CardioExchange Archive

Could getting rid of copayments improve adherence to post-discharge medications, leading to better  outcomes and reduced costs? That’s the theory tested by the MI FREEE (Post-Myocardial Infarction Free Rx Event and Economic Evaluation) trial, which was presented at the AHA and  published simultaneously in the New England Journal of Medicine.

Niteesh Choudhry and colleagues randomized 5855 post-MI patients with Aetna insurance to either full prescription coverage or usual prescription coverage for statins, beta-blockers, ACE inhibitors, or ARBs. The rate of adherence increased for all drug categories with full prescription coverage (P<0.001 for all categories):

• ACE inhibitor or ARB increased from 35.9% to 41.1%
• Beta-blocker increased from 45.0% to 49.3%
• Statins increased from 49.0% to 55.1%
• All three medications increased from 38.9% to 43.9%

However, the study did not find a significant difference in the primary outcome of the trial, which was the rate of first major vascular event or revascularization: 17.6 per 100 person-years in the full coverage group versus 18.8% in the usual coverage group (HR, 0.93; 95% CI, 0.82-1.04; P=0.21). On the other hand, benefits were observed in secondary outcomes and in individual components of the composite outcomes:

• total major vascular events or revascularization: HR, 0.89; 95% CI, 0.80-0.99; P=0.03
• first major vascular event: HR 0.86; 95% CI, 0.74-0.99; P=0.03
• stroke: HR, 0.69; 95% CI, 0.50-0.96; P=0.03

Total spending was not significantly different between the 2 groups: $66,008 in the full-coverage group and 71,778 in the usual coverage group. The authors noted that “an intervention that reduces patients’ financial burdens without changing overall spending and with possible clinical benefits is a rarity in health care and suggests that eliminating cost sharing for secondary prevention after myocardial infarction may be cost-effective.”

In an accompanying editorial, Lee Goldman and Arnold Epstein write that “perhaps the most sobering findings were both the low baseline adherence and the small improvement in adherence in what should have been a highly motivated group of patients after myocardial infarction.” Nevertheless, they continue, “reducing or eliminating the costs of highly beneficial medicines is almost certainly one key component of increasing adherence, even if its absolute benefit is distressingly modest.”