González López-Valcárcel Beatriz, Librero Julián, García-Sempere Aníbal, Peña Luz María, Bauer Sofía, Puig-Junoy Jaume, Oliva Juan, Peiró Salvador, Sanfélix-Gimeno Gabriel
Department of Quantitative Methods in Economics and Management, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain.
Health Services Research Unit, Center for Public Health Research (CSISP-FISABIO), Valencia, Spain.
Heart. 2017 Jul;103(14):1082-1088. doi: 10.1136/heartjnl-2016-310610. Epub 2017 Mar 1.
Cost-sharing scheme for pharmaceuticals in Spain changed in July 2012. Our aim was to assess the impact of this change on adherence to essential medication in patients with acute coronary syndrome (ACS) in the region of Valencia.
Population-based retrospective cohort of 10 563 patients discharged alive after an ACS in 2009-2011. We examined a control group (low-income working population) that did not change their coinsurance status, and two intervention groups: pensioners who moved from full coverage to 10% coinsurance and middle-income to high-income working population, for whom coinsurance rose from 40% to 50% or 60%. Weekly adherence rates measured from the date of the first prescription. Days with available medication were estimated by linking prescribed and filled medications during the follow-up period.
Cost-sharing change made no significant differences in adherence between intervention and control groups for essential medications with low price and low patient maximum coinsurance, such as antiplatelet and beta-blockers. For costlier ACE inhibitor or an angiotensin II receptor blocker (ACEI/ARB) and statins, it had an immediate effect in the proportion of adherence in the pensioner group as compared with the control group (6.8% and 8.3% decrease of adherence, respectively, p<0.01 for both). Adherence to statins decreased for the middle-income to high-income group as compared with the control group (7.8% increase of non-adherence, p<0.01). These effects seemed temporary.
Coinsurance changes may lead to decreased adherence to proven, effective therapies, especially for higher priced agents with higher patient cost share. Consideration should be given to fully exempt high-risk patients from drug cost sharing.
西班牙药品费用分担计划于2012年7月发生了变化。我们的目的是评估这一变化对巴伦西亚地区急性冠状动脉综合征（ACS）患者基本药物依从性的影响。
基于人群的回顾性队列研究，纳入了2009 - 2011年急性冠状动脉综合征后存活出院的10563例患者。我们考察了一个未改变其共同保险状态的对照组（低收入在职人群），以及两个干预组：从全额保险转为10%共同保险的退休人员，以及从中等收入到高收入的在职人群，他们的共同保险从40%提高到了50%或60%。从首次处方日期开始测量每周的依从率。通过在随访期间将处方药物和配药药物相联系来估计有药可用的天数。
对于价格低廉且患者最高共同保险较低的基本药物，如抗血小板药物和β受体阻滞剂，费用分担变化在干预组和对照组之间的依从性上没有显著差异。对于更昂贵的血管紧张素转换酶抑制剂或血管紧张素II受体阻滞剂（ACEI/ARB）以及他汀类药物，与对照组相比，费用分担变化对退休人员组的依从比例有立即影响（依从性分别下降6.8%和8.3%，两者p<0.01）。与对照组相比，中等收入到高收入组的他汀类药物依从性下降（不依从性增加7.8%，p<0.01）。这些影响似乎是暂时的。
共同保险的变化可能导致对已证实的有效疗法的依从性降低，特别是对于患者费用分担较高的高价药物。应考虑将高风险患者完全免除药物费用分担。
