Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia.
Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.
JAMA Intern Med. 2018 Jul 1;178(7):943-950. doi: 10.1001/jamainternmed.2018.0783.
Current guidelines recommend prasugrel hydrochloride and ticagrelor hydrochloride as preferred therapies for patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). However, it is not well known how frequently these newer agents are being used in clinical practice or how adherence varies among the platelet adenosine diphosphate P2Y12 receptor (P2Y12) inhibitors.
To determine trends in use of the different P2Y12 inhibitors in patients who underwent PCI from 2008 to 2016 in a large cohort of commercially insured patients and differences in patient adherence and costs among the P2Y12 inhibitors.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study used administrative claims from a large US national insurer (ie, UnitedHealthcare) from January 1, 2008, to December 1, 2016, comprising patients aged 18 to 64 years hospitalized for PCI who had not received a P2Y12 inhibitor for 90 days preceding PCI. The P2Y12 inhibitor filled within 30 days of discharge was identified from pharmacy claims.
Proportion of patients filling prescriptions for P2Y12 inhibitors within 30 days of discharge by year, as well as medication possession ratios (MPRs) and total P2Y12 inhibitor copayments at 6 and 12 months for patients who received drug-eluting stents.
A total of 55 340 patients (12 754 [23.0%] women; mean [SD] age, 54.4 [7.1] years) who underwent PCI were included in this study. In 2008, 7667 (93.6%) patients filled a prescription for clopidogrel bisulfate and 521 (6.4%) filled no P2Y12 inhibitor prescription within 30 days of hospitalization. In 2016, 2406 (44.0%) patients filled clopidogrel prescriptions, 2015 (36.9%) filled either prasugrel or ticagrelor prescriptions, and 1045 (19.1%) patients filled no P2Y12 inhibitor prescription within 30 days of hospitalization. At 6 months, mean MPRs for patients who received a drug-eluting stent filling clopidogrel, prasugrel, and ticagrelor prescriptions were 0.85 (interquartile range [IQR], 0.82-1.00), 0.79 (IQR, 0.66-1.00), and 0.76 (IQR, 0.66-0.98) (P < .001), respectively; mean copayments for a 6 months' supply were $132 (IQR, $47-$203), $287 (IQR, $152-$389), and $265 (IQR, $53-$387) (P < .001), respectively. At 12 months, mean MPRs for clopidogrel, prasugrel, and ticagrelor were 0.76 (IQR, 0.58-0.99), 0.71 (IQR, 0.49-0.98), and 0.68 (IQR, 0.41-0.94) (P < .001), respectively; mean total copayments were $251 (IQR, $100-$371), $556 (IQR, $348-$730), and $557 (IQR, $233-$744) (P < .001), respectively.
Between 2008 and 2016, increased use of prasugrel and ticagrelor was accompanied by increased nonfilling of prescriptions for P2Y12 inhibitors within 30 days of discharge. Prasugrel and ticagrelor had higher patient costs and lower adherence in the year following PCI compared with clopidogrel. The introduction of newer, more expensive P2Y12 inhibitors was associated with lower adherence to these therapies.
目前的指南推荐盐酸普拉格雷和盐酸替卡格雷作为急性冠状动脉综合征（ACS）患者经皮冠状动脉介入治疗（PCI）的首选治疗药物。然而，目前尚不清楚这些新型药物在临床实践中的使用频率如何，以及血小板二磷酸腺苷（ADP）P2Y12 受体（P2Y12）抑制剂之间的依从性差异。
在一个大型商业保险公司（即联合健康保险）的患者中，确定 2008 年至 2016 年期间接受 PCI 的患者中不同 P2Y12 抑制剂的使用趋势，并确定 P2Y12 抑制剂之间的患者依从性和成本差异。
设计、地点和参与者：一项回顾性队列研究使用了来自美国大型保险公司（即联合健康保险）的行政索赔数据，时间为 2008 年 1 月 1 日至 2016 年 12 月 1 日，包括年龄在 18 至 64 岁之间、因 PCI 住院且在 PCI 前 90 天内未使用 P2Y12 抑制剂的患者。出院后 30 天内开出的 P2Y12 抑制剂可从药房索赔中确定。
每年出院后 30 天内开具 P2Y12 抑制剂处方的患者比例，以及接受药物洗脱支架治疗的患者在 6 个月和 12 个月时的药物利用率（MPR）和总 P2Y12 抑制剂共付额。
共纳入 55340 例接受 PCI 的患者（女性 12754 例[23.0%]；平均[标准差]年龄 54.4[7.1]岁）。2008 年，7667 例（93.6%）患者开具了硫酸氯吡格雷双羟萘酸盐处方，521 例（6.4%）患者在住院期间未开具任何 P2Y12 抑制剂处方。2016 年，2406 例（44.0%）患者开具氯吡格雷处方，2015 例（36.9%）患者开具普拉格雷或替卡格雷处方，1045 例（19.1%）患者在出院后 30 天内未开具任何 P2Y12 抑制剂处方。在 6 个月时，接受药物洗脱支架治疗的患者服用氯吡格雷、普拉格雷和替卡格雷的平均 MPR 分别为 0.85（四分位距[IQR]，0.82-1.00）、0.79（IQR，0.66-1.00）和 0.76（IQR，0.66-0.98）（P<.001）；6 个月的平均共付额分别为 132 美元（IQR，47-203 美元）、287 美元（IQR，152-389 美元）和 265 美元（IQR，53-387 美元）（P<.001）。在 12 个月时，氯吡格雷、普拉格雷和替卡格雷的平均 MPR 分别为 0.76（IQR，0.58-0.99）、0.71（IQR，0.49-0.98）和 0.68（IQR，0.41-0.94）（P<.001）；总共付额分别为 251 美元（IQR，100-371 美元）、556 美元（IQR，348-730 美元）和 557 美元（IQR，233-744 美元）（P<.001）。
2008 年至 2016 年期间，普拉格雷和替卡格雷的使用增加伴随着出院后 30 天内不服用 P2Y12 抑制剂的处方增加。与氯吡格雷相比，普拉格雷和替卡格雷在 PCI 后一年的患者费用更高，依从性更低。新型、更昂贵的 P2Y12 抑制剂的引入与这些治疗方法的依从性降低有关。
