Xiyue Li

Background: There is no gold standard for measuring adherence to a complex medication regimen. Heart failure is a chronic disease state that requires multiple medications for optimal control, known as guideline-directed-medical therapy (GDMT), and can be used a model to explore approaches to assessing multi-medication adherence. We aimed to compare seven proportion of days covered (PDC) measures for assessing adherence to multiple GDMT medications and to evaluate their association with clinical outcomes. Methods: We conducted a large, single center, retrospective cohort study of 34,603 patients with heart failure who filled a GDMT prescription between April 2021 and July 2022. The primary outcomes were the seven PDC-based adherence measures derived from electronic health record and pharmacy data. PDC was defined as the proportion of days in which patients had possession of GDMT medications. Our secondary outcome was the combined clinical outcome of ED visits, hospitalizations, and death. Results: The seven measures provided a wide range of measured PDC adherence. Using the strictest measure, ‘each’ (>= 80% of days with each drug available) 54% of patients were considered adherent, compared with 73% measured adherence for the least restrictive measure, ‘at least one’. Variability increased with increasing number of medications across all non-average based measures. For example, using the ‘all’ measure (a more restrictive PDC measure) adherence ranged from 0.53 to 0.41 with increasing number of GDMT prescriptions. Higher PDC for each of the seven measures was associated with increased number of ED, visits, hospitalizations, and death. There was no association with the combined outcome in patients with heart failure with reduced ejection fraction. Conclusions and Relevance: There was a wide variability in adherence measures for assessing adherence to GDMT depending on the measure used. This variability has significant implications for the policy, clinical, and intervention context to which the measure is applied.

Background: Despite the exponential growth in telemedicine visits in clinical practice due to the COVID-19 pandemic, it remains unknown if telemedicine visits achieved similar adherence to prescribed medications as in-person office visits for patients with heart failure. Objective: Our study examined the association between telemedicine visits (vs in-person visits) and medication adherence in patients with heart failure. Methods: This was a retrospective cross-sectional study of adult patients with a diagnosis of heart failure or an ejection fraction of ≤40% using data between April 1 and October 1, 2020. This period was used because New York University approved telemedicine visits for both established and new patients by April 1, 2020. The time zero window was between April 1 and October 1, 2020, then each identified patient was monitored for up to 180 days. Medication adherence was measured by the mean proportion of days covered (PDC) within 180 days, and categorized as adherent if the PDC was ≥0.8. Patients were included in the telemedicine exposure group or in-person group if all encounters were video visits or in-person office visits, respectively. Poisson regression and logistic regression models were used for the analyses. Results: A total of 9521 individuals were included in this analysis (telemedicine visits only: n=830 in-person office visits only: n=8691). Overall, the mean age was 76.7 (SD 12.4) years. Most of the patients were White (n=6996, 73.5%), followed by Black (n=1060, 11.1%) and Asian (n=290, 3%). Over half of the patients were male (n=5383, 56.5%) and over half were married or living with partners (n=4914, 51.6%). Most patients’ health insurance was covered by Medicare (n=7163, 75.2%), followed by commercial insurance (n=1687, 17.7%) and Medicaid (n=639, 6.7%). Overall, the average PDC was 0.81 (SD 0.286) and 71.3% (6793/9521) of patients had a PDC≥0.8. There was no significant difference in mean PDC between the telemedicine and in-person office groups (mean 0.794, SD 0.294 vs mean 0.812, SD 0.285) with a rate ratio of 0.99 (95% CI 0.96-1.02; P=.09). Similarly, there was no significant difference in adherence rates between the telemedicine and in-person office groups (573/830, 69% vs 6220/8691, 71.6%), with an odds ratio of 0.94 (95% CI 0.81-1.11; P=.12). The conclusion remained the same after adjusting for covariates (eg, age, sex, race, marriage, language, and insurance). Conclusions: We found similar rates of medication adherence among patients with heart failure who were being seen via telemedicine or in-person visits. Our findings are important for clinical practice because we provide real-world evidence that telemedicine can be an approach for outpatient visits for patients with heart failure. As telemedicine is more convenient and avoids transportation issues, it may be an alternative way to maintain the same medication adherence as in-person visits for patients with heart failure.

Background: Angiotensin receptor neprilysin inhibitors (ARNI) reduce mortality and hospitalization for patients with heart failure. However, relatively high copayments for ARNI may contribute to suboptimal adherence, thus potentially limiting their benefits. Methods and Results: We conducted a retrospective cohort study within a large, multi‐site health system. We included patients with: ARNI prescription between November 20, 2020 and June 30, 2021; diagnosis of heart failure or left ventricular ejection fraction ≤40%; and available pharmacy or pharmacy benefit manager copayment data. The primary exposure was copayment, categorized as $0, $0.01 to $10, $10.01 to $100, and >$100. The primary outcome was prescription fill nonadherence, defined as the proportion of days covered $100. Patients with higher copayments had higher rates of nonadherence, ranging from 17.2% for $0 copayment to 34.2% for copayment >$100 ( P $100 (OR, 2.58 [95% CI, 1.63–4.18], P <0.001), as compared with $0 copayment. Similar associations were seen when assessing proportion of days covered as a proportion. Conclusions: We found higher rates of not filling ARNI prescriptions among patients with higher copayments, which persisted after multivariable adjustment. Our findings support future studies to assess whether reducing copayments can increase adherence to ARNI and improve outcomes for heart failure.