psychiatric unit. Antipsychotic adherence, which was staged based on the 'proportion of days covered' method, as well as other clinical outcomes was compared between pre- and post-index mirror periods. In both Oral-only (n = 46) and Oral + LAI (n = 35) groups, the number of hospitalizations, convictions and months spent in the hospital were significantly lower in the post-index period than the pre-index period. Differences in these three variables between pre- and post-index periods were NS between the two groups. A mixed effect ordinal logistic regression model with random intercept showed that the odds ratio of obtaining a higher treatment adherence score in the post-index period was more pronounced in the Oral + LAI group than in the Oral-only group, considering adherence at baseline and the length of stay during the index hospitalization as potential confounders. Discharge with LAIs in a forensic psychiatric cohort of SSD was associated with a greater mid- to long-term improvement in antipsychotic medication adherence compared to discharge with oral-only antipsychotics.

Extemporaneous combination therapy with nebivolol/valsartan for the treatment of hypertension: a study of real-world evidence in Europe

OBJECTIVE

To explore real-life use of the extemporaneous combination of nebivolol and valsartan (NV-EXC) in adult hypertensive patients in Europe.

METHODS

Retrospective analysis of patients starting NV-EXC treatment conducted using prescription databases in Italy, Germany, Hungary, and Poland. The selection period during which study patients were identified covered a time span ranging from 3 to 9 years (until 30 June 2020) according to availability of the different data sources. Patient demographics, clinical information, and treatment adherence, measured by proportion of days covered, were evaluated. Additionally, the potential eligibility of Italian patients for the single pill combination (SPC) of nebivolol and valsartan over a one-year period was estimated.

RESULTS

The study included 170,682 patients initiating NV-EXC across the databases. Most patients were females (from 51 to 60%) and primarily aged over 60 years. Few patients received prescriptions of both available dosages of valsartan (80 and 160 mg) during follow-up (from 3.2 to 8.5%). Common comorbidities included dyslipidemia (19.2%) and diabetes (19.1%). Around 59.5% of patients did not require cardiologic visits during the study period. Adherence to NV-EXC, as indicated by the Italian database, was low in 53.3% of patients, with only 16.1% showing high adherence. The Italian database revealed 680 prevalent NV-EXC users in 2019, estimating a potential 30,222 adult patients eligible for the nebivolol/valsartan SPC.

CONCLUSIONS

The combination of nebivolol and valsartan is frequently prescribed for hypertension, but adherence remains a challenge. A potential nebivolol/valsartan SPC holds promise in enhancing adherence and optimizing therapeutic outcomes for hypertension management.

Real-world Impact of Fremanezumab on Migraine-Related Health Care Resource Utilization in Patients with Comorbidities, Acute Medication Overuse, and/or Unsatisfactory Prior Migraine Preventive Response

INTRODUCTION

Fremanezumab, a humanized monoclonal antibody targeting calcitonin gene-related peptide, is indicated for preventive treatment of migraine in adults. Real-world evidence assessing the effect of fremanezumab on migraine-related medication use, health care resource utilization (HCRU), and costs in patient populations with comorbidities, acute medication overuse (AMO), and/or unsatisfactory prior migraine preventive response (UPMPR) is needed.

METHODS

Data for this US, retrospective claims analysis were obtained from the Merative® MarketScan® Commercial and supplemental databases. Eligible adults with migraine initiated fremanezumab between 1 September 2018 and 30 June 2019 (date of earliest fremanezumab claim is the index date), had ≥ 12 months of continuous enrollment prior to initiation (preindex period) and ≥ 6 months of data following initiation (postindex period; variable follow-up after 6 months), and had certain preindex migraine comorbidities (depression, anxiety, and cardiovascular disease), potential AMO, or UPMPR. Changes in migraine-related concomitant acute and preventive medication use, HCRU, and costs were assessed pre- versus postindex.

RESULTS

In total, 3193 patients met the eligibility criteria. From pre- to postindex, mean (SD) per patient per month (PPPM) number of migraine-related acute medication and preventive medication claims (excluding fremanezumab), respectively, decreased from 0.97 (0.90) to 0.86 (0.87) (P < 0.001) and 0.94 (0.74) to 0.81 (0.75) (P < 0.001). Migraine-related outpatient and neurologist office visits, emergency department visits, and other outpatient services PPPM decreased pre- versus postindex (P < 0.001 for all), resulting in a reduction in mean (SD) total health care costs PPPM from US$541 (US$858) to US$490 (US$974) (P = 0.003). Patients showed high adherence and persistence rates, with mean (SD) proportion of days covered of 0.71 (0.29), medication possession ratio of 0.74 (0.31), and persistence duration of 160.3 (33.2) days 6 months postindex.

CONCLUSIONS

Patients with certain migraine comorbidities, potential AMO, and/or UPMPR in a real-world setting had reduced migraine-related medication use, HCRU, and costs following initiation of fremanezumab. Graphical abstract available for this article.

Poor adherence to and persistence with biologics in generalized pustular psoriasis: A claim-based study using real-world data from two large US databases

Background

Generalized pustular psoriasis (GPP) is a rare skin disease characterized by episodes of widespread sterile pustules.

Methods

A retrospective cohort study using data from the US IBM MarketScan Commercial and Optum Clinformatics Data Mart databases between October 1, 2015 and March 31, 2020 was performed to describe adherence and persistence to biologics in patients with GPP. Patients were aged ≥18 years with newly diagnosed GPP (International Classification of Diseases code L40.1) and had ≥1 inpatient or ≥2 outpatient claims.

Results

Biologics were dispensed to 110 of 502 (22%) and 73 of 528 (14%) patients from MarketScan and Optum databases, respectively. The mean proportion of days covered (PDC) (range) was similar in both databases (MarketScan, 65% [8%-100%]; Optum, 59% [8%-99%]), and good adherence (≥80% PDC) was uncommon (MarketScan, 36%; Optum, 24%). Mean (standard deviation) persistence was similar in both databases (MarketScan, 287 [122] days; Optum, 261 [134] days). In Optum, the mean PDC was similar between age categories; good adherence was more common in patients aged 18 to 64 years (28%) versus ≥65 years (13%). Mean persistence was longer in patients aged 18 to 64 years (267 days) versus ≥65 years (242 days).

Conclusions

Overall, adherence and persistence were generally poor and varied according to the biologic class, database, and age. Improving adherence may help improve GPP treatment outcomes.

A Retrospective Review on HIV Pre-Exposure Prophylaxis in Davao City

Objectives: Evaluating the adherence to HIV Pre-Exposure Prophylaxis (PrEP) is essential for increasing its utilization and decreasing the risk of HIV transmission among Davao City's vulnerable groups. Methods: The research method utilized in the study is a quantitative, retrospective, descriptive research design. This method was employed to retrospectively review the de-identified data, which involved the fill and refill dates of PrEP and tablets supplied, to calculate the Proportion of Days Covered (PDC) among individuals in Davao City from January 2021 to December 2023. The study also included some demographic characteristics such as age and gender. Results: From 178 data entries collected, the age group of 25 to 34 years old was found to have the highest HIV PrEP use (52.25%), followed by those between 18 to 24 (30.90%), 35 to 44 (13.48%), and 45 years old and older (3.37%). Out of 178, only 2 clients were female. Furthermore, 73.60% of the 178 entries in the pharmacy records were identified to be taking PrEP daily. Descriptive statistics showed that the frequency of adherent clients across the years were 36.36%, 44.74% and 38.46%, respectively. Furthermore, the average PDC through the years was found to be 70.13%, 80.48%, and 72.8%. Age did not significantly affect adherence to PrEP during the years investigated (p-values > 0.05). Conclusion: Adherence to PrEP improved consistently in 2022 but declined in 2023, showing erratic adherence rates. Furthermore, adherence to HIV PrEP in Davao City was found to be suboptimal and while there are clients who are adherent, many are not. The results emphasize the need for targeted interventions and suggest that other socio-behavioral factors may play a role in this. To improve adherence and prevent HIV contractions, both short-term actions like public education campaigns about HIV PrEP and long-term plans like incorporating PrEP into the community pharmacies can be contributive.

Long-Term Reductions in Opioid Medication Use After Spinal Stimulation: A Claims Analysis Among Commercially-Insured Population

Purpose

Chronic, non-cancer pain significantly and negatively impacts patient quality of life. Neuromodulation is a major component of multi-modal interdisciplinary approaches to chronic pain management, which includes opioid and nonopioid medications. In randomized controlled trials, spinal cord stimulation (SCS) has been shown to reduce pain and decrease short-term opioid use for patients. This study sought to evaluate the effect of SCS on longer term opioid and non-opioid pain medication usage among patients over ≥3 years of follow-up.

Patients and Methods

Claims analysis was conducted using the Merative™ MarketScan® Commercial Database. Patients aged ≥18 who initiated SCS between 1/1/2010 and 3/31/2021 with ≥1 year of baseline data and ≥3 years of follow-up data were included. Opioid discontinuation, daily dose (DD) reduction, proportion of days covered (PDC), concomitant co-medication with benzodiazepines and/or gabapentinoids, and polypharmacy were evaluated during the baseline and follow-up periods. Adjusted logistic regression was used to evaluate the impact of baseline dosages on discontinuation and dose reduction.

Results

During follow-up, 60% of 2,669 SCS patients either discontinued opioid use or reduced opioid DD by at least 20% from baseline; another 15% reduced DD by 1-19%. Logistic regression showed patients with higher baseline dosages were less likely to discontinue opioids completely (odds ratio[OR] 95% confidence intervals[CI]: 0.31[0.18,0.54]) but more likely to reduce their daily dose (OR[CI]: 7.14[4.00,12.73], p<0.001). Mean PDC with opioids decreased from 0.58 (210 of 365 days) at baseline to 0.51 at year 3 (p<0.001). With SCS, co-medication with benzodiazepines decreased from 47.3% at baseline to 30.3% at year 3, co-medication with gabapentinoids reduced from 58.6% to 42.2%, and polypharmacy dropped from 15.6% to 9.6% (all p<0.001).

Conclusion

Approximately three-quarters of patients who received SCS therapy either discontinued or reduced systemic opioid use over the study period. SCS could assist in reducing long-term reliance on opioids and other pain medications to treat chronic non-cancer pain.

Preventive Pharmacological Therapy and Risk of Recurrent Urinary Stone Disease

BACKGROUND

Urinary stone disease is a prevalent condition associated with a high recurrence risk. Preventive pharmacological therapy has been proposed to reduce recurrent stone episodes. However, limited evidence exists regarding its effectiveness, contributing to its underutilization by physicians. This study aimed to evaluate the association between preventive pharmacological therapy (thiazide diuretics, alkali therapy, and uric acid-lowering medications) and clinically significant urinary stone disease recurrence.

METHODS

Using data from the Veterans Health Administration, adults with an index episode of urinary stone disease from 2012 through 2019 and at least one urinary abnormality (hypercalciuria, hypocitraturia, or hyperuricosuria) on 24-hour urine collection were included. The primary outcome was a composite variable representing recurrent stone events that resulted in emergency department visits, hospitalizations, or surgery for urinary stone disease. Cox proportional hazards regression was performed to estimate the association between preventive pharmacological therapy use and recurrent urinary stone disease while adjusting for relevant baseline patient characteristics.

RESULTS

Among the cohort of patients with urinary abnormalities ( n =5637), treatment with preventive pharmacological therapy was associated with a significant 19% lower risk of recurrent urinary stone disease during the 12-36-month period after the initial urine collection (hazard ratio, 0.81; 95% confidence interval, 0.65 to 1.00; P = 0.0496). However, the effectiveness of preventive pharmacological therapy diminished over longer follow-up periods (12-48 and 12-60 months after the urine collection) and did not reach statistical significance. When examining specific urinary abnormalities, only alkali therapy for hypocitraturia was associated with a significant 26% lower recurrence risk within the 12-36-month timeframe (hazard ratio, 0.74; 95% confidence interval, 0.56 to 0.97; P = 0.03).

CONCLUSIONS

When considering all urinary abnormalities together, this study demonstrates that the use of preventive pharmacological therapy is associated with a lower risk of clinically significant recurrent episodes of urinary stone disease in the 12-36 month timeframe after urine collection, although only the association with the use of alkali therapy for hypocitraturia was significant when individual abnormalities were examined.

Montelukast as a repurposable additive drug for standard-efficacy multiple sclerosis treatment: Emulating clinical trials with retrospective administrative health claims data

BACKGROUND

Effective and safe treatment options for multiple sclerosis (MS) are still needed. Montelukast, a leukotriene receptor antagonist (LTRA) currently indicated for asthma or allergic rhinitis, may provide an additional therapeutic approach.

OBJECTIVE

The study aimed to evaluate the effects of montelukast on the relapses of people with MS (pwMS).

METHODS

In this retrospective case-control study, two independent longitudinal claims datasets were used to emulate randomized clinical trials (RCTs). We identified pwMS aged 18-65 years, on MS disease-modifying therapies concomitantly, in de-identified claims from Optum's Clinformatics® Data Mart (CDM) and IQVIA PharMetrics® Plus for Academics. Cases included 483 pwMS on montelukast and with medication adherence in CDM and 208 in PharMetrics Plus for Academics. We randomly sampled controls from 35,330 pwMS without montelukast prescriptions in CDM and 10,128 in PharMetrics Plus for Academics. Relapses were measured over a 2-year period through inpatient hospitalization and corticosteroid claims. A doubly robust causal inference model estimated the effects of montelukast, adjusting for confounders and censored patients.

RESULTS

pwMS treated with montelukast demonstrated a statistically significant 23.6% reduction in relapses compared to non-users in 67.3% of emulated RCTs.

CONCLUSION

Real-world evidence suggested that montelukast reduces MS relapses, warranting future clinical trials and further research on LTRAs' potential mechanism in MS.

The role of ambulatory blood pressure monitoring in enhancing medication adherence among patients with newly diagnosed hypertension: an analysis of the National Health Insurance cohort database

BACKGROUND

Improving adherence to antihypertensive medication (AHM) is a key challenge in hypertension management. This study aimed to assess the impact of ambulatory blood pressure monitoring (ABPM) on AHM adherence.

METHODS

We utilized the Korean National Health Insurance Service database. Among patients newly diagnosed with hypertension who started AHM between July 2010 and December 2013, we compared clinical characteristics and adherence between 28,116 patients who underwent ABPM prior to starting AHM and 118,594 patients who did not undergo ABPM. Good adherence was defined as a proportion of days covered (PDC) of 0.8 or higher.

RESULTS

The total study population was 146,710, with a mean age of 50.5 ± 6.4 years; 44.3% were female. Co-morbidities were noted in 4.2%. About a third of patients (33.1%) showed good adherence. The ABPM group had a notably higher PDC (total PDC: 0.64 ± 0.35 vs. 0.45 ± 0.39; P < 0.001), irrespective of the number of medications, dosing frequency, or prescription duration. After adjusting for significant clinical variables, ABPM was still closely linked with good adherence (odds ratio, 2.35; 95% confidence interval, 2.28-2.41; P < 0.001).

CONCLUSIONS

In newly diagnosed hypertension, undergoing ABPM prior to AHM prescription appears to enhance adherence to AHM. The exact mechanisms driving this association warrant further exploration.

Factors Influencing the Medication Adherence in Adults With Attention-Deficit/Hyperactivity Disorder (ADHD) and Its Impact on Healthcare Utilization

OBJECTIVE

This study aims to investigate the factors influencing medication adherence among adults with Attention-Deficit/Hyperactivity Disorder (ADHD) and impact of central nervous system stimulants (CNS) adherence on healthcare utilization (HCU). Methods: This was a cross-sectional study using Medical Expenditure Panel Survey 2013 to 2019, with participants (≥18 years of age) with ADHD and had at least one CNS prescription. Multivariate logistic and linear regression were utilized to evaluate the medication adherence and its impact on HCU, respectively.

RESULT

Total 798 (10,718,005 weighted) ADHD patients, were mostly White (81%), aged between 18 and 25 (35%), and non-adherent to CNS (65%). The use of extended-release medications (OR = 1.51 [1.03, 2.23]) and new users (OR = 3.46 [2.12, 5.63], p ≤ .05) were positively associated with medication adherence. The adherent group utilized more outpatient visits (0.04 vs. 0.46) and prescription refills (18.38 vs. 31.25) compared to non-adherent.

CONCLUSION

Our findings can be applied to improve the medication adherence, patient education, and optimize intervention for adults with ADHD.

Drug utilization and medication adherence for the treatment of psoriatic arthritis: an Italian study

Introduction

This study aims to evaluate the persistence, treatment adherence and drug cost associated with biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in the management of psoriatic arthritis (PsA) in Italy, with a focus on biosimilar drugs.

Methods

This was a retrospective observational study involving eight hospital pharmacies, between January 2017 and December 2020, on naïve patients with at least one b/tsDMARD dispensation indicated for PsA. Patients were followed up for 12 months and persistence and adherence were evaluated by proportion of days covered (PDC). The originator and biosimilar for adalimumab and etanercept were compared. Furthermore, the real annual cost per patient based on adherence to therapy was calculated.

Results

Patients initiating b/tsDMARDs for PsA had a mean persistence of 263 days and 48.6% remained persistent for 1 year. Adherent patients (PDC ≥ 0.8) were 47.6% for the overall population. Similar persistence and adherence were observed between patients treated with the adalimumab originator and its biosimilar, while patients treated with the etanercept originator showed lower persistence and adherence compared to those treated with its biosimilar (mean persistence: 222 vs. 267 days, patient persistent at 1 year: 29.4% vs. 51.5%, mean PDC: 0.53 vs. 0.70, adherent patients: 23.5% vs. 51.5%). The average annual drug cost ranged from €8,724 (etanercept) to €14,783 (ustekinumab), with an annual saving of more than €2,500 by using biosimilars.

Conclusion

Poor adherence to medications contributes to suboptimal clinical outcomes. The comparison between biosimilar and originator offers further evidence in support of the biosimilar to optimizing resources in healthcare.

Effect of statin therapy patterns on readmission and mortality in patients with intracerebral hemorrhage

There is limited and inconsistent evidence for the association of statin therapy and statin treatment patterns with the risk of recurrent intracerebral hemorrhage (ICH) in patients with prior ICH. To assess the association of statin therapy and its intensity, type, initiation time, and discontinuation with the risk of recurrent ICH and mortality in Chinese patients with ICH. Patients with newly diagnosed ICH in the Beijing Employee Medical Claims Data database from 2010 to 2017 were included. Post-ICH statin users (post-diagnosis only) and nonusers (never), statin discontinuers (pre-diagnosis only) and continuers (pre- and post-diagnosis) were matched on a 1:1 propensity score, respectively. Adjusted Cox proportional risk models were used to estimate the risk ratios for ICH readmission and mortality under various statin patterns. A total of 2668 post-ICH statin users and 2668 nonusers without a history of statin use were enrolled. Post-ICH statin users had a lower risk of ICH readmission (HR, 0.57; 95% CI 0.48, 0.69) and all-cause death (0.56: 0.49, 0.63) than nonusers. Low/moderate-intensity treatment was associated with a 63% lower risk of recurrent ICH compared with nonusers (0.37: 0.29, 0.46), whereas high-intensity treatment did not reduce the risk (0.93: 0.74, 1.16). Both low/moderate-intensity (0.42: 0.36, 0.48) and high-intensity statins (0.57: 0.48, 0.69) were associated with a lower risk of all-cause mortality. The risk of ICH readmission was 53% (0.47: 0.30, 0.74) lower with adherence to rosuvastatin than with atorvastatin. Only starting medication within 30 days of the first diagnosis of ICH reduced the risk of ICH readmission (0.49: 0.40, 0.60). Among patients with a history of statin use, 1807 discontinuing and 1,807 continuing users of statins were included. The risk of ICH readmission (4.00: 3.32, 4.80) and the risk of all-cause death (4.01: 3.57, 4.50) were substantially increased in statin discontinuation compared with continued statin use. Statin therapy after ICH was associated with lower risks for ICH readmission and all-cause mortality compared with non-statin therapy, especially at low/moderate intensity and early initiation of statins after ICH. Adherence to rosuvastatin was associated with a lower risk of recurrence of ICH than atorvastatin. Among patients with a statin history prior to ICH, discontinuation of statins after ICH was associated with increased risk of ICH recurrence and death.

Ticagrelor or prasugrel vs. clopidogrel in patients with atrial fibrillation undergoing percutaneous coronary intervention for myocardial infarction

Aims

The efficacy and safety of ticagrelor or prasugrel vs. clopidogrel in patients with atrial fibrillation (AF) on oral anticoagulation (OAC) undergoing percutaneous coronary intervention (PCI) for myocardial infarction (MI) have not been established.

Methods and results

This was a nationwide cohort study of patients on OAC for AF who underwent PCI for MI from 2011 through 2019 and were prescribed a P2Y12 inhibitor at discharge. The primary efficacy outcome was major adverse cardiovascular events (MACE), defined as a composite of death from any cause, stroke, recurrent MI, or repeat revascularization. The primary safety outcome was cerebral, gastrointestinal, or urogenital bleeding requiring hospitalization. Absolute and relative risks for outcomes at 1 year were calculated through multivariable logistic regression with average treatment effect modelling. Outcomes were standardized for the individual components of the CHA2DS2-VASc and HAS-BLED scores as well as type of OAC, aspirin, and proton pump inhibitor use. We included 2259 patients of whom 1918 (84.9%) were prescribed clopidogrel and 341 (15.1%) ticagrelor or prasugrel. The standardized risk of MACE was significantly lower in the ticagrelor or prasugrel group compared with the clopidogrel group (standardized absolute risk, 16.3% vs. 19.4%; relative risk, 0.84, 95% confidence interval, 0.70-0.98; P = 0.02), while the risk of bleeding did not differ (standardized absolute risk, 5.5% vs. 5.1%; relative risk, 1.07, 95% confidence interval, 0.73-1.41; P = 0.69).

Conclusion

In patients with AF on OAC who underwent PCI for MI, treatment with ticagrelor or prasugrel vs. clopidogrel was associated with reduced ischaemic risk, without a concomitantly increased bleeding risk.

Extemporaneous combination therapy with amlodipine/zofenopril in hypertensive patients: a real-world data analysis in Italy

OBJECTIVES

To provide clinical characteristics and to quantify the number of patients receiving the extemporaneous combination of the calcium channel blocker amlodipine and the angiotensin converting enzyme inhibitor zofenopril in a real-world setting. This evidence can provide a snapshot of the potential users of the two molecules in a single pill combination (SPC).

METHODS

Retrospective observational study using data from the IQVIA Italian Longitudinal Patient Database. Adult patients firstly prescribed with amlodipine and zofenopril between 1 July 2011 and 30 June 2020 were identified and demographic and clinical characteristics were extracted. Treatment adherence was evaluated as proportion of days covered (PDC). The potential number of patients eligible for a SPC was calculated.

RESULTS

A population of 2394 hypertensive patients, mean age of 68.6 years ±12.7, 52.6% male were treated with amlodipine and zofenopril. The majority of patients (54.5%) were low adherent (PDC <40%), 25.9% were intermediate adherent and only 19.6% were high adherent (>80%) to therapy. Around 42,500 adult hypertensive patients were estimated to be prescribed the extemporaneous combination in 2019 in Italy, being potentially eligible for treatment with amlodipine and zofenopril SPC.

CONCLUSIONS

The administration of the extemporaneous combination of zofenopril and amlodipine in hypertensive patients is a common practice in Italy. The development of a SPC can be a viable treatment option to simplify therapy and to increase adherence in hypertensive patients who are already on the two monotherapies in combination.

Long-Term Medical Treatment and Adherence in Patients With Left Ventricular Assist Devices: A Danish Nationwide Cohort Study

The use of a left ventricular assist device (LVAD) in treating advanced heart failure has increased. However, data regarding medical treatment and adherence following LVAD implantation is sparse, particularly whether socioeconomic factors (cohabitation status, educational level, employment status, and income) and multimorbidity influence these aspects, which are known to impact adherence in heart failure patients. We performed a nationwide cohort study of 119 patients with LVAD implanted between January 1, 2006, and December 31, 2018, who were discharged alive with LVAD therapy. We linked individual-level data from clinical LVAD databases, the Scandiatransplant Database, and Danish medical and administrative registers. Medical treatment 90-day pre-LVAD and 720-day post-LVAD were assessed using descriptive statistics in 90-day intervals. Medication adherence (proportion of days covered ≥80%) was assessed 181- to 720-day post-LVAD. The proportions of patients using angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (88.7%), beta-blockers (67.0%), mineralocorticoid receptor antagonists (62.9%), warfarin (87.6%), and aspirin (55.7%) within 90-day post-LVAD were higher than pre-LVAD and were stable during follow-up. Medication adherence ranged from 86.7% (aspirin) to 97.8% (warfarin). Socioeconomic factors and multimorbidity did not influence medical medication use and adherence. Among LVAD patients, medical treatment and adherence are at high levels, regardless of socioeconomic background and multimorbidity.

Relationship between medication adherence for opioid use disorder and health care costs and health care events in a claims dataset

INTRODUCTION

Medication for opioid use disorder (MOUD) has well-documented benefits for treating OUD, though its efficacy depends on patient adherence. We know little about outcomes of MOUD nonadherence compared to treatment regimens without MOUD, and this article aims to address the gap. This analysis focused on office-based MOUD treatment (buprenorphine and naltrexone) to evaluate the long-term impact of adherence on subsequent health care costs and health care events.

METHODS

With claims data from 2017 to 2019, we used propensity score (PS) weighting to create three comparable cohorts of patients: 1) Adherent: filled MOUD prescription & ≧80 % of days covered by MOUD (N = 1045); 2) Nonadherent: filled MOUD & < 80 % of days covered (N = 1116), 3) did not fill MOUD (N = 16,784). The study defined three time intervals based on a patient's most recent MOUD episode: A 6-month baseline period before initiation of MOUD or random index date for those with MOUD; a 6-month treatment period, during which adherence or nonadherence was established; and a 12-month follow-up period to evaluate outcome measures. The study used generalized PS methodology to examine the effect of proportion of days covered (PDC) as a continuous measure of adherence.

RESULTS

Among patients who filled MOUD, adherence to MOUD was significantly predicted by having less severe OUD, being older, having fewer inpatient visits and lower outpatient costs before the start of treatment. Adherent patients displayed significantly lower health care costs in the follow-up period compared to nonadherent MOUD patients, and lower odds of experiencing health care events. The nonadherent MOUD group displayed significantly higher odds of health care events compared to patients who had no evidence of receiving MOUD in claims data (NO-MOUD). Among patients prescribed MOUD, each 10 % increase in PDC was associated with a significant decrease in inpatient/outpatient costs and in odds of health care events.

CONCLUSIONS

This analysis aligns with previous findings about the importance of maintaining long-term adherence to MOUD in supporting patient outcomes. The results also suggest a novel finding that despite confounder control via PS methods, nonadherent patients display poorer outcomes compared to similar NO-MOUD patients.

Real-world data to measure and improve quality of asthma care

In this issue of the Annals, the paper “Association of quality-of-care indicators with asthma outcomes: An observational study for asthma care in Singapore” by Lam et al.1 illustrates the use of real-world data to generate real-world evidence in the area of asthma care in Singapore.

Is statin therapy after ischaemic stroke associated with increased intracerebral hemorrhage? The association may be dependent on intensity of statin therapy

BACKGROUND

There has been concern that statin therapy may be associated with an increased risk of intracerebral hemorrhage (ICH). We investigated whether the intensity and type of statin therapy instituted after ischemic stroke (IS) were associated with risk of future ICH in a region of northern China with a high incidence of stroke.

METHODS

Newly diagnosed IS patients who were not treated with lipid-lowering drugs in the Beijing Employee Medical Claims Data database from 2010 to 2017 were included. The primary exposure variable was any statin prescription within 1 month of the first documented stroke diagnosis. High-intensity statin therapy was defined as atorvastatin ⩾ 80 mg, simvastatin ⩾ 80 mg, pravastatin ⩾ 40 mg, and rosuvastatin ⩾ 20 mg per day or equivalent combination. An adjusted Cox proportional hazards model was used to estimate the hazard ratio (HR) for ICH during follow-up in groups exposed and not exposed to statins.

RESULTS

Of 62,252 participants with IS and 628 ICH readmissions were recorded during a median follow-up of 3.17 years. The risk of ICH among statin users (N = 43,434) was similar to that among nonusers (N = 18,818) with an adjusted HR and 95% confidence interval (CI) of 0.86 (0.73, 1.02). Compared with non-statin therapy, patients with low/moderate-intensity therapy had a lower risk of ICH (0.62: 0.52, 0.75), while patients with high-intensity therapy had a substantially higher risk (2.12: 1.72, 2.62). For patients with different types of statin therapy, adherence to rosuvastatin had the lowest risk of ICH compared to adherence to atorvastatin (0.46: 0.34, 0.63), followed by simvastatin (0.60: 0.45, 0.81).

CONCLUSION

In patients with IS, any statin therapy was not associated with an increased risk of ICH. However there appeared to be differential risk according to the dose of statin with high-intensity statin therapy being associated with an increased risk of ICH, while low/moderate-intensity therapy was associated with a lower risk.

Association of patient copayment and medication adherence in systemic lupus erythematosus

OBJECTIVE

To investigate the association of medication copayment and treatment adherence to hydroxychloroquine and immunosuppressants for SLE.

METHODS

We conducted a retrospective analysis of health claims data using Optum's de-identified Clinformatics Data Mart Database. Individuals with SLE continuously enrolled for 180 days from 1 July 2010 to 31 December 2019 were included. Adherence was defined as the proportion of days covered ≥80%. Copayment for a 30-day supply of medication was dichotomised as high (≥$10) or low (<$10). We examined the association between copayment and odds of adherence in multivariable-adjusted logistic regression models, including age, sex, race or ethnicity, comorbidities, educational attainment and household income.

RESULTS

We identified 12 510 individuals (age 54.2±15.5 years; 88.2% female sex), of whom 9510 (76%) were prescribed hydroxychloroquine and 1880 (15%) prescribed hydroxychloroquine and an additional immunosuppressant (azathioprine, methotrexate or mycophenolate mofetil). Median (IQR) 30-day copayments were $8 (4-10) for hydroxychloroquine, $7 (2-10) for azathioprine, $8 (3-11) for methotrexate and $10 (5-20) for mycophenolate mofetil. High copayments were associated with OR of adherence of 0.61 (95% CI 0.55 to 0.68) for hydroxychloroquine, OR 0.44 (95% CI 0.30 to 0.66) for azathioprine and OR 0.69 (95% CI 0.49 to 0.96) for mycophenolate mofetil. For methotrexate, the association was not significant.

CONCLUSION

In a large, administrative health claims database, we identified that high copayments were associated with reduced adherence to commonly prescribed medications for SLE. Incorporating awareness of the burden of copayments and its consequences into healthcare is essential to promote optimal medication adherence.

Cost-effectiveness analysis of monthly, 3-monthly, and 6-monthly long-acting injectable and oral paliperidone in adults with schizophrenia

BACKGROUND: Paliperidone is among the most cost-effective antipsychotics in adults with schizophrenia, and it has different formulations, including oral paliperidone extended-release (ER) and long-acting injectable (LAI) paliperidone formulations administered every month (PP1M), 3 months (PP3M), or 6 months (PP6M). However, cost-effectiveness analyses comparing different paliperidone formulations were limited. OBJECTIVE: To compare the cost-effectiveness across different paliperidone formulations. METHODS: A Markov model was developed to simulate 1,000 adults aged 40 years with stable schizophrenia transitioning among stable disease-medication adherent, stable disease-medication nonadherent, relapse with hospitalization, relapse with ambulatory care, and death states every 3 months for 5 years. Drug costs were estimated using the prices listed in the Veterans Affairs Federal Supply Schedule, and costs for treating complications were estimated from published studies. All costs were estimated from the US health care system perspective and standardized to 2022 US dollars using the Consumer Price Index Inflation Calculator. Quality-adjusted life-years (QALYs) were estimated using relapse rates from randomized clinical trials and health-related quality of life scores from observational studies. The estimated future costs and QALYs were discounted at 3%. We reported incremental net monetary benefits between alternative formulations at the $50,000 willingness-to-pay (WTP) threshold with a positive value indicating cost-effectiveness. The impact of parameter uncertainty on study outcomes was assessed using 1-way deterministic and probabilistic sensitivity analyses. RESULTS: In adults with schizophrenia stabilized with paliperidone ER, switching to LAI formulations was associated with increased QALY (PP1M = 0.05, PP3M = 0.14, PP6M = 0.15) and increased cost (PP1M = 49,433, PP3M = 26,698, PP6M = 26,147), leading to a negative incremental net monetary benefit (PP1M = -$46,804, PP3M = -$19,508, PP6M = -$18,886) compared with continuing ER. Among LAI formulations, PP6M was cost-saving with the most QALYs gained (cost = $63,277, QALY = 3.731), followed by PP3M (cost = $63,828, QALY = 3.729) and PP1M (cost = $86,563, QALY = 3.638). At the $50,000 WTP threshold, the probabilities for PP1M, PP3M, and PP6M being cost-effective compared with paliperidone ER were 0.4%, 10.2%, and 9.8%, respectively. The probability of PP6M being cost-effective was 92.6% for the PP6M-PP1M pair and 55.2% for the PP6M-PP3M pair, and 91.1% of PP3M use was cost-effective in the PP3M-PP1M pair. The results were generally robust in the sensitivity analyses, even at the $190,000 WTP threshold. CONCLUSIONS: For patients with schizophrenia stabilized with paliperidone ER, switching to LAI formulations was not cost-effective, suggesting the high drug costs for LAI may not justify the improved quality of life within 5 years. Among LAI formulations, PP6M was cost-effective over PP1M and PP3M.

Use and persistence of single and multiple inhaler triple therapy prescribed for patients with COPD in France: a retrospective study on THIN database (OPTI study)

INTRODUCTION

From 2018 single inhaler triple therapy (SITT) became available in France to treat moderate-to-severe chronic obstructive pulmonary disease (COPD). Given its simplified inhaler use compared with multiple inhaler triple therapy (MITT), this therapeutic option has the potential to offer benefit in terms of improved persistence and adherence. Given the lack of real-world evidence of the effectiveness of triple therapy, this study was designed to evaluate the use of MITT and SITT in France and compare persistence.

METHODS

A retrospective cohort study was performed. Patients with COPD who initiated triple therapy between 1 July 2017 and 31 December 2019 were included from The Health Improvement Network, a large electronic medical database in France, which includes pharmacy data. A 60-day treatment gap defined discontinuation and thereby persistence.

RESULTS

A total of 3134 patients initiated triple therapy for COPD in the study period, among them 485 with SITT. In 2019, the rate of use of SITT was 28.2%. The mean age (67.3 years) and sex (44.2% female) of patients initiating triple therapy was similar between MITT and SITT, and most patients had escalated from dual therapy (84.1%). However, SITT was more frequently initiated by a pulmonologist (59.8%) and a higher prevalence of comorbid asthma was observed for SITT (47.0% vs 37.9%). Persistence was assessed among patients who did not discontinue after a single dispensation of triple therapy (n=1674). Median persistence was 181 days for SITT and 135 days for MITT, and the covariate-adjusted HR for persistence was 1.47 (p<0.001) and the estimated persistence at 1 year was 33% for SITT compared with 18% for MITT.

DISCUSSION

This study suggests that persistence was higher for the patients treated with SITT compared with MITT in France. Moreover, most patients initiated with triple therapy were previously treated with dual therapy and had exacerbations in the previous year.

Extemporaneous combination of donepezil and memantine to treat dementia in Alzheimer disease: evidence from Italian real-world data

OBJECTIVE

Providing evidence on donepezil and memantine administration as extemporaneous combination (DM-EXT) to treat Alzheimer Disease (AD) in Italy, and describing demographic and clinical features of AD patients prescribed DM-EXT.

METHODS

Retrospective observational study using IQVIA Italian LifeLink Treatment Dynamics (LRx) and Longitudinal Patient Database (LPD). Prevalent users of DM-EXT were identified on the databases (cohorts DMp_LRx and DMp_LPD) including patients with donepezil and memantine overlapping prescriptions during the selection period (DMp_LRx: "July 2018-June 2021"; DMp_LPD: "July 2012-June 2021"). Demographic and clinical profiles of patients were provided. Starting from cohort DMp_LPD, new users of DM-EXT were selected to calculate treatment adherence. Three additional cohorts of prevalent users of DM-EXT were identified on IQVIA LRx over subsequent 12-month periods, from July 2018 to June 2021, to get national-level yearly estimates accounting for database representativeness.

RESULTS

Cohorts DMp_LRx and DMp_LPD included 9862 and 708 patients, respectively. For both cohorts, two-third of patients were female, and more than half were aged 80+. Concomitant conditions and co-treatments prevalence was very high; most frequent comorbidities included psychiatric and cardiovascular diseases. An intermediate-to-high adherence was observed in 57% of DM-EXT new users. National-level yearly estimates showed an increasing trend (+4%) in DM-EXT prescription, which led to estimate about 10,000 patients being treated during the period "July 2020-June 2021".

CONCLUSIONS

Prescription of DM-EXT is a common practice in Italy. Because the administration of fixed-dose (FDCs) instead of extemporaneous combinations improves treatment adherence, the introduction of an FDC containing donepezil and memantine might enhance AD patients' management and reduce caregiver burden.