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Mohanty AF, Levitan EB, King JB, Dodson JA, Vardeny O, Cook J, Herrick JS, He T, Patterson OV, Alba PR, Russo PA, Obi EN, Choi ME, Fang JC, Bress AP. Sacubitril/Valsartan Initiation Among Veterans Who Are Renin-Angiotensin-Aldosterone System Inhibitor Naïve With Heart Failure and Reduced Ejection Fraction. J Am Heart Assoc 2021; 10:e020474. [PMID: 34612065 PMCID: PMC8751890 DOI: 10.1161/jaha.120.020474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Sacubitril/valsartan, a first‐in‐class angiotensin receptor neprilysin inhibitor, received US Food and Drug Administration approval in 2015 for heart failure with reduced ejection fraction (HFrEF). Our objective was to describe the sacubitril/valsartan initiation rate, associated characteristics, and 6‐month follow‐up dosing among veterans with HFrEF who are renin‐angiotensin‐aldosterone system inhibitor (RAASi) naïve. Methods and Results Retrospective cohort study of veterans with HFrEF who are RAASi naïve defined as left ventricular ejection fraction (LVEF) ≤40%; ≥1 in/outpatient heart failure visit, first RAASi (sacubitril/valsartan, angiotensin‐converting enzyme inhibitor [ACEI]), or angiotensin‐II receptor blocker [ARB]) fill from July 2015 to June 2019. Characteristics associated with sacubitril/valsartan initiation were identified using Poisson regression models. From July 2015 to June 2019, we identified 3458 sacubitril/valsartan and 29 367 ACEI or ARB initiators among veterans with HFrEF who are RAASi naïve. Sacubitril/valsartan initiation increased from 0% to 26.5%. Sacubitril/valsartan (versus ACEI or ARB) initiators were less likely to have histories of stroke, myocardial infarction, or hypertension and more likely to be older and have diabetes mellitus and lower LVEF. At 6‐month follow‐up, the prevalence of ≥50% target daily dose for sacubitril/valsartan, ACEI, and ARB initiators was 23.5%, 43.2%, and 47.1%, respectively. Conclusions Sacubitril/valsartan initiation for HFrEF in the Veterans Administration increased in the 4 years immediately following Food and Drug Administration approval. Sacubitril/valsartan (versus ACEI or ARB) initiators had fewer baseline cardiovascular comorbidities and the lowest proportion on ≥50% target daily dose at 6‐month follow‐up. Identifying the reasons for lower follow‐up dosing of sacubitril/valsartan could support guideline recommendations and quality improvement strategies for patients with HFrEF.
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Affiliation(s)
- April F Mohanty
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Emily B Levitan
- Department of Epidemiology University of Alabama at Birmingham School of Public Health Birmingham AL
| | - Jordan B King
- Department of Population Health Sciences University of Utah School of Medicine Salt Lake City UT.,Institute for Health Research Kaiser Permanente Colorado Aurora CO
| | - John A Dodson
- Leon H. Charney Division of Cardiology Department of Medicine New York University School of Medicine New York NY
| | - Orly Vardeny
- University of Minnesota Medical School Minneapolis MN
| | - James Cook
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Jennifer S Herrick
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Tao He
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Olga V Patterson
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Patrick R Alba
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Patricia A Russo
- US Health Economics & Outcomes Research Novartis Pharmaceuticals CorporationEast Hanover NJ
| | - Engels N Obi
- US Health Economics & Outcomes Research Novartis Pharmaceuticals CorporationEast Hanover NJ
| | | | - James C Fang
- Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Adam P Bress
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT.,Department of Population Health Sciences University of Utah School of Medicine Salt Lake City UT
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Iacoviello M, Vitale E, Corbo MD, Correale M, Brunetti ND. Disease-modifier Drugs in Patients with Advanced Heart Failure: How to Optimize Their Use? Heart Fail Clin 2021; 17:561-573. [PMID: 34511205 DOI: 10.1016/j.hfc.2021.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Therapy based on disease-modifier drugs is among the required criteria to diagnose advanced heart failure (AdvHF). Nevertheless, several conditions, such as hospitalization, hypotension, renal dysfunction, electrolyte abnormalities, medical inertia, and patients' adherence, can make the maintenance of optimal medical therapy in patients with AdvHF challenging. Moreover, in recent years, new classes of drugs able have been shown to be able to further modify the natural history of heart failure with reduced ejection fraction, but they are still not widely adopted. This article discusses the optimal use of disease-modifier drugs in patients with AdvHF as well as the possible usefulness of the new therapeutic opportunities.
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Affiliation(s)
- Massimo Iacoviello
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, Foggia, Italy.
| | - Enrica Vitale
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, Foggia, Italy
| | - Maria Delia Corbo
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, Foggia, Italy
| | - Michele Correale
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, Foggia, Italy
| | - Natale Daniele Brunetti
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, Foggia, Italy
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Ozaki AF, Krumholz HM, Mody FV, Tran TT, Le QT, Yokota M, Jackevicius CA. Prior Authorization, Copayments, and Utilization of Sacubitril/Valsartan in Medicare and Commercial Plans in Patients With Heart Failure With Reduced Ejection Fraction. Circ Cardiovasc Qual Outcomes 2021; 14:e007665. [PMID: 34465124 DOI: 10.1161/circoutcomes.120.007665] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Slow uptake of sacubitril/valsartan in patients with heart failure with reduced ejection fraction has been reported, which may negatively impact clinical outcomes. We characterized prior authorization (PA) burden, prescription copayment, and utilization of sacubitril/valsartan by insurance plan type to identify potential barriers to its use. METHODS We conducted a national population-level, cross-sectional study using PA data from an insurance coverage website accessed in March 2019 and IQVIA National Prescription Audit data from August 2018 to July 2019. Primary outcomes were proportion of plans requiring PA, frequency of specific PA criteria, number of sacubitril/valsartan prescriptions, and copayments per insurance plan type. RESULTS Overall, 48.1% (1394/2896) of insurance plans required PA for sacubitril/valsartan. Fewer Medicare (27.7%) than commercial (57.2%) plans required PA (P<0.001). For both plan types, the most frequently required PA criteria were ejection fraction (71.6%, 90.9%) and New York Heart Association class (60.4%, 90.8%) for Medicare and commercial plans, respectively. Copayment amounts varied by plan type, with more sacubitril/valsartan prescriptions for commercial plans not requiring a patient copayment (32.4%) compared with Medicare plans (19.3%; P<0.001). There were 814 437 sacubitril/valsartan prescriptions for Medicare and 822 292 for commercial plans dispensed from August 2018 to July 2019. Based on estimated heart failure with reduced ejection fraction populations for each plan type, 4-fold more sacubitril/valsartan prescriptions were dispensed in commercial than in Medicare plans (820 versus 215 prescriptions/1000 individuals in the heart failure with reduced ejection fraction population). The estimated proportion of heart failure with reduced ejection fraction patients prescribed sacubitril/valsartan was 3.6% (1.5%-6.8%) for Medicare and 13.7% (4.9%-31.8%) for commercial plan populations. CONCLUSIONS Despite commercial plans having greater PA requirements than Medicare, population-adjusted use of sacubitril/valsartan was higher in commercial plans. Given that commercial plans had more prescriptions with low copayments than Medicare, copayment policies may be more influential on sacubitril/valsartan use than its PA policies. Low sacubitril/valsartan use in both plan types highlights the multifactorial nature of medication underutilization that includes factors beyond the drug policies that we evaluated.
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Affiliation(s)
- Aya F Ozaki
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA (A.F.O., T.T.T., Q.T.L., M.Y., C.A.J.).,Department of Pharmacy, Veterans Affairs Greater Los Angeles Healthcare System, CA (A.F.O., C.A.J.)
| | - Harlan M Krumholz
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (H.M.K.).,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.)
| | - Freny Vaghaiwalla Mody
- Division of Cardiology, Veterans Affairs Greater Los Angeles Healthcare System, CA (F.V.M.).,David Geffen School of Medicine, University of California, Los Angeles, CA (F.V.M.)
| | - Tien T Tran
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA (A.F.O., T.T.T., Q.T.L., M.Y., C.A.J.)
| | - Quan T Le
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA (A.F.O., T.T.T., Q.T.L., M.Y., C.A.J.)
| | - Mai Yokota
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA (A.F.O., T.T.T., Q.T.L., M.Y., C.A.J.)
| | - Cynthia A Jackevicius
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA (A.F.O., T.T.T., Q.T.L., M.Y., C.A.J.).,Department of Pharmacy, Veterans Affairs Greater Los Angeles Healthcare System, CA (A.F.O., C.A.J.).,ICES, Toronto, ON, Canada (C.A.J.).,Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada (C.A.J.)
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Carnicelli AP, Lippmann SJ, Greene SJ, Mentz RJ, Greiner MA, Hardy NC, Hammill BG, Shen X, Yancy CW, Peterson PN, Allen LA, Fonarow GC, O'Brien EC. Sacubitril/Valsartan Initiation and Postdischarge Adherence Among Patients Hospitalized for Heart Failure. J Card Fail 2021; 27:826-836. [PMID: 34364659 DOI: 10.1016/j.cardfail.2021.03.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND We investigated associations between timing of sacubitril/valsartan initiation and postdischarge adherence among patients hospitalized for heart failure with reduced ejection fraction (HFrEF). Clinical trials support initiation of sacubitril/valsartan among patients hospitalized with HFrEF. The association between timing of initiation and postdischarge adherence is unknown. METHODS AND RESULTS We analyzed patients hospitalized for HFrEF (EF of ≤40%) within the Get With The Guidelines Heart Failure registry linked with Medicare claims between October 2015 and September 2017 who were eligible for sacubitril/valsartan. Follow-up was through December 2018. Patients were grouped by timing of sacubitril/valsartan initiation. Sacubitril/valsartan adherence at 90 and 365 days after discharge was assessed by calculating proportion of days covered (PDC) using medication fills. Among 4666 patients, 108 (2.3%) were continued on sacubitril/valsartan (on sacubitril/valsartan at admission and discharge), 191 (4.1%) were initiated as inpatients, 130 (2.8%) were initiated at discharge, and 4237 (90.1%) were discharged without sacubitril/valsartan. Median (25th, 75th) proportion of days covered through 90 days among those continued, initiated as inpatients, and initiated at discharge was 0.9 (0.6-0.1), 0.3 (0.0-0.7), and 0.0 (0.0-0.7), respectively (P < .001). Patients discharged without sacubitril/valsartan had very low rates of any sacubitril/valsartan fills within 90 and 365 days of discharge (2.1% and 7.7% of surviving patients, respectively). CONCLUSIONS In 2015-2017 US clinical practice, more than 90% of eligible patients hospitalized for HFrEF were discharged without sacubitril/valsartan. Patients initiated as inpatients had a higher postdischarge proportion of days covered than patients initiated at discharge. Patients discharged without sacubitril/valsartan were unlikely to receive it during follow-up. These findings highlight the importance of initiating sacubitril/valsartan during hospitalization to improve the quality of care.
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Affiliation(s)
- Anthony P Carnicelli
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Bradley G Hammill
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Pamela N Peterson
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Denver, Colorado
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Denver, Colorado
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.
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Morris KL, Sheikh F, Ravichandran A. Implementing a PARADIGM Shift. J Card Fail 2021; 27:837-838. [PMID: 34364660 DOI: 10.1016/j.cardfail.2021.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Kathleen L Morris
- Advanced Heart Failure and Transplant Cardiology, Ascension St. Vincent Hospital, Indianapolis, Indiana.
| | - Farooq Sheikh
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Ashwin Ravichandran
- Advanced Heart Failure and Transplant Cardiology, Ascension St. Vincent Hospital, Indianapolis, Indiana
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Ozaki AF, Krumholz HM, Mody FV, Jackevicius CA. National Trends in the Use of Sacubitril/Valsartan. J Card Fail 2021; 27:839-847. [PMID: 34364661 DOI: 10.1016/j.cardfail.2021.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/06/2021] [Accepted: 05/06/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Better understanding of recent sacubitril/valsartan prescription patterns may help identify factors that influence its use. The aim of the study was to characterize sacubitril/valsartan use and dosage patterns nationally. METHODS AND RESULTS We conducted a population-level cohort study using IQVIA Inc. National Prescription Audit™ data in the United States from August 2016 to July 2019. Over 3 years, there was a 5.6-fold increase in the number of sacubitril/valsartan prescriptions dispensed per month, totaling 3.3 million prescriptions. For the most recent year, this extrapolates to a best-case scenario of 13.8% of patients with heart failure with reduced ejection fraction using sacubitril/valsartan, representing at most one-half of those eligible for sacubitril/valsartan use. During the most recent year, 48.7% of dispensed prescriptions were for the lowest strength (24/26 mg) and only 20.6% for the target strength (97/103 mg). A greater proportion of the target strength was used in younger patients (< 65years: 24.6%; ≥ 85: 11.1%; P<0.0001). Cardiologists prescribed 59.0% of all dispensed prescriptions, and noncardiologists showed a greater increase (7.5-fold vs 4.9-fold; P<0.0001) over time. CONCLUSIONS Recent use of sacubitril/valsartan has increased greatly in the United States; however, a substantial proportion of eligible patients with heart failure with reduced ejection fraction did not receive treatment, and only 1 in 5 prescriptions dispensed were for the target strength. Further exploration of barriers to the use of sacubitril/valsartan and dosing uptitration and their clinical implications warrant further evaluation.
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Affiliation(s)
- Aya F Ozaki
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, California; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Harlan M Krumholz
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Freny V Mody
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; Division of Cardiology, University of California, Los Angeles, Los Angeles, California; David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Cynthia A Jackevicius
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, California; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; ICES, Toronto, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada.
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