Pharmacy Assistance Programs Research Articles

Evaluation of guideline recommended treatment utilization among Black and White men with metastatic prostate cancer.

103 Background: Prostate cancer is the second leading cause of cancer death among men with a disproportionate burden on Black men. 1 Black men are twice as likely to die from prostate cancer compared to White counterparts. 2 Racial disparities in care delivery for early-stage disease are well documented and may contribute to disparate outcomes, 3–6 but less is known about racial gaps in advanced prostate cancer care, a stage where effective therapies can prolong life for years. 7 We sought to evaluate if treatment disparities were evident among Black and White men with metastatic prostate cancer. Methods: We performed a retrospective cohort study of patients with metastatic prostate cancer receiving treatment at a large public tertiary care health system between 2015 and 2020. Demographic, clinical, treatment, and medication prescribing data were extracted from the electronic health record. We excluded patients without ICD codes indicating metastatic disease, those without any documented medication data in our health system, and those who did not identify as Black or White race. We estimated the prevalence ratio (PR) of being prescribed each of the recommended treatment options for metastatic prostate cancer per National Comprehensive Care Network guidelines, including androgen deprivation therapy (ADT), novel anti-androgens, chemotherapy, and bone protection comparing Black men to White men using log-binomial regression. Results: We identified 1,594 patients with metastatic prostate cancer; 485 (30%) were Black. Black patients were younger and had higher Charlson scores compared to White men. Both groups were highly insured, Medicaid was more common for Black men (7.2% vs 2.2%). Prescribing of systemic treatments was similar by race (Table). Combination ADT and novel antiandrogen prescribing was also similar by race (PR 1.04 95% CI:(0.91 - 1.17), p=0.6). About 30% of both Black and White patients interacted with our Patient Navigation team, a group of oncology nurses focused on ensuring patients receive recommended care. Conclusions: In a large public tertiary care health system, we did not observe racial disparities in receipt of guideline recommended therapies for metastatic prostate cancer. High rates of insurance, a robust patient navigation program, and a well-developed pharmacy assistance program may have helped mitigate racial disparities in care. Ongoing analyses are evaluating prescribing patterns among patients with de novo metastatic disease. Future studies should explore delivery of prostate cancer therapies across health systems and the influence of patient navigation and pharmacy assistance programs on medication receipt. Prevalence ratios of treatment by race. Medication PR (95% CI) for Black v White men p-value ADT 1.04 (0.98-1.11) 0.19 Novel Antiandrogen 1.05 (0.95-1.16) 0.31 Bone protection 0.89 (0.76-1.04) 0.13 Chemotherapy 1.09 (0.85-1.39) 0.51

Pharmacy Assistance Programs for Oral Anticancer Drugs: A Narrative Review.

Oral anticancer medications (OAMs) are high priced with a significant cost-sharing burden to patients, which can lead to catastrophic financial, psychosocial, and clinical repercussions. Cost-conscious prescribing and inclusion of low-cost alternatives can help mitigate this burden, but cost transparency at the point of prescribing remains a major barrier to doing so. Pharmacy assistance programs, including co-payment cards and patient assistance programs administered by manufacturers and foundation-based grants, remain an essential resource for patients facing prohibitive co-payments for OAMs. However, access to these programs is fraught with complexities, including lack of trained financial navigators, limited transparency on eligibility criteria, onerous documentation burdens, and limits in available funding. Despite these drawbacks and the potential for such programs to incentivize manufacturers to keep list prices high, assistance programs have been demonstrated to improve financial well-being for patients with cancer. The increasing development of integrated specialty pharmacies with dedicated, trained pharmacy staff can help improve and standardize access to such programs, but these services are disproportionately available to patients seen at tertiary care centers. Multistakeholder interventions are needed to mitigate the burden of cost sharing for OAMs, including increased clinician knowledge of financial resources and novel assistance mechanisms, investment of institutions in trained financial navigation services and centralized platforms to identify assistance programs, and policies to cap out-of-pocket spending and improve transparency of rates charged by pharmacy benefit managers to a health plan.

Perceptions of PGY-2 Oncology Programs on Financial Toxicity Education and Preparedness.

Cancer patients experience a rising monetary burden due to increased direct and in-direct costs associated with cancer treatment. This as a result has an adverse effect on the financial well-being of a cancer patient, also known as financial toxicity. Currently, there is a lack of literature surrounding the implementation of financial toxicity in post-graduate oncology residency training for pharmacists. The objective of this study was to describe the perceptions of PGY-2 oncology pharmacy residents and residency program directors on the incorporation of financial toxicity within their training programs and to assess self-perceptions of their level of abilities and experience managing financial toxicity for patients.A qualitative RedCap electronic survey was emailed in December 2020 to resident and directors of PGY-2 oncology programs in the United States.Out of 40 respondents, 64% of residency program directors were highly comfortable with the concept of financial toxicity, while 73% of pharmacy residents were uncomfortable with the concept of financial toxicity within their program. Furthermore, a majority of residents were either uncomfortable or highly uncomfortable managing financial toxicity for patients. In addition, the most commonly utilized method of incorporating the concept of financial toxicity in all programs was through specialty pharmacy and patient assistance programs (PAPs); residents also preferred these methods along with guest speakers to provide this training.Financial toxicity concepts should be considered as an educational standard and incorporated through unique methods of education. We suggest introducing the concept through guest speakers, followed by practical applications integrated in specialty pharmacies and PAPs.

PDB25 THE EFFECT OF MEDICATION NON-ADHERENCE ON HOSPITALIZATION COSTS AMONG MEDICARE ENROLLEES WITH DRUG COVERAGE THROUGH A PHARMACY ASSISTANCE PROGRAM

To examine the association between medication nonadherence and hospitalization costs among Medicare enrollees who received medications through a pharmacy assistance program. This study included Medicare enrollees (≥ 65 years) who received oral antidiabetic medications (OAMs) through Pharmaceutical Assistance Contract for Elderly (PACE) program of Pennsylvania in 2015 and had at least one inpatient hospital admission during 12-months from the index date (when first prescription for OAM was filled). Medication adherence was estimated as proportion of days covered (PDC) [adherent: PDC ≥ 80%, nonadherent: PDC < 80%]. The hospitalization costs (2015 USD) were calculated by applying hospital-level Medicare-specific cost-to-charge ratios (CCRs) to hospital inpatient charges obtained from Pennsylvania Health Care Cost Containment Council’s (PHC4), which included only direct charges for hospital services. General linear model with a gamma distribution and log link function was used to examine the association between medication nonadherence and hospitalization costs (all-cause and diabetes-related), while controlling for covariates such as sociodemographic characteristics, lived in a pharmacy desert or not, number of unique medications received and out-of-pocket drug costs. Among 1,907 Medicare enrollees included in the study, 1,447 (73.5%) patients were adherent. Total study population cost the Medicare program $35.5 million for all-cause and $9.1 million for diabetes-related inpatient hospital admissions. The annual mean healthcare cost per patient was $18,066 and $4,416 for all-cause and diabetes-related hospitalizations respectively. All-cause hospitalization cost was significantly higher for nonadherent than adherent patients (mean $23,059 vs $16,266; p < 0.0001). GLM models showed that medication nonadherence was associated with significant increase in all-cause hospitalization costs ($22,670 vs $16,383; p < 0.0001) and diabetes-related hospitalization costs ($13,518 vs $12,634; p= 0.0003). Medicare enrollees who were nonadherent to OAMs received through prescription assistance program had more hospitalization costs as compared to adherent patients.

Satisfação dos Usuários Atendidos pela Farmácia Básica do Sus no Município de Agudo – RS

Neste estudo, analisou-se o grau de satisfação dos usuários do Programa de Assistência Farmacêutica, como parte da Política Pública na área de Saúde, na qual o medicamento é o insumo essencial e está no centro de um conjunto de ações voltadas para a promoção, proteção e recuperação da saúde humana, que prevê o acesso da população aos medicamentos necessários para o controle de suas enfermidades. O programa abrange o processo, desde o desenvolvimento do medicamento, até sua distribuição e consumo pelo indivíduo atendido. Assim, é de suma importância conhecer o processo antes de procederem-se as análises quanto à situação encontrada. Para tanto, realizou-se um estudo de caso, mediante pesquisa descritiva e qualitativa, sendo analisados os pontos positivos e negativos do serviço prestado no município de Agudo no Rio Grande do Sul. Selecionaram-se 134 pessoas que acessam o referido programa por amostragem aleatória simples, as quais responderam ao questionário formulado. Utilizou-se a escala de cinco pontos de Rensis Likert. Buscou-se identificar por meio da opinião dos participantes, o grau de satisfação em relação ao atendimento prestado pela farmácia do SUS nesta localidade. Verificou-se que a maioria dos usuários se encontra satisfeita quanto aos serviços da farmácia e constatou-se que há descontentamento no que se refere à disponibilidade de medicamentos e ao empenho dos funcionários na resolução desse problema.

The explanatory role of stroke as a mediator of the mortality risk difference between older adults who initiate first- versus second-generation antipsychotic drugs.

Antipsychotic drugs are used to treat dementia-related symptoms in older adults, and observational studies show higher risks of death and stroke associated with the use of first-generation antipsychotic drugs (FGAs) compared with second-generation antipsychotic drugs (SGAs). However, the extent to which stroke explains the differential mortality risk between FGA use and SGA use in older adults is unclear. We followed those who initiated use of antipsychotic drugs (9,777 FGA users and 21,164 SGA users) aged 65 years or older, and who were enrolled in Medicare and either the New Jersey or Pennsylvania pharmacy assistance program during 1994 to 2005, over 180 days for the outcomes of stroke and death. We estimated direct and indirect effects by comparing 180-day mortality risks associated with the use of FGAs versus SGAs as mediated by stroke on the risk ratio scale, as well as the proportion mediated on the risk difference scale. FGA use was associated with marginally higher risks of stroke (risk ratio =1.24, 95% confidence interval (CI): 1.01, 1.53) and death (risk ratio = 1.15, 95% CI: 1.08, 1.22) compared with SGA use, but stroke explained little (2.7%) of the observed difference in mortality risk. The indirect effect was null (risk ratio = 1.004, 95% CI: 1.000, 1.008), and the direct effect was equal to the total effect of antipsychotic drug type (FGA vs. SGA) on mortality risk (risk ratio = 1.15, 95% CI: 1.08, 1.22). These results suggest that the difference in mortality risk between users of FGAs and SGAs may develop mostly through pathways that do not involve stroke.

The University of North Carolina's Health Care Pharmacy Assistance Progam.

UNC Health Care has a Pharmacy Assistance Program (PAP) that provides financial assistance to uninsured patients in North Carolina who need prescription medications. Despite significant investment in the program, little is known about the patients accessing it or the specific health care services they use. Our objectives were to describe the PAP population, to examine their use of prescription medications and health services, and to characterize changes in prescription medication use and expenditures from 2009 through 2011. We used a repeated cross-sectional study design, merging prescription claims with health records from Carolina Data Warehouse for Health, to measure use of prescription medications and use of inpatient, outpatient, and emergency department care by PAP participants. Prescription claims were grouped into therapeutic categories. We generated descriptive statistics for key variables to examine health service utilization from 2009 through 2011. From 2009 through 2011, PAP served 7,180 patients from 81 counties in North Carolina. PAP users received a mean of 23 prescriptions, at an average cost of $754 per recipient per year. An average of $2.93 million per year was spent on the program, with an 8% rise in spending from 2009 to 2011. Inpatient care and emergency department care were utilized by 30% and 31% of PAP users, respectively, and there was minimal change in these rates over 3 years. Data were limited to medications dispensed through PAP and to health services provided by UNC Health Care. With the state's decision to not expand Medicaid, PAP will continue to be an important resource for North Carolina's low income citizens.

Patterns of medication adherence and health care utilization among patients with chronic disease who were enrolled in a pharmacy assistance program.

Poor medication adherence due to high drug costs is a barrier to optimal health outcomes among low-income uninsured patients with chronic conditions. Charitable pharmacy assistance programs provide medications to such patients, but little is known about the utilization patterns of program participants. We used a retrospective cohort design to investigate 6-month outcomes for participants in the University of North Carolina (UNC) Health Care Pharmacy Assistance Program (PAP) who received medications indicated for hypertension, diabetes, and/or hyperlipidemia from 2009 through 2011. Logistic regression was used to analyze predictors of medication adherence and to evaluate the association between adherence and use of emergency and inpatient care. The 3 study cohorts included 866 patients receiving antihypertensive agents, 265 patients receiving oral glucose-lowering agents, and 455 patients receiving statins. When assessed 6 months after program enrollment, 52%, 45%, and 38% of patients in these 3 groups, respectively, were at least 80% adherent to treatment. Adherent patients in all cohorts had lower odds of requiring inpatient or emergency department care, but the decrease was only statistically significant among those taking antihypertensive agents (odds ratio for hospitalization = 0.58; 95% confidence interval, 0.39-0.87). Selection bias and inability to capture utilization data from sources other than UNC Health Care may have biased results. Approximately 50% of PAP participants were adherent to chronic disease medications. Adherence to such therapies among patients who are receiving financial assistance with medications may reduce their need for costly health care services. Future research should assess the long-term ability of pharmacy assistance programs to promote medication adherence and should examine alternative strategies for improving adherence and health outcomes among low-income uninsured patients.

Interest groups and health care reform across the United States

Preface and Acknowledgments Introduction: Interests and Health Policy 1. Health Care and Organized Interests in the United States 2. The Theory and Structure of Health Interest Communities in the States 3. State Pharmacy Assistance Programs as Innovations 4. The Politics of Managing Managed Care 5. Universal Health Care in the States 6. Conclusion: Lessons Learned and Opportunities for Influence in the ACA Policy Environment Appendix 2.1: Descriptions of Health Interest Organization Subguilds Appendix 2.2: States Ranked by Health Interest Group Density Appendix 2.3: Density by Subguild, Raw Numbers in 1998 Appendix 2.4: Data Source for Political Action Committes Appendix 3.1: List of Data Sources Appendix 3.2: Estimation of Annual Interest Group Measures Using the ESA Model Appendix 4.1: Data Sources of Dependent Variables Appendix 4.2: Managed Care Regulation Descriptive Statistics Appendix 4.3: Definitions and Sources of Independent Variables Appendix 5.1: Sources of Dependent Variables Appendix 5.2: Sources of Independent Variables References Index

Appropriateness of cardiovascular care in elderly adult cancer survivors

Research suggests that the quality of non-cancer-related care among cancer survivors (CS) is suboptimal. Secondary disease prevention is an important component of survivorship care that has not been previously evaluated. Our aims were (1) to assess the utilization of and adherence to medications and treatments for the secondary prevention of myocardial infarction (MI) in CS versus non-cancer patients (NCP) and (2) to compare temporal trends in cardiovascular care between these two patient cohorts. Linking data from Medicare, pharmacy assistance programs, and cancer registries, we calculated the percentage of individuals receiving preventive medications (statins, β-blockers, angiotensin-converting enzyme inhibitors) and revascularization interventions (angioplasty, stent, bypass surgery) within 90 days after acute MI in CS and propensity score-matched NCP. We assessed trends over time and determined predictors of appropriate preventive care using modified Poisson regression. We identified 1,119 CS and 7,886 NCP. Compared to NCP, more survivors received statins (38 vs. 31 %) and β-blockers (67 vs. 59 %), but fewer underwent bypass surgery (1.5 vs. 2.8 %) after MI. From 1997 to 2004, both survivors and NCP were increasingly prescribed medications to prevent future coronary events. Over the same time period, receipt of bypass surgery was significantly lower among survivors. Co-morbidities, such as depression and lung disease, and demographic factors, such as advanced age and female, were associated with underuse of preventive care among survivors when compared to NCP. Use of preventive medications and procedures has generally improved, but uptake of bypass surgery among CS still lags behind NCP.

Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors: Challenges in Comparative Effectiveness Using Medicare Data

An evidence gap exists in comparing the effectiveness of angiotensin receptor II blockers (ARBs) vs. angiotensin-converting enzyme inhibitors (ACEIs). We identified elderly hypertensive patients who initiated ACEI/ARBs after a hospitalization for coronary artery disease, heart failure, or stroke eligible for Medicare and state pharmacy assistance programs. Among 18,801 initiators of ACEIs and 2,641 initiators of ARBs, 2,535 deaths were identified. We observed substantial differences in characteristics between ARB and ACEI initiators, suggesting that ARB users were more health-seeking. The incidence of death and sudden cardiac death (SCD) in ACEI initiators was 77 and 22 per 1000 person-years, respectively. The relative risk for SCD was 0.69 (95% CI 0.50–0.96) in ARB initiators, which was 1.1 after restricting to low ejection fraction (EF) patients. The reduced risk of SCD is explained, at least partly, by 1) residual confounding by ARB users being healthier on unobserved domains and 2) lack of data on EF.

Adherence to Statin Therapy in Elderly Patients After Hospitalization for Coronary Revascularization

Low levels of statin adherence have been documented in patients with coronary artery disease (CAD), but whether coronary revascularization is associated with improved adherence rates has yet to be evaluated. We identified all Medicare beneficiaries enrolled in 2 statewide pharmacy assistance programs who were ≥65 years old, who had been hospitalized for CAD from 1995 through 2004, and who had been prescribed statin therapy within 90 days of discharge (n = 13,130). Statin adherence was measured based on the proportion of days covered with statin therapy after hospital discharge, and full adherence was defined as proportion of days covered ≥80%. Statin adherence was compared in patients with CAD treated with medical therapy (n = 3,714), percutaneous coronary intervention (n = 6,309), or coronary artery bypass graft surgery (n = 3,107). Statin adherence significantly increased over the period of the study from 70.5% to 75.4% (p <0.0001). After hospitalization for CAD, patients treated with percutaneous coronary intervention and coronary artery bypass graft surgery had full adherence rates of 70.6% and 70.2%, respectively. Full adherence rates were significantly lower for patients treated with coronary revascularization compared to patients treated with medical therapy (79.4%, p <0.0001). Independent predictors of higher statin adherence included treatment with medical therapy, later year of hospital admission, white race, previous statin use, and use of other cardiac medications after CAD hospitalization (p <0.01 for all comparisons). In conclusion, in patients receiving invasive coronary treatment, statin adherence remains suboptimal, despite strong evidence supporting their use. Given the health and economic consequences of nonadherence, these findings highlight the need for developing cost-effective strategies to improve medication adherence after coronary revascularization.

A combined comorbidity score predicted mortality in elderly patients better than existing scores

Objective To develop and validate a single numerical comorbidity score for predicting short- and long-term mortality, by combining conditions in the Charlson and Elixhauser measures. Study Design and Setting In a cohort of 120,679 Pennsylvania Medicare enrollees with drug coverage through a pharmacy assistance program, we developed a single numerical comorbidity score for predicting 1-year mortality, by combining the conditions in the Charlson and Elixhauser measures. We externally validated the combined score in a cohort of New Jersey Medicare enrollees, by comparing its performance to that of both component scores in predicting 1-year mortality, as well as 180-, 90-, and 30-day mortality. Results C-statistics from logistic regression models including the combined score were higher than corresponding c-statistics from models including either the Romano implementation of the Charlson Index or the single numerical version of the Elixhauser system; c-statistics were 0.860 (95% confidence interval [CI]: 0.854, 0.866), 0.839 (95% CI: 0.836, 0.849), and 0.836 (95% CI: 0.834, 0.847), respectively, for the 30-day mortality outcome. The combined comorbidity score also yielded positive values for two recently proposed measures of reclassification. Conclusion In similar populations and data settings, the combined score may offer improvements in comorbidity summarization over existing scores.

Adherence to cardiovascular (CV) medications after myocardial infarction (MI) in cancer survivors (CS).

6095 Background: Studies of noncancer patients (NCP) indicate that medication adherence is poor. Adherence among CS has not been evaluated specifically even though this is a crucial aspect of their ongoing care. Our aims were to 1) characterize adherence to CV medications in CS vs NCP, 2) compare temporal trends in adherence in these 2 cohorts, and 3) determine predictors for adherence. Methods: Using linked data from Medicare, pharmacy assistance programs, and cancer registries, we identified patients discharged from hospital for MI between 1997 and 2004. For those prescribed a statin, β-blocker, ACE inhibitor (ACEi) or all 3, we assessed adherence between CS and propensity score (PS) matched NCP. Adherence was measured using proportion of days covered (PDC), which was the number of days (NOD) of medication supplied divided by NOD in the 1st year after initial prescription. Patient was considered adherent if PDC ≥ 80%. Modified Poisson regression was used to describe trends over time and predictors of adherence. Results: In total, 964 CS and 6,923 NCP received at least 1 CV medication. Median ages were 80.3/80.2 years, 66/68% were female, and 90/91% were white, respectively. Adherence rates were suboptimal in both cohorts (18 to 45%). Between 1997 and 2004, adherence to statins and β-blockers (p<0.01 for both), but not ACEi, increased significantly among NCP (see Table). For CS over the same period, only adherence to statins improved (p<0.01). Of those prescribed all 3 medications, there was improvement in adherence among NCP (p<0.01), but not for CS (p=0.26). Comorbidities, such as heart failure and depression, were associated with poor adherence. Conclusions: Adherence to highly efficacious therapies remains low. While adherence to β-blockers and all 3 medications improved over time for NCP, this trend was not observed among CS. Medication All years P for baseline difference Year of MI P for trend P for difference in trend 1997–1998 1999–2000 2001–2002 2003–2004 Statin CS 45% 0.92 42% 51% 49% 55% < 0.01 0.24 NCP 44% 39% 47% 49% 54% < 0.01 β-blocker CS 40% 0.54 42% 40% 42% 41% 0.78 0.04 NCP 41% 39% 43% 47% 50% < 0.01 ACEi CS 38% 0.06 45% 39% 38% 39% 0.96 0.70 NCP 43% 41% 43% 45% 43% 0.11 All 3 medications CS 18% 0.21 22% 21% 20% 21% 0.26 0.02 NCP 22% 21% 24% 26% 27% < 0.01 No significant financial relationships to disclose.

Effect of an Expenditure Cap on Low‐Income Seniors' Drug Use and Spending in a State Pharmacy Assistance Program

To estimate the impact of a soft cap (a ceiling on utilization beyond which insured enrollees pay a higher copayment) on low-income elders' use of prescription drugs. Claims and enrollment files for the first year ( June 2002 through May 2003) of the Illinois SeniorCare program, a state pharmacy assistance program, and Medicare claims and enrollment files, 2001 through 2003. SeniorCare enrolled non-Medicaid-eligible elders with income less than 200 percent of Federal Poverty Level. Minimal copays increased by 20 percent of prescription cost when enrollee expenditures reached $1,750. Models were estimated for three dependent variables: enrollees' average monthly utilization (number of prescriptions), spending, and the proportion of drugs that were generic rather than brand. Observations included all program enrollees who exceeded the cap and covered two periods, before and after the cap was exceeded. On average, enrollees exceeding the cap reduced the number of drugs they purchased by 14 percent, monthly expenditures decreased by 19 percent, and the proportion generic increased by 4 percent, all significant at p<.01. Impacts were greater for enrollees with greater initial spending, for enrollees without one of five chronic illness diagnoses in the previous calendar year, and for enrollees with lower income. Near-poor elders enrolled in plans with caps or coverage gaps, including Part D plans, may face sharp declines in utilization when they exceed these thresholds.

Reforming Patient Assistance Programs: Perfect World Meets Real World

Drug company-sponsored pharmacy assistance programs (PAPs) are an imperfect solution to a wide-ranging access problem. These programs help millions of people with chronic conditions get life-saving medications. Spending funds to tinker with these programs would distract from the systemic problems facing the health care system and risk placing a higher bureaucratic burden on providers and patients. The net effect would be reduced access to prescription drugs for many who rely on PAPs for their medications. Solutions should be sought to tackle fundamental problems facing an overburdened health care system. These solutions must involve a reexamination of priorities, not of functioning programs.

Improvements in Long-Term Mortality After Myocardial Infarction and Increased Use of Cardiovascular Drugs After Discharge: A 10-Year Trend Analysis

Improvements in Long-Term Mortality After Myocardial Infarction and Increased Use of Cardiovascular Drugs After Discharge: A 10-Year Trend Analysis Soko Setoguchi, Robert J. Glynn, Jerry Avorn, Murray A. Mittleman, Raisa Levin, Wolfgang C. Winkelmayer The use of recommended cardiovascular medications after myocardial infarction (MI) has increased during the past decade. Little is known whether the increasing use of drugs contributed to the improvements in MI prognosis. Using data from Medicare and pharmacy programs in 2 states, we assessed trends in the mortality and the contribution to increasing medication use after MI in multivariate models. Among 21,484 MI patients, mortality decreased significantly with a 3% reduction in each year (1995 to 2004). Adjusting for the use of cardiovascular medications completely eliminated the mortality trend, suggesting that the mortality improvement is mainly due to increased use of these medications. We sought to assess the relationship between increasing use of cardiovascular medications and trends in long-term prognosis after myocardial infarction (MI) in the elderly. During the past decade, statins, beta-blockers (BBs), angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin-II receptor blockers (ARBs) have been increasingly used after MI. However, little is known about the relationship between increasing use of these medications and improvements in prognosis after MI. Using data from pharmacy assistance programs and Medicare in 2 states (1995 to 2004), we identified patients with MI who survived ≥30 days after discharge. We assessed age, gender, race, comorbidities, and coronary interventions during the MI hospitalization and recorded filled prescriptions for statins, BBs, ACEIs/ARBs, or antiplatelet agents within 30 days after discharge. All patients were tracked until they died or until the end of the eligibility/study period. We built multivariate Cox proportional hazards regression models to assess trends in long-term mortality and the contribution to increasing medication use after MI. Of 21,484 patients identified, 12,142 died during 74,982 person-years of follow-up. After adjusting for demographics and comorbidities, we found that mortality after MI decreased significantly from 1995 to 2004 (hazard ratio for annual trend 0.97; 95% confidence interval 0.97 to 0.98), a 3% reduction in mortality each year. Adjusting for the use of statins, BBs, ACEIs/ARBs, and antiplatelet drugs after discharge completely eliminated the association between time trend and mortality (hazard ratio 1.00; 95% confidence interval 0.99 to 1.01). The observed improvement in long-term mortality in elderly patients with MI may be mainly due to increased use of cardiovascular medications after discharge.

The economic consequences of non–evidence-based clopidogrel use

Clinical trials have helped clarify the efficacy of clopidogrel for the treatment and prevention of vascular disease. Costs for its use exceeded $5.9 billion in 2005, making it the second greatest source of drug expenditure in the world. However, little is known about the appropriateness of that use. Overuse of clopidogrel could have important implications for health care quality and drug expenditures. We conducted a retrospective cohort study linking all filled prescriptions to all clinical encounter data for Medicare beneficiaries enrolled in a large state-wide pharmacy assistance program. We identified all patients newly prescribed clopidogrel during a recent 2-year period and determined the proportion who had indications for clopidogrel, the mean number of tablets filled by patients with and without apparent indications in the year after starting therapy, and the costs associated with the observed patterns of clopidogrel use. We identified 4977 patients who were newly prescribed clopidogrel. Of these patients, only 47% had > or = 1 documented indications for clopidogrel according to clinical trial findings. Using looser criteria, the number of patients with appropriate indications was 56%. During the first year of therapy, 43% ($2.05 million) of total clopidogrel expenditures for the patients studied was spent on patients without an indication that this agent was required, using the extended criteria for evidence-based use. More than 40% of the clopidogrel used in this population appears to have been prescribed to patients for whom the drug had no documented advantage over aspirin or no antiplatelet therapy. If the same proportion applies nationally, in 2005, it would represent almost $1.5 billion of potentially unnecessary health care expenditure.

Long-term trends of angiotensin-converting enzyme inhibitor and angiotensin-receptor blocker use after heart failure hospitalization in community-dwelling seniors

Background Despite multiple trials demonstrating the benefit of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) for heart failure (HF) patients with systolic dysfunction, studies have reported underuse of these drugs. Little is known about recent trends in the use of ACEI/ARB in community-dwelling seniors. Methods Using administrative data from pharmacy assistance programs and Medicare in two states, we identified all patients hospitalized for HF between 1995 and 2004 who survived ≥ 90 days after discharge. The study outcomes were filled prescriptions for an ACEI or ARB within 90 days after discharge. We assessed age, gender, race, and comorbidities. Multivariate modified Poisson regression was used to analyze temporal trends. Results Of 54,453 patients identified, 26,166 (48%) filled prescriptions for ACEIs/ARBs within 90 days after discharge from HF, but utilization of these drugs did not increase during the decade studied. Among those who were on ACEI/ARB before the index hospitalization, 74% filled at least one ACEI/ARB prescription within 90 days after the hospitalization. These results were similar among the subgroup of HF patients with prior MI. Conclusions Use of ACEI/ARB after discharge from HF hospitalization in seniors did not increase over the decade of observation and may still be inadequate.

Ten-Year Trends of Cardiovascular Drug Use After Myocardial Infarction Among Community-Dwelling Persons ≥65 Years of Age

Guidelines for post-myocardial infarction (MI) management emphasize treatment with statins, beta blockers (BBs), and angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs). Little is known about the temporal trends and racial differences in such use after discharge. This study assessed temporal trends and racial differences in the use of statins, BBs, and ACEIs or ARBs after MI discharge in community-dwelling seniors. Administrative data from pharmacy assistance programs and Medicare in 2 states (1995 to 2004) were used to identify all patients hospitalized for MI who survived > or =90 days after discharge. Age, gender, race, co-morbidities, and MI-specific procedures during hospitalization were assessed. The study outcomes were filled prescriptions for any statin, BB, or ACEI or ARB <90 days after discharge. Multivariate regression was used for trend and racial difference analyses. Of 19,368 patients identified, 6,577 (34.0%) filled prescriptions for statins, 12,387 (64.0%) for BBs, and 9,934 (51.3%) for ACEIs or ARBs <90 days after MI discharge. The use of these drugs increased from 1995 to 2004, most steeply for statins (11% to 61%), less so for BBs (47% to 80%), and least for ACEIs or ARBs (46% to 58%) (all p for trend <0.001). Black patients were 14% and 5% less likely to receive statins and BBs, respectively (all p <0.05). No evidence of an interaction between race and time trend was found. In conclusion, the use of cardiovascular medications after discharge from MI hospitalization in older patients may still be inadequate but has increased over time. The underuse of statins and BBs was marked in black patients and did not improve over time.