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ORLANDO -- When patient co-payments were reduced, physicians were more likely to prescribe ticagrelor (Brilinta) over clopidogrel (Plavix), and patients were more likely to adhere to treatment, researchers reported here.

When vouchers were on offer that equalized the cost of the two P2Y12 inhibitor, doctors prescribed ticagrelor 59.6 % of the time and clopidogrel 36% of the time. Without the vouchers, physicians wrote prescription for clopidogrel 54.7% of the time and for ticagrelor 32.4% of the time (P<0.0001), according to Tracy Wang, MD, of Duke University School of Medicine in Durham, North Carolina, and colleagues.

However, clinical outcomes between the two groups were no different, they reported at the American College of Cardiology (ACC) annual meeting. The 1-year major adverse cardiovascular events rate was 10.17% in the voucher group versus an event rate of 10.63% in the patients who were under usual care (P=0.65).

In the multi-center Affordability and Real-world Antiplatelet Treatment Effectiveness after Myocardial Infarction Study (ARTEMIS) study, the researchers enrolled 11,001 MI patients from June 2015 to June 2016. Doctors at participating U.S. hospitals provided usual care, but at roughly half the sites selected randomly, the cost of anti-platelet medications were offset by vouchers over the course of the 1-year study.

Payment vouchers eliminated price differences between clopidogrel and ticagrelor, which generally has higher out-of-pocket costs. Doctors had full discretion on which of the two drugs to prescribe.

Enrolled patients had a median age of 62, and 31% were female, while 12% were non-white. Almost half of patients had ST-Elevation MI (STEMI), 20% had a prior MI, 33% had diabetes, and percutaneous coronary intervention was performed in 90% of patients.

All patients had health insurance with 42% on Medicare, 9% Medicaid and 64% on private insurance. The authors stated that 17% reported previously not filling a medication due to cost.

Patients given the vouchers did stay on their medications for a year versus the usual care cohort. Non-persistence of using the P2Y₁₂Inhibitor was 12.96% of the patients who used any of the vouchers compared with 16.21% of the usual care patients (P<0.0001).

When patients were asked about their medication use, 80% to 85% reported that they filled all their prescriptions continuously, but the study's analysis of pharmacy fill data indicated that only 55% had been fully compliant. About 28% of the patients given vouchers for their medicine never used any of the vouchers, Wang observed.

Regardless of the measure of medication use, the study confirmed that more of the patients who got the pay vouchers stuck to their recommended drug regimens.

But those improvements did not appear to result in a reduced rate of death, heart attacks, or strokes compared with patients who got usual care.

"We are dealing with just one drug class in this study," Dr. Wang told 番茄社区app. "And we discharge our patients on several very important therapies, so we might have been targeting too narrow of a treatment difference. We also have to ask ourselves why it was that 28% of the patients who had the vouchers decided not to use them."

She noted that the medications are associated with different outcomes, with ticagrelor having better outcomes than clopidogrel.

Craig Beavers, PharmD, of the University of Kentucky in Lexington, said, "To me as a pharmacist, this study emphasizes the complexity of treating patients. Even when you give them the resources to receive medication, some patients don't even utilize them in some circumstances."

He suggested that a follow-up trial might target those patients most likely to use the vouchers and the patients who are at highest risk of events.

Beavers, who was not involved in the study, suggested that questions about education and psychology need to be addressed in terms of patients and their medications. "We need a multi-pronged approach to distill down what is the individual component of these programs," he said. "It may take a variety of things that work in play. This is a case of 'If you take a horse to the water, how do you get it to drink?'"

"The implementation of science needs to get a lot better because we often don't understand the behaviors of our patients," commented ACC press conference moderator Kim Eagle, MD, of the University of Michigan in Ann Arbor.

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