Department of Medicine (Cardiology) New York University School of Medicine New York NY.
Department of Population Health New York University School of Medicine New York NY.
J Am Heart Assoc. 2022 Dec 20;11(24):e027662. doi: 10.1161/JAHA.122.027662. Epub 2022 Dec 1.
Background Angiotensin receptor neprilysin inhibitors (ARNI) reduce mortality and hospitalization for patients with heart failure. However, relatively high copayments for ARNI may contribute to suboptimal adherence, thus potentially limiting their benefits. Methods and Results We conducted a retrospective cohort study within a large, multi-site health system. We included patients with: ARNI prescription between November 20, 2020 and June 30, 2021; diagnosis of heart failure or left ventricular ejection fraction ≤40%; and available pharmacy or pharmacy benefit manager copayment data. The primary exposure was copayment, categorized as $0, $0.01 to $10, $10.01 to $100, and >$100. The primary outcome was prescription fill nonadherence, defined as the proportion of days covered <80% over 6 months. We assessed the association between copayment and nonadherence using multivariable logistic regression, and nonbinarized proportion of days covered using multivariable Poisson regression, adjusting for demographic, clinical, and neighborhood-level covariates. A total of 921 patients met inclusion criteria, with 192 (20.8%) having $0 copayment, 228 (24.8%) with $0.01 to $10 copayment, 206 (22.4%) with $10.01 to $100, and 295 (32.0%) with >$100. Patients with higher copayments had higher rates of nonadherence, ranging from 17.2% for $0 copayment to 34.2% for copayment >$100 (<0.001). After multivariable adjustment, odds of nonadherence were significantly higher for copayment of $10.01 to $100 (odds ratio [OR], 1.93 [95% CI, 1.15-3.27], =0.01) or >$100 (OR, 2.58 [95% CI, 1.63-4.18], <0.001), as compared with $0 copayment. Similar associations were seen when assessing proportion of days covered as a proportion. Conclusions We found higher rates of not filling ARNI prescriptions among patients with higher copayments, which persisted after multivariable adjustment. Our findings support future studies to assess whether reducing copayments can increase adherence to ARNI and improve outcomes for heart failure.
血管紧张素受体脑啡肽酶抑制剂（ARNI）可降低心力衰竭患者的死亡率和住院率。然而，ARNI 的较高共付额可能导致用药依从性不佳，从而限制其获益。
我们在一个大型多地点医疗系统中开展了一项回顾性队列研究。我们纳入了以下患者：2020 年 11 月 20 日至 2021 年 6 月 30 日期间处方 ARNI；诊断为心力衰竭或左心室射血分数≤40%；且有药房或药房福利管理共付额数据。主要暴露因素为共付额，分为 0 美元、0.01 美元至 10 美元、10.01 美元至 100 美元和>100 美元。主要结局是处方填服不依从，定义为 6 个月内的用药天数覆盖比例<80%。我们使用多变量逻辑回归评估共付额与不依从的关联，并使用多变量泊松回归评估非二进制的用药天数覆盖比例，调整了人口统计学、临床和社区水平的协变量。共有 921 名患者符合纳入标准，其中 192 名（20.8%）的共付额为 0 美元，228 名（24.8%）的共付额为 0.01 美元至 10 美元，206 名（22.4%）的共付额为 10.01 美元至 100 美元，295 名（32.0%）的共付额>100 美元。共付额较高的患者不依从率更高，0 美元共付额的不依从率为 17.2%，>100 美元共付额的不依从率为 34.2%（<0.001）。多变量调整后，10.01 美元至 100 美元（比值比[OR]，1.93[95%置信区间[CI]，1.15-3.27]，=0.01）或>100 美元（OR，2.58[95%CI，1.63-4.18]，<0.001）的共付额与不依从的相关性具有统计学意义，与 0 美元共付额相比。当评估用药天数覆盖比例作为比例时，也观察到了类似的关联。
我们发现共付额较高的患者未开具 ARNI 处方的比例较高，多变量调整后仍存在这种情况。我们的研究结果支持未来的研究，以评估降低共付额是否可以提高 ARNI 的用药依从性并改善心力衰竭患者的结局。
