The effects of reduced copayments on discontinuation and adherence failure to statin medication in Australia

Association between initial continuity of care status and diabetes-related health outcomes in older patients with type 2 diabetes mellitus: A nationwide retrospective cohort study in South Korea

BACKGROUND AND AIM

Timely and continuous care is necessary for patients with diabetes to prevent hospitalization and complications. This study investigated the association between initial Continuity of Care Index (COCI) status after diagnosis of type 2 diabetes mellitus (T2DM) and short- and long-term diabetes-related health outcomes.

METHODS

It targeted elderly patients aged 60 years and above diagnosed with T2DM and used the National Health Insurance Service Senior cohort data from 2008 to 2019. The outcome measures were diabetic avoidable hospitalization and diabetic complication incidence for a five-year period. The main independent variable was the first-year COCI status after T2DM diagnosis. Survival analyses were performed using the Cox proportional hazards model.

RESULTS

Participants with a good COCI status within the first year of being diagnosed with T2DM experienced a reduced risk of diabetes-induced avoidable hospitalization (five years: Hazard ratio (HR) 0.39, 95 % Confidence interval (CI) 0.27-0.57; overall period: HR 0.56, 95 % CI 0.43-0.72) and diabetic complications (five years: HR 0.74, 95 % CI 0.68-0.80; overall period: HR 0.77, 95 % CI 0.71-0.82).

CONCLUSIONS

In the short- and long-term, there is a need for early management and improved healthcare accessibility of diabetes to prevent diabetes-avoidable hospitalization and diabetes-related complications.

Factors related to under-treatment of secondary cardiovascular risk, including primary healthcare: Australian National Health Survey linked data analysis

OBJECTIVE

To inform national evidence gaps on cardiovascular disease (CVD) preventive medication use and factors relating to under-treatment - including primary healthcare engagement - among CVD survivors in Australia.

METHODS

Data from 884 participants with self-reported CVD from the 2014-15 National Health Survey were linked to primary care and pharmaceutical dispensing data for 2016 through the Multi-Agency Data Integration Project. Logistic regression quantified the relation of combined blood pressure- and lipid-lowering medication use to participant characteristics.

RESULTS

Overall, 94.8% had visited a general practitioner (GP) and 40.0% were on both blood pressure- and lipid-lowering medications. Medication use was least likely in: women versus men (OR=0.49[95%CI:0.37-0.65]), younger participants (e.g. 45-64y versus 65-85y: OR=0.58[0.42-0.79])and current versus never-smokers (OR=0.73[0.44-1.20]). Treatment was more likely in those with ≥9 versus ≤4 conditions (OR=2.15[1.39-3.31]), with ≥11 versus 0-2 GP visits/year (OR=2.62[1.53-4.48]) and with individual CVD risk factors (e.g. high blood pressure OR=3.13 [2.34-4.19]) versus without); the latter even accounting for GP service-use frequency.

CONCLUSIONS

Younger people, smokers, those with infrequent GP visits or without CVD risk factors were the least likely to be on medication.

IMPLICATIONS FOR PUBLIC HEALTH

Substantial under-treatment, even among those using GP services, indicates opportunities to prevent further CVD events in primary care.

Chronic Disease Management for People With Hypertension

Objectives: To assess the effectiveness of continuity of care policies by identifying the impact of a chronic disease management program on the continuity of care in patients with hypertension in South Korea.

Methods: The propensity score matching method was used to control selection bias, and the difference-in-differences method was used to compare the impact on the treatment and control groups according to the policy intervention.

Results: The continuity of care index of hypertensive patients using the difference-in-differences analysis outcome of the chronic disease management program was higher than that of the non-participating hypertensive patients.

Conclusion: Continuous treatment is vital for chronic diseases such as hypertension. However, the proportion of those participating in the intervention was low. Encouraging more hypertensive patients to participate in policy intervention through continuous research and expanding the policy to appropriately reflect the increasing number of chronic diseases is necessary.

The relationship of socioeconomic factors to the use of preventative cardiovascular disease medications: A prospective Australian cohort study

Cardiovascular disease (CVD) events are highly preventable through appropriate treatment and disproportionally affect socioeconomically disadvantaged individuals. This study quantified the relationship of socioeconomic factors to dispensing and persistent use of lipid- and blood pressure-lowering medication following hospital admission for a major CVD event (myocardial infarction, ischaemic stroke/transient ischaemic attack). Data from 8285 people with such events aged ≥45 years from the Australian 45 and Up Study with linked medication data were used to estimate relative risks (RRs) for combined lipid- and blood pressure-lowering dispensing at three-months following hospital discharge and for 12-month persistent use, in relation to education, income, and level of medication subsidisation. Overall, 56% were dispensed guideline-recommended medications at three months and 37% persistently used them across 12 months. After adjusting for demographic factors, type of CVD and history of CVD hospitalisation, RRs for lowest (no educational qualifications) compared to highest education level (university degree) were 1.14 (95% CI: 1.06, 1.22) for medication dispensing and 1.15 (1.02, 1.29) for persistent medication use; 1.14 (1.06, 1.22) and 1.17 (1.04, 1.32) respectively for lowest (<$20,000) versus highest (≥$70,000) household pre-tax income; and 1.25 (1.17, 1.33) and 1.28 (1.15, 1.43) respectively for those receiving highest versus lowest subsidisation. There was little to no evidence of a relationship of income and education to medication use after adjustment for medication subsidisation. While preventive medication use is sub-optimal, subsidisation is substantially associated with increased use and accounts for most of the relationship with socioeconomic position, suggesting subsidy schemes are working in the intended direction.

Impact of the removal of patient co-payments for antiretroviral therapy (ART) on out-of-pocket expenditure, adherence and virological failure among Australian adults living with HIV

BACKGROUND

In 2015, New South Wales (Australia) removed patient co-payments for ART of HIV. We hypothesized the policy change would reduce overall out-of-pocket (OOP) healthcare expenditure, improve ART adherence, and better maintain HIV suppression.

METHODS

Using data from a national, 2-year prospective study of adults with HIV on ART (n=364) (2013-2017), we compared OOP healthcare expenditure, ART adherence, and virological failure (VF) in participants subject to the co-payment policy change with participants from other jurisdictions who never paid, and who always paid, co-payments. We used fixed effects regression models to compare outcomes, and incidence rates for VF.

RESULTS

Although ART co-payments declined, there was no significant change in total OOP healthcare expenditure in participants ceasing co-payments compared to those who continued (adjusted coefficient 0.09, 95% CI -0.31 to 0.48). Co-payment removal did not significantly reduce suboptimal ART adherence (from 17.5% to 16.3%) or VF (from 5.0 to 3.7 episodes per-100-person-years). Participants in the lowest income group but not receiving concessional government benefits incurred a non-significant increase in total OOP healthcare expenses; while concessional participants experienced a significant increase in non-ART HIV healthcare costs after the policy changed.

CONCLUSION

In this population, ART co-payments represented a small proportion of OOP healthcare expenditure. Its removal did not materially impact ART adherence or VF, although the study was not powered to detect these.

Impact of financial medication assistance on medication adherence: a systematic review

BACKGROUND: The prevalence of financial medication assistance (FMA), including patient assistance programs, coupons/copayment cards, vouchers, discount cards, and programs/pharmacy services that help patients apply for such programs, has increased. The impact of FMA on medication adherence and persistence has not been synthesized. OBJECTIVE: The primary objective of this study was to review published studies evaluating the impact of FMA on the three phases of medication adherence (initiation [or primary adherence], implementation [or secondary adherence], and discontinuation) and persistence. Among these studies, the secondary objective was to report the impact of FMA on patient out-of-pocket costs and clinical outcomes. METHODS: A systematic review was performed using MEDLINE and Web of Science. RESULTS: Of 656 articles identified, eight studies met all inclusion criteria. Seven studies examined FMA for medications treating cardiovascular diseases, while one study assessed FMA for cancer medications. Among included studies, FMA had a positive impact on medication adherence or persistence, and most measured this impact over one year or less. Of the three phases of medication adherence, implementation (5 of 8) was most commonly reported, followed by discontinuation (3 of 8), and then initiation (1 of 8). Regarding implementation, users of FMA had a higher mean medication possession ratio (MPR) than nonusers, ranging from 7 to 18 percentage points higher. The percentage of patients who discontinued medication was 7 percentage points lower in users of FMA versus nonusers for cardiovascular disease states. In one cancer study, FMA had a larger impact on initiation than discontinuation, ie, compared to nonusers, users of FMA were less likely to abandon an initial prescription (risk ratio= 0.12, 95% confidence interval [CI]: 0.08-0.18), and this effect was larger than the decreased likelihood of discontinuing the medication (hazard ratio = 0.76, 95% CI: 0.66-0.88). In 3 of 8 studies reporting on medication persistence, FMA increased the odds of medication persistence for one year ranged from 11% to 47%, depending on the study. In addition to adherence, half of the studies reported on FMA impacts on patient out-of-pocket costs and 3 of 8 studies reported on clinical outcomes. Impacts on patient out-of-pocket costs were mixed; two studies reported that out-of-pocket costs were higher for users of a coupon or a voucher versus nonusers, one study reported the opposite, and one study reported null effects. Impacts on clinical outcomes were either positive or null. CONCLUSIONS: We found that FMA has positive impacts on all phases of medication adherence as well as medication persistence over one year. Future studies should assess whether FMA has differential impacts based on phase of medication adherence and report on its longer-term (ie, beyond one year) impacts on medication adherence. DISCLOSURES: This work was sponsored by a grant from Pharmaceutical Research and Manufacturers of America (PhRMA). PhRMA had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Hung reports past employment by Blue Cross Blue Shield Association and CVS Health and a grant from PhRMA outside of the submitted work. Zullig reports research funding from Proteus Digital Health and the PhRMA Foundation. consulting fees from Novartis. Reed reports receiving research support from Abbott Vascular, AstraZeneca, Janssen Research & Development, Monteris, PhRMA Foundation, and TESARO and consulting fees from Sanofi/Regeneron, NovoNordisk, SVC Systems, and Minomic International, Inc. Bosworth reports research grants from the PhRMA Foundation, Proteus Digital Health, Otsuka, Novo Nordisk, Sanofi, Improved Patient Outcomes, Boehinger Ingelheim, NIH, and VA, as well as consulting fees from Sanofi, Novartis, Otsuka, Abbott, Xcenda, Preventric Diagnostics, and the Medicines Company. The other authors have nothing to report. This work was presented as a poster presentation at the ESPACOMP Annual Meeting in November 2020.

A randomized, open-label, parallel, multi-center Phase IV study to compare the efficacy and safety of atorvastatin 10 and 20 mg in high-risk Asian patients with hypercholesterolemia

Background

Although accumulating evidence suggests a more extensive reduction of low-density lipoprotein cholesterol (LDL-C), it is unclear whether a higher statin dose is more effective and cost-effective in the Asian population. This study compared the efficacy, safety, and cost-effectiveness of atorvastatin 20 and 10 mg in high-risk Asian patients with hypercholesterolemia.

Methods

A 12-week, open-label, parallel, multicenter, Phase IV randomized controlled trial was conducted at ten hospitals in the Republic of Korea between October 2017 and May 2019. High-risk patients with hypercholesterolemia, defined according to 2015 Korean guidelines for dyslipidemia management, were eligible to participate. We randomly assigned 250 patients at risk of atherosclerotic cardiovascular disease to receive 20 mg (n = 124) or 10 mg (n = 126) of atorvastatin. The primary endpoint was the difference in the mean percentage change in LDL-C levels from baseline after 12 weeks. Cost-effectiveness was measured as an exploratory endpoint.

Results

LDL-C levels were reduced more significantly by atorvastatin 20 mg than by 10 mg after 12 weeks (42.4% vs. 33.5%, p < 0.0001). Significantly more patients achieved target LDL-C levels (<100 mg/dL for high-risk patients, <70 mg/dL for very high-risk patients) with atorvastatin 20 mg than with 10 mg (40.3% vs. 25.6%, p < 0.05). Apolipoprotein B decreased significantly with atorvastatin 20mg versus 10 mg (−36.2% vs. −29.9%, p < 0.05). Lipid ratios also showed greater improvement with atorvastatin 20 mg than with 10 mg (total cholesterol/high-density lipoprotein cholesterol ratio, −33.3% vs. −29.4%, p < 0.05; apolipoprotein B/apolipoprotein A1 ratio, −36.7% vs. −31.4%, p < 0.05). Atorvastatin 20 mg was more cost-effective than atorvastatin 10 mg in terms of both the average and incremental cost-effectiveness ratios. Safety and tolerability of atorvastatin 20 mg were comparable to those of atorvastatin 10 mg.

Conclusion

In high-risk Asian patients with hypercholesterolemia, atorvastatin 20 mg was both efficacious in reducing LDL-C and cost-effective compared with atorvastatin 10 mg.

Out-of-pocket costs, primary care frequent attendance and sample selection: Estimates from a longitudinal cohort design

This paper examines the effect of out-of-pocket costs on subsequent frequent attendance in primary care using data from the Personality and Total Health (PATH) Through Life Project, a representative community cohort study from Canberra, Australia. The analysis sample comprised 1197 respondents with two or more GP consultations, and uses survey data linked to administrative health service use (Medicare) data which provides data on the number of consultations and out-of-pocket costs. Respondents identified in the highest decile of GP use in a year were defined as Frequent Attenders (FAs). Logistic regression models that did not account for potential selection effects showed that out-of-pocket costs incurred during respondents' prior two consultations were significantly associated with subsequent FA status. Respondents who incurred higher costs ($15-$35; or >$35) were less likely to become FAs than those who incurred no or low (<AUS$15 per consultation) costs, with no difference evident between the no and low-cost groups. However, a counterfactual model that adjusted for factors associated with the selection into payment levels did not find an influence of payment, with only a non-significant gradient in the expected direction. Hence these findings raise doubts that price drives FA behaviour, suggesting that co-payments are unlikely to affect the number of GP consultations amongst frequent attenders.

Does a fixed-dose combination of amlodipine and atorvastatin improve persistence with therapy in the Australian population?

AIM

To compare persistence in people who initiate the combination of amlodipine and statin as a fixed-dose combination (FDC) or separate pill combination (SePC), and assess the impact of prior medicine exposure on this outcome.

METHOD

Prescription dispensing data from a national administrative dataset was used to identify patients initiating FDCs or SePCs of amlodipine and statin between April and September 2013. Each cohort was stratified according to dispensing of calcium channel blockers (CCBs) or statins in the prior 12 months. Time to cessation of combination therapy (persistence) was analyzed over 12 months using Kaplan Meyer survival analysis and Cox proportional hazards (PH) models. Patient factors associated with length of treatment were identified using Cox PH modeling.

RESULTS

Of 26,000 people who initiated combination amlodipine and statin, the majority initiated SePCs (77%). The unadjusted cessation rates at 12 months were SePC 40% and FDC 44%. Following adjustment for patient factors, the risk of ceasing combination therapy was higher in those taking the SePC versus FDC, hazard ratio (95% CI): 1.15 (1.11, 1.21). Patients naïve to both therapies had double the cessation rate compared to those who had at least one prior dispensing of a statin. Factors positively associated with persistence were prior use of other antihypertensive drugs and reaching the medicine subsidy safety-net: factors that were more common in users of SePC amlodipine and statin.

CONCLUSION

In this study we found a lower risk (15%) of ceasing combination therapy when people initiate amlodipine and statin in the form of a FDC. While this outcome supports findings in other countries that FDCs improve persistence with combination therapy, prior experience with component or similar medicines has a larger impact on persistence regardless of formulation initiated.

Prior experience with cardiovascular medicines predicted longer persistence in people initiated to combinations of antihypertensive and lipid-lowering therapies: findings from two Australian cohorts

PURPOSE

Many studies of persistence involving fixed dose combinations (FDCs) of cardiovascular medicines have not adequately accounted for a user's prior experience with similar medicines. The aim of this research was to assess the effect of prior medicine experience on persistence to combination therapy.

PATIENTS AND METHODS

Two retrospective cohort studies were conducted in the complete Pharmaceutical Benefits Scheme prescription claims dataset. Initiation and cessation rates were determined for combinations of: ezetimibe/statin; and amlodipine/statin. Initiators to combinations of these medicines between April and September 2013 were classified according to prescriptions dispensed in the prior 12 months as either: experienced to statin or calcium channel blocker (CCB); or naïve to both classes of medicines. Cohorts were stratified according to formulation initiated: FDC or separate pill combinations (SPC). Cessation of therapy over 12 months was determined using Kaplan-Meier survival analysis. Risk of cessation, adjusted for differences in patient characteristics was assessed using Cox proportional hazard models.

RESULTS

There were 12,169 people who initiated combinations of ezetimibe/statin; and 26,848 initiated combinations of amlodipine/statin. A significant proportion of each cohort were naïve initiators: ezetimibe/statin cohort, 1,964 (16.1%) of whom 81.9% initiated a FDC; and amlodipine/statin cohort, 5,022 (18.7%) of whom 55.4% initiated a FDC. Naïve initiators had a significantly higher risk of ceasing therapy than experienced initiators regardless of formulation initiated: ezetimibe/statin cohort, naïve FDC versus experienced FDC HR=3.0 (95% CI 2.8, 3.3) and naïve SPC versus experienced SPC HR=4.4 (95% CI 3.8, 5.2); and amlodipine/statin cohort naïve FDC versus experienced FDC HR=2.0 (95% CI 1.8, 2.2) and naïve SPC versus experienced SPC HR=1.5 (95% CI 1.4, 1.6).

CONCLUSION

Prescribers are initiating people to combinations of two cardiovascular medicines without prior experience to at least one medicine in the combination. This is associated with a higher risk of ceasing therapy than when combination therapy is initiated following experience with one component medicine. The use of FDC products does not overcome this risk.

Impact of consumer copayments for subsidised medicines on health services use and outcomes: a protocol using linked administrative data from Western Australia

INTRODUCTION

Across the world, health systems are adopting approaches to manage rising healthcare costs. One common strategy is a medication copayments scheme where consumers make a contribution (copayment) towards the cost of their dispensed medicines, with remaining costs subsidised by the health insurance service, which in Australia is the Federal Government.In Australia, copayments have tended to increase in proportion to inflation, but in January 2005, the copayment increased substantially more than inflation. Results from aggregated dispensing data showed that this increase led to a significant decrease in the use of several medicines. The aim of this study is to determine the demographic and clinical characteristics of individuals ceasing or reducing statin medication use following the January 2005 Pharmaceutical Benefit Scheme (PBS) copayment increase and the effects on their health outcomes.

METHODS AND ANALYSIS

This whole-of-population study comprises a series of retrospective, observational investigations using linked administrative health data on a cohort of West Australians (WA) who had at least one statin dispensed between 1 May 2002 and 30 June 2010. Individual-level data on the use of pharmaceuticals, general practitioner (GP) visits, hospitalisations and death are used.This study will identify patients who were stable users of statin medication in 2004 with follow-up commencing from 2005 onwards. Subgroups determined by change in adherence levels of statin medication from 2004 to 2005 will be classified as continuation, reduction or cessation of statin therapy and explored for differences in health outcomes and health service utilisation after the 2005 copayment change.

ETHICS AND DISSEMINATION

Ethics approvals have been obtained from the Western Australian Department of Health (#2007/33), University of Western Australia (RA/4/1/1775) and University of Notre Dame (0 14 167F). Outputs from the findings will be published in peer reviewed journals designed for a policy audience and presented at state, national and international conferences.

Evaluation of the chronic disease management program for appropriateness of medication adherence and persistence in hypertension and type-2 diabetes patients in Korea

The chronic disease management program (CDMP), a multilevel intervention including copayment reduction and physician incentives, was introduced in 2012 in Korea to improve blood pressure and glycemic control by strengthening the function of clinic as primary care institutions in managing hypertension and diabetes. This study, therefore, aimed to evaluate the effect of CDMP on the appropriateness of medication adherence and persistence in hypertension or type-2 diabetes patients.A pre-post retrospective study was conducted using claims cohort data from 2010 to 2013. Hypertension or type-2 diabetes patients were selected as the CDMP group, while dyslipidemia patients were the control group. Study groups were further categorized as clinic shifters or non-shifters on the basis of whether hospital use changed to clinic use during the study period. Pre-post changes in adherence and persistence were assessed. Adherence was measured by medication possession ratio (MPR) and categorized as under (<0.8), appropriate (0.8-1.1), and over-adherence (>1.1). Persistence was measured by 12-month cumulative persistence rate.The pre-post change was significantly improved for appropriate-adherence (hypertension, +6.0%p; diabetes, +6.1%p), 12-month cumulative persistence (hypertension, +6.5%p; diabetes, +10.8%p), and over-adherence (hypertension, -5.3%p; diabetes, -2.8%p) only among the shifters in the CDMP group. Among these, patients visiting the same, single clinic showed a significant increase in appropriate-adherence, whereas those who changed their clinics showed a nonsignificant increase. No significant improvement was verified among the non-shifters in the CDMP group.CDMP improved medication adherence and persistence by significantly increasing appropriate-adherence and 12-month cumulative persistence rate in hypertension and type-2 diabetes patients. Particularly, CDMP significantly improved over-adherence, which was associated with increasing healthcare costs and hospitalization risk.

Effect of cost sharing on adherence to evidence-based medications in patients with acute coronary syndrome

Objectives

Cost-sharing scheme for pharmaceuticals in Spain changed in July 2012. Our aim was to assess the impact of this change on adherence to essential medication in patients with acute coronary syndrome (ACS) in the region of Valencia.

Methods

Population-based retrospective cohort of 10 563 patients discharged alive after an ACS in 2009–2011. We examined a control group (low-income working population) that did not change their coinsurance status, and two intervention groups: pensioners who moved from full coverage to 10% coinsurance and middle-income to high-income working population, for whom coinsurance rose from 40% to 50% or 60%. Weekly adherence rates measured from the date of the first prescription. Days with available medication were estimated by linking prescribed and filled medications during the follow-up period.

Results

Cost-sharing change made no significant differences in adherence between intervention and control groups for essential medications with low price and low patient maximum coinsurance, such as antiplatelet and beta-blockers. For costlier ACE inhibitor or an angiotensin II receptor blocker (ACEI/ARB) and statins, it had an immediate effect in the proportion of adherence in the pensioner group as compared with the control group (6.8% and 8.3% decrease of adherence, respectively, p<0.01 for both). Adherence to statins decreased for the middle-income to high-income group as compared with the control group (7.8% increase of non-adherence, p<0.01). These effects seemed temporary.

Conclusions

Coinsurance changes may lead to decreased adherence to proven, effective therapies, especially for higher priced agents with higher patient cost share. Consideration should be given to fully exempt high-risk patients from drug cost sharing.

Does tablet formulation alone improve adherence and persistence: a comparison of ezetimibe fixed dose combination versus ezetimibe separate pill combination?

AIMS

The aim of this study was to compare adherence and persistence in patients who add ezetimibe to statin therapy as a separate pill combination (SPC) or fixed dose combination (FDC).

METHOD

This is a retrospective cohort study of prescription data conducted in an Australian health dataset. Two cohorts were identified: those dispensed statins and subsequently ezetimibe as either SPC or FDC. We compared adherence to combination therapy using the medication possession ratio (MPR), multivariate linear and logistic regression. Persistence to initial combination medicines and any lipid-lowering therapies were analysed using Kaplan Meyer survival and Cox proportional hazards models.

RESULTS

A total of 3651 people initiated ezetimibe SPC and 5740 ezetimibe FDC. There was no significant difference in adherence with mean MPRs: ezetimibe SPC = 0.99 (95% confidence interval 0.98-1.01) and FDC = 0.97 (95% CI 0.95-0.99). One year persistence rates to initial combination medicines were ezetimibe SPC 49.1% vs. FDC 62.4%; hazard ratio (HR) = 1.81 (95% CI 1.76-1.90). However, persistence to any lipid-lowering therapy was higher in those initiating ezetimibe SPC = 84.9% vs. FDC = 76%; HR = 0.62 (95% CI 0.55-0.72). One year persistence rates to any two lipid-lowering medicines were similar: ezetimibe SPC 65.2% and FDC 65%.

CONCLUSION

In this study FDCs have little impact on either adherence or persistence to combination lipid-lowering therapy in people who have been taking statins. The benefit of higher persistence to FDCs in first episode of treatment with initial medicines is debatable as persistence to dual therapy was similar in both cohorts.

Using Classification and Regression Trees (CART) to Identify Prescribing Thresholds for Cardiovascular Disease

BACKGROUND AND OBJECTIVE

Many guidelines for clinical decisions are hierarchical and nonlinear. Evaluating if these guidelines are used in practice requires methods that can identify such structures and thresholds. Classification and regression trees (CART) were used to analyse prescribing patterns of Australian general practitioners (GPs) for the primary prevention of cardiovascular disease (CVD). Our aim was to identify if GPs use absolute risk (AR) guidelines in favour of individual risk factors to inform their prescribing decisions of lipid-lowering medications.

METHODS

We employed administrative prescribing information that is linked to patient-level data from a clinical assessment and patient survey (the AusHeart Study), and assessed prescribing of lipid-lowering medications over a 12-month period for patients (n = 1903) who were not using such medications prior to recruitment. CART models were developed to explain prescribing practice. Out-of-sample performance was evaluated using receiver operating characteristic (ROC) curves, and optimised via pruning.

RESULTS

We found that individual risk factors (low-density lipoprotein, diabetes, triglycerides and a history of CVD), GP-estimated rather than Framingham AR, and sociodemographic factors (household income, education) were the predominant drivers of GP prescribing. However, sociodemographic factors and some individual risk factors (triglycerides and CVD history) only become relevant for patients with a particular profile of other risk factors. The ROC area under the curve was 0.63 (95% confidence interval [CI] 0.60-0.64).

CONCLUSIONS

There is little evidence that AR guidelines recommended by the National Heart Foundation and National Vascular Disease Prevention Alliance, or conditional individual risk eligibility guidelines from the Pharmaceutical Benefits Scheme, are adopted in prescribing practice. The hierarchy of conditional relationships between risk factors and socioeconomic factors identified by CART provides new insights into prescribing decisions. Overall, CART is a useful addition to the analyst's toolkit when investigating healthcare decisions.

Reducing Medication Costs to Prevent Cardiovascular Disease: A Community Guide Systematic Review

INTRODUCTION

Hypertension and hyperlipidemia are major cardiovascular disease risk factors. To modify them, patients often need to adopt healthier lifestyles and adhere to prescribed medications. However, patients' adherence to recommended treatments has been suboptimal. Reducing out-of-pocket costs (ROPC) to patients may improve medication adherence and consequently improve health outcomes. This Community Guide systematic review examined the effectiveness of ROPC for medications prescribed for patients with hypertension and hyperlipidemia.

METHODS

We assessed effectiveness and economics of ROPC for medications to treat hypertension, hyperlipidemia, or both. Per Community Guide review methods, reviewers identified, evaluated, and summarized available evidence published from January 1980 through July 2015.

RESULTS

Eighteen studies were included in the analysis. ROPC interventions resulted in increased medication adherence for patients taking blood pressure and cholesterol medications by a median of 3.0 percentage points; proportion achieving 80% adherence to medication increased by 5.1 percentage points. Blood pressure and cholesterol outcomes also improved. Nine studies were included in the economic review, with a median intervention cost of $172 per person per year and a median change in health care cost of -$127 per person per year.

CONCLUSION

ROPC for medications to treat hypertension and hyperlipidemia is effective in increasing medication adherence, and, thus, improving blood pressure and cholesterol outcomes. Most ROPC interventions are implemented in combination with evidence-based health care interventions such as team-based care with medication counseling. An overall conclusion about the economics of the intervention could not be reached with the small body of inconsistent cost-benefit evidence.