Comparison of healthcare resource utilization and costs in patients hospitalized for acute coronary syndrome managed with percutaneous coronary intervention and receiving prasugrel or ticagrelor

OBJECTIVE

To compare healthcare resource utilization (HCRU) and healthcare costs in patients with acute coronary syndrome (ACS) managed with percutaneous coronary intervention (PCI) and treated with prasugrel or ticagrelor.

METHODS

Hospital charge master data were used to identify ACS-PCI patients aged ≥ 18 years with ≥ 1 in-hospital claim for prasugrel or ticagrelor between August 1, 2011-April 30, 2013. Treatment groups were propensity matched for baseline and index hospitalization characteristics. HCRU and costs were assessed through 90-days post-discharge. Costs were determined based on hospital-specific cost-to-charge ratios and adjusted to 2013 US dollars.

RESULTS

Before matching, ticagrelor patients were older, more-often female, and had increased cardiovascular (CV) and bleeding risks compared with prasugrel patients. Propensity-matched length of index hospital stay (4.7 vs 4.9 days, p = 0.23) and risk for all-cause [30-day: relative risk (RR) = 0.86; 95% CI = 0.73-1.0; 90-day: RR = 0.90; 95% CI = 0.80-1.0, and CV-related (30-day: RR = 0.77; 95% CI = 0.59-1.0; 90-day: RR = 0.89; 95% CI = 0.73-1.1) re-hospitalizations did not significantly differ between prasugrel and ticagrelor, respectively. Compared to ticagrelor, the propensity-matched risk of re-hospitalization for myocardial infarction (MI) (30-day: RR = 0.39; 95% CI = 0.21-0.75; 90-day: RR = 0.53; 95% CI = 0.34-0.81) and an outpatient medical encounter for dyspnea (30-day: RR = 0.49; 95% CI = 0.33-0.74; 90-day: RR = 0.60; 95% CI = 0.46-0.80) were significantly lower for prasugrel patients, with no significant differences in bleeding encounters between groups (30-day: RR =  0.87; 95% CI = 0.54-1.40; 90-day: RR = 1.0; 95% CI = 0.71-1.50). Matched total healthcare costs were not significantly different between groups during the index hospitalization ($36,011 vs $37,247, p = 0.21), 30-days post-discharge ($2007 vs $2522, p = 0.48), 90-days post-discharge ($4564 vs $5242, p = 0.49), and aggregate of the index hospitalization through 90-day follow-up ($40,576 vs $42,494, p = 0.09) timeframes.

CONCLUSIONS

Re-hospitalization for MI and outpatient encounters for dyspnea were lower in prasugrel treated than in ticagrelor treated ACS-PCI patients up to 90-days post-index hospitalization discharge, with no difference in bleeding encounters or healthcare costs between the two populations. This data supports the utility of prasugrel in routine clinical practice. These findings should be considered within limitations of observational research.

A medication adherence and persistence comparison of hypertensive patients treated with single-, double- and triple-pill combination therapy

OBJECTIVE

Fixed-dose combination therapy reduces pill burden and may, therefore, improve medication adherence and health outcomes. This study compared adherence to and persistence with single-, double-, and triple-pill treatment regimens among hypertensive patients in a US clinical practice setting.

METHODS

Adults with hypertension treated with three anti-hypertensive medications were identified. Index date was the first occurrence of a single-, double-, or triple-pill regimen with olmesartan or valsartan plus amlodipine and hydrochlorothiazide from July 2010 to September 2011. Patients were followed for 12 months to assess adherence (proportion of days covered [PDC] ≥ 80%) and time to discontinuation (medication gap ≥ 60 days) of the index regimen. Multivariate regression models were used to compare adjusted outcomes.

RESULTS

The number of prescribed pills in the index regimen was monotonically related to adherence with 55.3%, 40.4% and 32.6% of patients having PDC ≥ 80% in the single-, double- and triple-pill cohorts, respectively. In adjusted analysis, patients in the double- (odds ratio [OR]: 0.45; 95% confidence interval [CI]: 0.42-0.48) and triple-pill (OR: 0.26; 95% CI: 0.22-0.30) cohorts were less likely to be adherent to their index regimens than those in the single-pill cohort. Double-pill (hazard ratio [HR]: 1.89; 95% CI: 1.74-2.06) and triple-pill patients (HR: 2.49; 95% CI: 2.14-2.88) were more likely to discontinue treatment than single-pill patients.

CONCLUSIONS

Greater pill burden was directly and significantly associated with decreased adherence and persistence with antihypertensive therapies in real-practice settings. Use of fixed-dose combinations that reduce pill burden could help patients to continue treatment and may result in improved clinical outcomes. Typical of observational studies, the potential for residual confounding of adherence estimates remains due to lack of randomization of treatment groups.

Abstract 340: Thirty-day Repeat Hospitalizations for Patients Treated with Prasugrel Compared to Ticagrelor following Acute Coronary Syndrome: Findings from a Large Hospital Charge Master Database

Background: This retrospective, real-world claims data base study in patients (pts) with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI) demonstrated that prasugrel (pras) was non-inferior to ticagrelor (ticag) for 30 day safety and effectiveness outcomes. This report provides further evaluation between pras vs ticag of 30 day readmission rates for myocardial infarction (MI), revascularization (revasc), and bleeding.

Methods: IMS Patient-Centric Data Warehouse claims data was used to identify ACS-PCI pts ≥18 years old with at least one in-hospital claim for pras or ticag between 8/1/11-4/30/13. The groups were propensity matched (PM) based upon demographic and clinical characteristics using index and prior hospitalization records dating back to 1/1/2008. Relative risk (RR) and 95% confidence interval (CI) were estimated to assess binary endpoints. Non-inferiority was computed by comparing the mean from a normal distribution of log (RR) with log (1.2), a predefined non-inferiority margin. Three cohorts were predefined: ACS-PCI (primary), ACS-PCI without prior TIA or stroke (label), ACS-PCI pts without prior TIA or stroke and if age ≥75 years with evidence of diabetes or prior MI (core).

Results: Prior to PM, the primary cohort included 16,098 pts; 13,134 (82%) on pras, 2,964 (18 %) on ticag. Compared to pras, ticag pts were older, more often female, had increased cardiovascular risk factors, and more often treated at a teaching hospital. Unstable angina was seen more often in pras pts with no difference in STEMI or NSTEMI between the 2 groups. Using PM pts (table), pras was non-inferior to ticag in the primary cohort for rehosp for MI, revasc, and bleeding at 30 days post discharge. Rehosp for MI and bleeding was significantly lower with pras vs ticag while rehosp for revasc was lower, but not significantly. Results for the label and core cohorts had the same directionality as the primary cohort.

Conclusion: Rehosp for MI, revasc or bleeding was non-inferior for pras compared to ticag at 30 days post discharge. Pts treated with pras had lower 30 day rehosp rates, particularly related to readmission for MI, compared with ticag. Although limited by selection bias, these results support the clinical utility of pras, regardless of cohort, to limit 30 day rehosp for pts undergoing PCI for ACS.

Abstract 249: Economic Outcomes for Patients with Acute Coronary Syndrome Managed with Percutaneous Coronary Intervention and Receiving Prasugrel or Ticagrelor: A Retrospective US Hospital Database Analysis

Objectives: To compare all-cause healthcare resource utilization and costs with prasugrel (pras) vs. ticagrelor (ticag) with real world data in patients (pts) with ACS managed with PCI.

Methods: The IMS Patient-Centric Data Warehouse was used to identify ACS-PCI pts ≥18 years with an in-hospital claim for pras or ticag (index date) between 8/1/11 and 4/30/13. The baseline period began on 1/1/08 with the follow-up period spanning until 7/29/13. The two drug groups were propensity-matched (PM) based upon demographic and clinical characteristics. Three cohorts were pre-defined and analyzed: ACS-PCI (primary cohort), ACS-PCI without prior TIA or stroke (label cohort), and ACS-PCI patients without prior TIA or stroke and if age ≥75 years required evidence of diabetes or prior MI (core cohort). Hospital specific cost:charge ratios were used to determine costs and adjusted to 2013 US dollars. Total costs were the sum of medical costs, including lab and diagnostic tests, and pharmacy costs during hospitalization. Generalized estimating equations were used to evaluate PM-adjusted differences in length of stay (LOS) and costs. Costs are reported on a per patient basis. Resource utilization and costs were assessed during index hospitalization, 30 and 90 days post-discharge.

Results: 16,098 pts were in the primary cohort (pras: 13,134 [82%] and ticag: 2,964 [18%]). Compared to ticag pts, pras pts were younger, more likely men, and less likely to have cardiovascular or bleeding risk factors (P<0.05). In all 3 cohorts, unadjusted data showed that PCI characteristics (stent type, number of stents and vessels) were similar between pras and ticag, but ticag patients tended to have higher use of lab and diagnostic tests compared to pras during index hospitalization. For the index hospitalization, the unadjusted CCU/ICU and post-PCI LOS were shorter for pras vs. ticag, but overall LOS was not significantly different after adjustment. PM-adjusted mean all-cause total, medical, and pharmacy costs are presented in the table.

Conclusion: Economic outcomes of ACS-PCI pts receiving pras were similar to ticag for the primary population with significant savings in total and medical costs for pts without prior TIA or stroke. These data indicate that ticag has no economic advantage compared with pras in routine clinical practice.

Abstract 320: Healthcare Resource Utilization Among Patients with Acute Coronary Syndrome Managed with Percutaneous Coronary Intervention and Using Prasugrel or Ticagrelor: A Retrospective Database Analysis

Objective: To show that prasugrel (pras) was non-inferior to ticagrelor (ticag) in terms of healthcare resource utilization (HCRU) based upon 30- and 90-day all-cause rehospitalization rates among patients (pts) with acute coronary syndrome (ACS) managed with percutaneous coronary intervention (PCI).

Methods: This retrospective study used anonymized hospital data from the IMS Patient-Centric Data Warehouse to identify ACS-PCI pts aged ≥18 years with ≥1 in-hospital claim for pras or ticag between 8/1/11-4/30/13. Three cohorts were predefined and analyzed: ACS-PCI (primary cohort), ACS-PCI without prior TIA or stroke (label cohort), and ACS-PCI pts without prior TIA or stroke and if age ≥75 years required evidence of diabetes or prior MI (core cohort). The McNemar’s test was used to evaluate adjusted outcome differences between propensity matched (PM) groups. P-value for non-inferiority (p-NI) test was obtained through a one-sided Z test by comparing log (RR) with log(1.2), a predefined margin.

Results: Among 16,098 eligible pts, 13,134 (82%) received pras and 2,964 (18%) received ticag. Compared to ticag pts, pras pts were younger, more likely men, and less likely to have cardiovascular or bleeding risk factors (P<0.05). Of the total population, 1,375 (8.54%) and 2,374 (14.75%) were rehospitalized for any reason within 30 and 90 days post discharge, respectively. After PM adjustment, pras was non-inferior to ticag for 30- and 90-day all-cause rehospitalization rates in all 3 cohorts (p-NI < 0.01). Data are summarized in Table 1. All-cause rehospitalization for the label and core cohorts showed non-inferiority and a significantly lower 90-day rehospitalization rate with pras compared with ticag (Table).

Conclusions: All-cause rehospitalizations at 30-and 90-days post discharge in ACS-PCI pts were non-inferior with pras vs. ticag in all 3 cohorts. Pras was associated with significantly lower risk for 90-day all-cause rehospitalizations compared with ticag in the label and core cohorts, which are the majority of pts receiving pras. Although there appears to be inherent bias and unmeasured confounders related to use of pras vs. ticag, these data show reductions in HCRU with pras compared with ticag in the real-world setting at 30- and 90-days post-discharge.

The COSEHC™ Global Vascular Risk Management quality improvement program: first follow-up report

The Global Vascular Risk Management (GVRM) Study is a 5-year prospective observational study of 87,863 patients (61% females) with hypertension and associated cardiovascular risk factors began January 1, 2010. Data are gathered electronically and cardiovascular risk is evaluated using the Consortium for Southeastern Hypertension Control™ (COSEHC™)-11 risk score. Here, we report the results obtained at the completion of 33 months since study initiation. De-identified electronic medical records of enrolled patients were used to compare clinical indicators, antihypertensive medication usage, and COSEHC™ risk scores across sex and diabetic status subgroups. The results from each subgroup, assessed at baseline and at regular follow-up periods, are reported since the project initiation. Inference testing was performed to look for statistically significant differences between goal attainments rates between sexes. At-goal rates for systolic blood pressure (SBP) were improved during the 33 months of the study, with females achieving higher goal rates when compared to males. On the other hand, at-goal control rates for total and low-density lipoprotein (LDL) cholesterol (chol) were better in males compared to females. Diabetic patients had lower at-goal rates for SBP and triglycerides but higher rates for LDL-chol. The LDL-chol at-goal rates were higher for males, while high-density lipoprotein (HDL)-chol rates were higher for females. Utilization of antihypertensive medications was similar during and after the baseline period for both men and women. Patients taking two or more antihypertensive medications had higher mean COSEHC™-11 scores compared to those on monotherapy. With treatment, hypertensive patients can reach SBP and cholesterol goals; however, population-wide improvement in treatment goal adherence continues to be a challenge for physicians. The COSEHC™ GVRM Study shows, however, that continuous monitoring and feedback to physicians of accurate longitudinal data is an effective tool in achieving better control rates of cardiovascular risk factors.

Costs and outcomes associated with clopidogrel discontinuation in Medicare beneficiaries with acute coronary syndrome in the coverage gap

Background

Methods

Results

Conclusion

A value-based insurance design program at a large company boosted medication adherence for employees with chronic illnesses

This paper contributes to a small but growing body of evidence regarding the efficacy of value-based insurance design. In a retrospective, observational study of employees of a large global pharmaceutical firm, we evaluated how reduced patient cost sharing for prescription drugs for asthma, hypertension, and diabetes affected the use of these drugs and related medical services. We estimate that prescription medication use rose 5 percent per enrollee across the entire enrolled population. Increased use was most evident for patients taking cardiovascular medication. By the third year, adherence to cardiovascular medications was 9.4 percent higher, and patients realized cost savings over time. Overall, the program was mostly cost-neutral to the company, and there was no aggregate change in spending. However, we raise the prospect that this program may have saved the company money by reducing other medical costs.

Comparing pre-gap and gap behaviors for Medicare beneficiaries in a Medicare managed care plan

OBJECTIVE

To examine the impact of the coverage gap on pharmacy use, expenditures, and out-of-pocket costs for Medicare managed care beneficiaries before and after reaching the gap.

STUDY DESIGN

A longitudinal comparison of behaviors for beneficiaries with non-gap coverage before and after reaching the gap.

METHODS

Prescription drug use and expenditures were assessed for Medicare beneficiaries who reached the gap, including subsets with one of four chronic disorders (congestive heart failure (CHF), diabetes, dyslipidemia, or hypertension). Differences in pre- and post-prescription use were calculated using generalized estimating equations. Time until the end and start of the gap was estimated using a Cox proportional hazards model. Expenditure data were estimated using bootstrap methods.

RESULTS

Roughly a quarter (27.1 percent) of patients reached the gap in 2006, of whom 3.6 percent passed through the gap. The most prevalent disease state was hypertension (58.5 percent). Beneficiaries took an average of 8.1 months to reach the gap. Patients <65 years (HR = 1.42, 95% CI = 1.29 - 1.56) and those with diabetes (HR = 1.19, 95% CI = 1.12 - 1.27) were more likely to reach the gap sooner as compared to older beneficiaries (aged 65 to 74) and those without diabetes. These individuals were more likely to pass through the gap as well. Beneficiaries faced a 60.7 percent increase in out-of-pocket expenditures in the gap phase. Brand-name medication use decreased by 9.3 percent, while generic medication use increased by 7.4 percent. For chronic conditions, however, over 90 percent of individuals continued brand-name medication use in the gap.

CONCLUSIONS

Our findings suggest that, in general, beneficiaries take lower-cost generics while in the gap. However, taking brand-name medications is the predominant behavior for beneficiaries with chronic diseases. Health care reform provisions that close the gap over the next ten years may facilitate continuity of medication use while in the gap.

Adherence and persistence of single-pill ARB/CCB combination therapy compared to multiple-pill ARB/CCB regimens

OBJECTIVE

To evaluate the impact of angiotensin receptor blocker (ARBs)/dihydropyridine calcium channel blockers (CCBs) single-pill combination (SPC) on adherence to antihypertensive treatment in comparison to free combination of ARBs and CCBs.

RESEARCH DESIGN AND METHODS

A retrospective data analysis was performed using pharmacy claims data from a national pharmacy benefit management company. The study included patients who were newly initiated on ARB/CCB treatment between 01/01/2007 and 08/31/2008, aged ≥ 18 years, and continuously enrolled in the same health plan for 12 months prior to and 13 months after starting ARB/CCB treatment. Outcome variables were persistence, defined as time to discontinuation of therapy, and adherence, defined as proportion of days covered (PDC)  ≥ 0.80. Propensity score weighting was used to balance the characteristics of the two groups.

RESULTS

The final sample contained 2312 patients in the free-combination group and 2213 patients in the SPC group. Patients in the SPC group and the free-combination group were different in age, gender, type of insurance, history of antihypertensive therapy and co-morbidities. These differences were largely normalized after propensity score adjustment. Multivariate logistic model regression showed that patients in the SPC group had a 90% greater odds of being adherent to index therapy compared to patients in the free-combination group (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.75-2.08, p< 0.001). A Cox proportional hazards model showed that patients in the SPC group were less likely to discontinue ARB/CCB SPC therapy compared to patients in the free-combination group (hazard ratio [HR] 0.66, 95% CI 0.63-0.70, p < 0.001). In both models, higher copayment (copayment $50 and above) was associated with worse persistence and adherence in comparison to patients who had a lower copayment ($0-$5): HR = 1.23, p < 0.001 and OR = 0.67, p < 0.001.

CONCLUSION

Patients using SPC ARB/CCB therapy were more likely to be persistent and adherent to treatment compared to patients taking free-combination therapy.

Improved blood pressure control among school bus drivers with hypertension

The impact of a hypertension awareness and educational program, BP DownShift, was evaluated among school bus drivers in a southern US state. At baseline (August 2007), blood pressure (BP) measurements, self-reported demographics, and hypertension awareness and management practices were collected from drivers who consented to participate in the study. Interventions included 4 educational mailings, installation of BP machines at all bus terminals, and access to free dietitian consultations and gym memberships. BP was evaluated using Department of Transportation guidelines. BP was remeasured and a survey was administered at follow-up (May 2008). At baseline, 208 drivers consented to the BP screening; 120 (58%) returned for a follow-up assessment. Most participants completing the study were female (73%) and African American (72%). Mean age was 50 years and mean body mass index was 32 kg/m(2); 52% of participants were obese. In all, 58% of participants reported a prior diagnosis of hypertension by a physician, and 63% reported taking antihypertensive medication. Both systolic and diastolic BP (SBP and DBP) were lower at follow-up (135/82 mmHg vs. 145/87 mmHg at baseline; P < 0.001, both comparisons); 42% had a reduction in SBP > 10 mmHg, and 44% had a reduction in DBP > 5 mmHg. At follow-up, 58% were controlled to BP < 140/90, compared to 38% at baseline (P < 0.001). At follow-up, an increased proportion of previously diagnosed drivers reported home BP monitoring, healthy diet, and regular exercise as components of hypertension self-management. The implementation of our hypertension education, self-management, and awareness program was associated with an improvement in BP control, which may positively impact commercial driver's license recertification as well as improve employee health.

Predictors of compliance with antihypertensive therapy in a high-risk medicaid population

OBJECTIVE

To identify predictors of compliance with antihypertensive combination therapy in a Medicaid population.

METHODS

Retrospective medical and pharmacy claims data for Maryland Medicaid patients receiving angiotensin converting enzyme inhibitors (ACEls)/hydrochlorothiazides (HCTZs) or ACEl/calcium channel blockers as fixed-dose combinations or separate agents during the period of January 1, 2002 to December 31, 2004, were analyzed.

INCLUSION

Continuously enrolled patients 18 years and older and at least one year of follow-up. Exclusion: Use of fixed-dose combination antihypertensives between January 1, 2002 and June 30, 2002 (to identify incident cohort). Compliance was defined as medication possession ratio greater than or equal to 80%. Multivariate logistic regression was used to predict compliance as a function of age, gender, race, comorbidities (Charlson Comorbidity Index [CCI]), and use of either fixed-dose combination or separate agents.

RESULTS

There were 568 patients, 63.73% female, 68.83% African American, median age 52 years, 35.56% on fixed-dose combinations, 72.89% started on ACEI/HCTZ, and 24.82% complied with therapy. Patients younger than 40 years (OR, 0.38; p = .01; 95% CI, 0.18-0.81) and African American (OR, 0.45; p = .0004; 95% CI, 0.29-0.70) were less likely to be compliant than patients older than 60 years and Caucasian, respectively, Patients with a CCI of 1 (OR, 2.11; p = .05; 95% CI, 1.01-4.40) and those on fixed-dose combinations (OR, 1.60; p = .02, 95% CI, 1.06-2.40) were more likely to be compliant than those with higher CCIs and on separate agents, respectively.

CONCLUSION

Age, race, comorbidities, and simplified antihypertensive regimens were significant predictors of compliance. Higher compliance rates may enhance cardiovascular disease management outcomes.

Effects of initial antihypertensive drug class on patient persistence and compliance in a usual-care setting in the United States

Antihypertensive treatment regimen persistence and compliance were measured using a retrospective cohort study of pharmacy claims data. Newly treated patients receiving monotherapy with angiotensin II receptor blockers (ARBs), angiotensin-converting enzyme inhibitors (ACEIs), calcium channel blockers (CCBs), beta-blockers (BBs), or diuretics were followed for 1 year (N=242,882). A higher proportion of ARB patients (51.9%) were persistent in taking prescribed medication compared with those in the ACEI (48.0%), BB (40.3%), CCB (38.3%), and diuretic groups (29.9%). Compared with patients receiving diuretics, those receiving ARBs (hazard ratio [HR], 0.593; P<.0001), ACEIs (HR, 0.640; P<.0001), CCBs (HR, 0.859; P<.0001), and BBs (HR, 0.819; P<.0001) were all less likely to discontinue therapy. Compliance was similar in ACEI and ARB patients, but patients receiving ARBs and ACEIs had better compliance than those receiving BBs, CCBs, or diuretics. The lesser degree of compliance and persistence observed in patients receiving diuretics compared with other antihypertensive medications may have public health as well as cost implications.

Ethnic/racial variations in blood pressure awareness, treatment, and control

Understanding the impact of patient factors on blood pressure (BP) management is an important step to developing interventions to improve cardiovascular health. The National Health and Nutrition Examination Survey (NHANES) 1999-2002 was used to identify predictors of hypertension awareness, treatment, and control. An estimated 63.3 million (31.0%) US adults currently have BP exceeding 140/90 mm Hg, and prevalence is higher for blacks than for other racial/ethnic subgroups. Among antihypertensive medication-treated patients, 51.3% are controlled. Treated blacks and Mexican Americans have the lowest rates of BP control. Mexican Americans are 0.62 times as likely to be aware and 0.61 times as likely to be treated as white persons with hypertension. Compared with whites, treated Mexican Americans are 0.71 times as likely and treated blacks 0.59 times as likely to achieve BP control. Hypertension treatment and BP control in the United States remain suboptimal, and significant racial/ethnic disparities persist. Effective interventions targeting Mexican Americans and blacks as well as whites are essential to improving hypertension management.

Valsartan versus lisinopril or extended-release metoprolol in preventing cardiovascular and renal events in patients with hypertension

PURPOSE

The objective of this study was to compare cardiovascular and renal events in patients with hypertension receiving the angiotensin II-receptor blocker valsartan versus those receiving the angiotensin-converting-enzyme lisinopril or the beta-blocker metoprolol succinate in an extended-release formulation.

METHODS

A retrospective study was conducted using a health insurance claims database spanning the period from January 1997 through December 2003 and representing approximately 40 million members enrolled in over 70 health plans across the United States. Study subjects included all persons in the database with two or more outpatient prescriptions for valsartan, lisinopril, or extended-release metoprolol and two or more prior claims with a diagnosis of hypertension. Those with a history of major cardiovascular or renal events (diagnosis of myocardial infarction, stroke, heart failure, ventricular arrhythmias, or cardiac arrest; coronary revascularization procedure; diagnosis of renal failure; or dialysis or kidney transplantation) or using other antihypertensive medications except diuretics during the 12 months before treatment with valsartan, lisinopril, or extended-release metoprolol were excluded. Risks of major cardiovascular or renal event during follow-up were analyzed using Cox proportional hazards regression.

RESULTS

A total of 29,357 antihypertensive patients were identified who initiated therapy with valsartan (n = 6,645), lisinopril (n = 17,320), or extended-release metoprolol (n = 5,392). In multivariate analyses, therapy with valsartan was associated with a significantly lower risk of a major cardiovascular or renal event versus extended-release metoprolol (heart rate [HR], 0.70; 95% confidence interval [CI], 0.56-0.87; p = 0.0015). Patients receiving valsartan had a nominally lower risk of a major cardiovascular or renal event than those receiving lisinopril, although this difference was not statistically significant (HR, 0.89; 95% CI, 0.74-1.07; p = 0.1987).

CONCLUSION

Results of this observational study suggest that the use of valsartan may reduce the risk of major cardiovascular and renal events compared with extended-release metoprolol.

Effects of a step-therapy program for angiotensin receptor blockers on antihypertensive medication utilization patterns and cost of drug therapy

BACKGROUND

Step therapy for angiotensin receptor blockers (ARBs) requiring prior use of angiotensin-converting enzyme inhibitors (ACEIs) is a common cost-containment intervention in managed care.

OBJECTIVE

This study was designed to assess the effectiveness of the step-therapy intervention for ARBs, including ARB/hydrochlorthiazide (HCTZ) combinations, as measured by prescription use patterns and antihypertensive drug ingredient costs.

METHODS

Rejected and paid pharmacy claims data were evaluated from 3 health plans with a total membership of approximately 1 million. These plans had implemented a step-therapy intervention for ARBs from May 1, 2001, through February 28, 2003. Patients in the intervention group who had experienced a claim rejection for an ARB within the first 6 months of program implementation (i.e., had had no ACEI [or ACEI/HCTZ combination] or ARB [or ARB/HCTZ] claim in the preceding 3 months) were followed for 1 year after the ARB claim rejection. The rate of initiation of ARB versus ACEI and other outcomes was compared with similar data from a health plan with approximately 2 million members that did not have a step-therapy intervention for ARBs (comparison group). Mean and median total antihypertensive drug ingredient costs per patient and per day of therapy over 12 months were analyzed for the intervention and comparison groups. One pharmacy benefit manager administered the pharmacy benefits for the intervention and comparison health plans during the entire study period from May 1, 2001, through February 28, 2004, and the drug formulary was similar for all health plans.

RESULTS

In the step-therapy health plans, before the criterion for 15 months of continuous eligibility was applied, there were 8,904 patients (approximately 0.9% of health plan members) who either attempted and were rejected for an ARB or who newly started ACEI therapy, compared with 44,788 patients (approximately 2.2% of members in the comparison health plan) who newly started ARB or ACEI therapy without the step-therapy intervention. After the eligibility criterion was applied, there were 6,758 intervention health plan members (0.7% of members) and 33,709 comparison health plan members (1.7% of members) in the 2 study groups. In addition to the smaller proportion of total members affected by the intervention in the ARB step-therapy health plans, a smaller proportion of ARB/ACEI patients attempted to obtain an ARB (1,296/6,758 or 19.2%) compared with the health plan without step therapy (8,697/33,709 or 25.8%, P <0.001). Of the 1,296 patients who attempted to obtain an ARB and were rejected in the step-therapy group, 578 patients (44.6%) went through the prior-authorization process and received an ARB as initial therapy, 632 patients (48.8%) received other antihypertensive therapy, and 86 patients (6.6%) did not receive any antihypertensive therapy within the 12-month follow-up period. In the 12 months of follow-up, 51.1% (323/632) of patients in the intervention group who received other antihypertensives as index therapy switched to or added an ARB, and 1,234 of total ACE/ARB patients (n = 6,758, 18.3%) received ARB therapy in the health plan with step therapy compared with 10,498 of 33,709 total ACEI/ARB patients (31.1%) who received ARB therapy in the health plan without step therapy. The mean antihypertensive drug cost per patient was lower in the intervention group ($370.00) than in the comparison group ($445.12; P <0.001), and the average cost per day of antihypertensive drug therapy was 12.8% lower in the step-therapy group ($0.82) than in the comparison group ($0.94). Unadjusted annual cost savings were $75.12 per patient, and ordinary least squares regression analysis showed that the ARB step-therapy intervention was associated with $43.91 in antihypertensive drug cost savings per patient over 12 months.

CONCLUSIONS

Within 12 months of follow-up, a step-therapy intervention for ARBs was associated with an 18% ratio of ARB users to total ACEI/ARB users compared with a 31% ratio in a comparison health plan without the ARB step-therapy intervention. Approximately 45% of patients who did not receive an ARB as a result of the step-therapy intervention had either switched to or added an ARB within 12 months of the intervention, and almost 7% of patients did not receive any antihypertensive therapy. Antihypertensive drug cost was about 13% lower for the ACEI/ARB patients in the intervention group, creating approximately $368,000 in savings in 1 year or $0.03 per member per month across the 1 million health plan members.

Copayment level and compliance with antihypertensive medication: analysis and policy implications for managed care

OBJECTIVE

To measure the impact of medication copayment level and other predictors on compliance with antihypertensive medications, as measured by the medication possession ratio.

STUDY DESIGN

Retrospective observational analysis.

METHODS

We used claims data from a large managed care organization. The identification of subjects was based on a diagnosis of hypertension and a filled prescription for antihypertensive medication between January 1999 and June 2004. Multivariate logistic regression models were used to evaluate copayment level and patient characteristics as predictors of medication compliance.

RESULTS

Analysis of data for 114,232 patients filling prescriptions for antihypertensive medications revealed that compliance was lower for drugs in less preferred tiers. Relative to medications with a 5 dollars copayment, the odds ratio (95% confidence interval) for compliance with drugs having a 20 dollars copayment was 0.76 (0.75, 0.78); for drugs requiring a 20 dollars to 165 dollars copayment, the odds ratio for compliance was 0.48 (0.47, 0.49). Medication compliance also differed by patient age, morbidity level, and ethnicity, as well as by medication therapeutic class--with the best compliance observed for angiotensin receptor blockers, followed by calcium channel blockers, beta-adrenergic receptor antagonists (beta-blockers), angiotensin-converting enzyme inhibitors, and last, thiazide diuretics.

CONCLUSIONS

Copayment level, independent of other determinants, was found to be a strong predictor of compliance with antihypertensive medications, with greater compliance seen among patients filing pharmacy claims for drugs that required lower copayments. This finding suggests that patient use is sensitive to price. The potential impact on compliance should be considered when making pricing and policy decisions.

Relationship of blood pressure control to adherence with antihypertensive monotherapy in 13 managed care organizations

OBJECTIVE

This study was conducted to evaluate the relationship between medication compliance and blood pressure (BP) control among members of 13 managed care organizations with essential hypertension (HTN) who received antihypertensive monotherapy for at least 3 pharmacy claims prior to the blood pressure measurement.

METHODS

This was a retrospective review of medical and pharmacy claims over a 4-year period (1999-2002) from 13 U.S. health plans. Data were collected by trained health professionals from randomly selected patient medical records per Health Plan Employer Data and Information Set (HEDIS) technical specifications. Patients were selected if they (1) had received monotherapy or fixed-dose combination therapy (administered in one tablet or capsule) during the time BP was measured (thus those with no BP drug therapy were excluded); (2) had received 3 or more antihypertensive pharmacy claims for the antihypertensive drug therapy prior to BP measurement; and (3) had one or more antihypertensive pharmacy claims after BP was measured. Control of BP was defined according to guidelines of the Sixth Report of the Joint National Committee (JNC 6) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (<140/90 mm Hg, or <130/85 mm Hg for patients with diabetes). Medication adherence was measured using the medication possession ratio (MPR), and MPR was used to classify patients into 3 adherence levels: high (80%-100%), medium (50%-79%), and low (<50%). The relationship between medication adherence and BP control was assessed using a logistic regression model.

RESULTS

There were 1,017,181 patients with a diagnosis of HTN in medical claims data from which 10,734 (10.6%) were randomly selected for chart review. There were 1,032 patients (9.6%) in the sample who had a diagnosis of HTN but who were excluded because they had no HTN drug therapy. Of the total 9,894 patients (92.2%) who were excluded from the sample, 3,029 patients (28.2%) met all other inclusion criteria but were receiving more than one HTN drug. Of the 840 patients on HTN monotherapy, the mean age was 59 12.2 years; 422 (50%) were women, 16% had diabetes, and 43% had dyslipidemia. The monotherapy HTN drug was an angiotensin-converting enzyme inhibitor (27% of patients), calcium channel blocker (22%), beta-blocker (20%), or diuretic (11%). Of the 840 patients, 629 (74.8%) were determined to have high medication adherence, 165 (19.6%) had medium adherence, and 46 (5.5%) had low adherence. Approximately 270 (43%) of high adherence patients achieved BP control compared with 56 (34%) and 15 (33%) patients with medium and low adherence, respectively. High-adherence patients were 45% more likely to achieve BP control than those with medium or low compliance after controlling for age, gender, and comorbidities (odds ratio=1.45; P =0.026).

CONCLUSION

These results demonstrate that 75% of these health plan members with a diagnosis of essential HTN who were selected for receipt of at least 4 pharmacy claims for HTN monotherapy exhibited high medication adherence. However, only 43% of high-adherence patients attained their target (JNC 6) blood pressure goal compared with 33% to 34% of patients with medium or low adherence to antihypertensive monotherapy.