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Can we improve post-MI medication adherence for FREEE?

Can we improve post-MI medication adherence for FREEE?. Eric D. Peterson, MD, MPH Fred Cobb, MD Distinguished Professor of Medicine Duke University School of Medicine Associate Director, Duke Clinical Research Institute (DCRI ). Background and Design.

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Can we improve post-MI medication adherence for FREEE?

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  1. Can we improve post-MI medication adherence for FREEE? Eric D. Peterson, MD, MPHFred Cobb, MD Distinguished Professor of MedicineDuke University School of MedicineAssociate Director, Duke Clinical Research Institute (DCRI)

  2. Background and Design • Several medications can improve post-MI outcomes • Including beta-blockers, ACE-I/ARB, and stains • Discharge prescription of these meds now near optimal • Yet long-term adherence notoriously poor • Many blame high drug costs as cause • Could giving them away improve patient adherence? • MI FREEE Trial - Design • Cluster RCT in 2,980 plan sponsors (n=5,855 patients) • Intervention (waive plan co-pay) vs. control (usual care) • Primary endpoint: 1st readmit for vascular event/revasc • Secondary: med adherence, other events, costs

  3. MI FREEE Major Findings • Medication adherence in follow-up was low • Absolute Adherence: ACE/ARB 35%, BB 41%, statin 49% • Full (80%+) adherence for 3 meds: 9% • Full coverage improved med adherence slightly • Increasing absolute rates by 4-6% • Primary outcome: 1st major vascular event/revasc • 17.6 vs18.8 events /100 ptyr: HR 0.93 (0.82-1.04) p=0.21 • Secondary outcomes: • Total vascular events/revasc: HR 0.89 (0.80-0.99) 0.03 • Major vascular events: HR 0.86 (0.74-0.99) 0.03 • Total costs: $66,008 vs. $71,778, HR 0.89 (0.50-1.56) 0.68

  4. Trial Strengths and Issues • Trial had several strengths • Very important clinical and health policy topic • Designed as practical clinical trial • Intervention potentially ‘scale-able’ to nation • Collected costs of intervention and its impact • Factors that may have limited impact on adherence • Employed population, all with prescription coverage • Intervention only affected 3 meds (avoiding clopidogrel) • Delayed time to intervention (median: 49 days post D/C) • Factors that may have limited impact on outcomes • Underpowered (originally designed for 7500 pts) • Young population; follow-up median 1yr; low event rates • Limited impact of intervention on adherence

  5. Conclusions • While MI FREEE had only a modest impact on medication adherence and missed its primary endpoint, it showed providing free post-MI medications could… • Reduce total vascular events and pay for itself! • Thus, widespread adoption is recommended • MI FREEE also highlights the huge challenges for post-MI secondary prevention - even when meds are given free, • Adherence rates for each med less than 50% and • Only 1 in 10 patients consistently take all their meds • Thus, novel adherence strategies desperately needed!

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