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Original Investigation
November 13, 2019

Association of a P2Y12 Inhibitor Copayment Reduction Intervention With Persistence and Adherence With Other Secondary Prevention Medications: A Post Hoc Analysis of the ARTEMIS Cluster-Randomized Clinical Trial

Author Affiliations
  • 1Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, University of Pennsylvania, Philadelphia
  • 2Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia
  • 3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
  • 4Department of Medicine, Duke University, Durham, North Carolina
  • 5Duke Clinical Research Institute, Duke University, Durham, North Carolina
  • 6Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
  • 7Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
  • 8Center for Healthcare Delivery Sciences (C4HDS), Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
  • 9The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio
  • 10University of Missouri–Kansas City School of Medicine, Kansas City
  • 11AstraZeneca, BioPharmaceuticals Medical, Wilmington, Delaware
  • 12Division of Cardiology, Ronald Reagan–UCLA Medical Center, Los Angeles, California
  • 13Associate Editor, JAMA Cardiology
JAMA Cardiol. Published online November 13, 2019. doi:https://doi.org/10.1001/jamacardio.2019.4408
Key Points

Question  Does providing patients with copayment assistance for P2Y12 inhibitors also have an association with patient persistence in taking other cardiovascular medications?

Findings  In this secondary analysis of the Affordability and Real-World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study (ARTEMIS) cluster-randomized trial, providing copayment assistance for P2Y12 inhibitors significantly increased patient persistence in taking β-blockers and statins in addition to P2Y12 inhibitors but not in taking angiotensin-converting enzyme inhibitors or angiotensin II–receptor blockers.

Meaning  The association of the P2Y12 inhibitor copayment assistance program evaluated in the ARTEMIS trial with persistence in taking other cardiovascular medications may have important implications important implications for the clinical utility and cost-effectiveness of similar programs.

Abstract

Importance  The Affordability and Real-World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study (ARTEMIS) cluster-randomized trial found that copayment reduction for P2Y12 inhibitors improved 1-year patient persistence in taking that medication.

Objective  To assess whether providing copayment reduction for P2Y12 inhibitors increases patient persistence in taking other secondary prevention cardiovascular medications.

Design, Setting, and Participants  This post hoc analysis of the ARTEMIS trial includes data from 287 hospitals that enrolled patients between June 2015 and September 2016. Patients hospitalized with acute myocardial infarction were included. Data analysis occurred from May 2018 through August 2019.

Interventions  Hospitals randomized to the intervention provided patients vouchers that waived copayments for P2Y12 inhibitors fills for 1 year. Hospitals randomized to usual care did not provide study vouchers.

Main Outcomes and Measures  Persistence in taking β-blocker, statin, and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker medications at 1 year, defined as the absence of a gap in medication supply of 30 or more days by pharmacy fill data in the intervention-arm (intent-to-treat) population.

Results  A total of 131 hospitals (with 5109 patients) were randomized to the intervention, and 156 hospitals (with 3264 patients) randomized to the control group. Patients discharged from intervention hospitals had higher persistence in taking statins (2247 [46.1%] vs 1300 [41.9%]; adjusted odds ratio, 1.11 [95% CI, 1.00-1.24]), and β-blockers (2235 [47.6%] vs 1277 [42.5%]; odds ratio, 1.23 [95% CI, 1.10-1.38]), although the association was smaller than that seen for P2Y12 inhibitors (odds ratio, 1.47 [95% CI, 1.29-1.66]). Persistence in taking angiotensin-converting enzyme inhibitors or angiotensin II-receptor blockers were also numerically higher among patients in the intervention arm than in the usual-care arm, but this was not significant after risk adjustment (1520 [43.9%] vs 847 [40.5%]; adjusted odds ratio, 1.10 [95% CI, 0.97-1.24]). Patients in the intervention arm reported greater financial burden associated with medication cost than the patients in the usual-care arm at baseline, but these differences were no longer significant at 1 year.

Conclusions and Relevance  Reducing patient copayments for 1 medication class increased persistence not only to that therapy class but may also have modestly increased persistence to other post–myocardial infarction secondary prevention medications. These findings have important implications for the clinical utility and cost-effectiveness of medication cost-assistance programs.

Trial Registration  ClinicalTrials.gov Identifier: NCT02406677

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