Program On Regulation, Therapeutics, And Law; Division of Pharmacoepidemiology and Pharmacoeconomics; Department of Medicine; Brigham and Women's Hospital; Boston, MA; Harvard Medical School, Boston, MA.
Program On Regulation, Therapeutics, And Law; Division of Pharmacoepidemiology and Pharmacoeconomics; Department of Medicine; Brigham and Women's Hospital; Boston, MA; Harvard Medical School, Boston, MA.
Am Heart J. 2021 Mar;233:109-121. doi: 10.1016/j.ahj.2020.12.010. Epub 2021 Jan 14.
In patients with atrial fibrillation, incomplete adherence to anticoagulants increases risk of stroke. Non-warfarin oral anticoagulants (NOACs) are expensive; we evaluated whether higher copayments are associated with lower NOAC adherence.
Using a national claims database of commercially-insured patients, we performed a cohort study of patients with atrial fibrillation who newly initiated a NOAC from 2012 to 2018. Patients were stratified into low (<$35), medium ($35-$59), or high (≥$60) copayments and propensity-score weighted based on demographics, insurance characteristics, comorbidities, prior health care utilization, calendar year, and the NOAC received. Follow-up was 1 year, with censoring for switching to a different anticoagulant, undergoing an ablation procedure, disenrolling from the insurance plan, or death. The primary outcome was adherence, measured by proportion of days covered (PDC). Secondary outcomes included NOAC discontinuation (no refill for 30 days after the end of NOAC supply) and switching anticoagulants. We compared PDC using a Kruskal-Wallis test and rates of discontinuation and switching using Cox proportional hazards models.
After weighting patients across the 3 copayment groups, the effective sample size was 17,558 patients, with balance across 50 clinical and demographic covariates (standardized differences <0.1). Mean age was 62 years, 29% of patients were female, and apixaban (43%), and rivaroxaban (38%) were the most common NOACs. Higher copayments were associated with lower adherence (P < .001), with a PDC of 0.82 (Interquartile range [IQR] 0.36-0.98) among those with high copayments, 0.85 (IQR 0.41-0.98) among those with medium copayments, and 0.88 (IQR 0.41-0.99) among those with low copayments. Compared to patients with low copayments, patients with high copayments had higher rates of discontinuation (hazard ratio [HR] 1.13, 95% confidence interval [CI] 1.08-1.19; P < .001).
Among atrial fibrillation patients newly initiating NOACs, higher copayments in commercial insurance were associated with lower adherence and higher rates of discontinuation in the first year. Policies to lower or limit cost-sharing of important medications may lead to improved adherence and better outcomes among patients receiving NOACs.
在患有心房颤动的患者中，抗凝药物治疗不依从会增加中风风险。非华法林口服抗凝剂（NOAC）价格昂贵；我们评估了较高的共付额是否与较低的 NOAC 依从性相关。
我们使用全国商业保险患者的索赔数据库，对 2012 年至 2018 年新开始使用 NOAC 的心房颤动患者进行了队列研究。患者分为低（<$35）、中（$35-$59）或高（≥$60）共付额，并根据人口统计学、保险特征、合并症、既往医疗保健利用情况、日历年度和接受的 NOAC 进行倾向评分加权。随访 1 年，随访截止点为改用其他抗凝剂、行消融术、退出保险计划或死亡。主要结局为通过比例天数覆盖（PDC）测量的依从性。次要结局包括 NOAC 停药（NOAC 供应结束后 30 天无再配药）和更换抗凝剂。我们使用 Kruskal-Wallis 检验比较 PDC，使用 Cox 比例风险模型比较停药和换药率。
在对 3 个共付额组的患者进行加权后，有效样本量为 17558 例患者，50 个临床和人口统计学协变量平衡（标准化差异<0.1）。平均年龄为 62 岁，29%的患者为女性，最常见的 NOAC 为阿哌沙班（43%）和利伐沙班（38%）。较高的共付额与较低的依从性相关（P<0.001），高共付额组的 PDC 为 0.82（四分位距 [IQR] 0.36-0.98），中共付额组为 0.85（IQR 0.41-0.98），低共付额组为 0.88（IQR 0.41-0.99）。与低共付额组相比，高共付额组的停药率更高（风险比 [HR] 1.13，95%置信区间 [CI] 1.08-1.19；P<0.001）。
在新开始使用 NOAC 的心房颤动患者中，商业保险中较高的共付额与第一年较低的依从性和较高的停药率相关。降低或限制重要药物费用共付额的政策可能会提高接受 NOAC 治疗的患者的依从性并改善其结局。
