Effect of the Medicare Part D Coverage Gap on Medication Use Among Patients With Hypertension and Hyperlipidemia
Effect of the Medicare Part D Coverage Gap on Medication Use Among Patients With Hypertension and Hyperlipidemia
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DOI：
10.7326/0003-4819-156-11-201206050-00004
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发表时间：
2012-06-05
影响因子：
39.2
通讯作者：
Doshi, Jalpa A.
中科院分区：
文献类型：
--
作者：
Li, Pengxiang;McElligott, Sean;Doshi, Jalpa A.
背景：先前关于医疗保险D部分覆盖缺口的研究在普遍性和范围上是有限的。目的：了解覆盖差距对老年高血压高脂血症患者无症状（降压药、降脂药）和症状（止痛药、抑酸药、抗抑郁药）用药的影响。设计：准实验研究，采用前后设计和同期对照组。背景：2005年和2006年的医疗保险索赔档案，随机抽样5%的医疗保险受益人。患者：在2006年的空白期，患有高血压或高脂血症的65岁或以上的D部分计划参保者没有保险，只有通用保险，或品牌和通用保险。完全符合低收入补助条件的患者作为对照组。测量：每月30天的处方供应，药物依从性，抗高血压或降脂药物连续间隔30天或更长时间；在保险缺口进入前后，每月30天的止痛药、抑酸药或抗抑郁药供应处方。结果：无间隙覆盖的患者在间隙期间每月降压药和降脂药处方减少。该组不依从性也增加（抗高血压药物：优势比[OR]， 1.60 [95% CI, 1.50 ~ 1.71]；降脂药物：OR， 1.59 [CI, 1.50 ~ 1.68]）。无缺口覆盖的患者在降脂药物使用和降压药物使用方面存在持续用药缺口的比例，由于覆盖缺口，分别绝对增加了7.3% （OR, 1.38 [CI, 1.29 ~ 1.46]）和3.2% （OR, 1.35 [CI, 1.25 ~ 1.45]）。在没有间隙覆盖的患者中，止痛药和抗抑郁药的使用减少幅度较小，而酸抑制剂的使用减少幅度较大。仅覆盖仿制药的患者心血管药物的使用减少，但对症用药的使用没有变化。在品牌和通用保险组中没有测量变化。敏感性分析结果与主要研究结果一致。局限性：由于本研究是非随机的，在研究组之间可能仍然存在未观察到的差异。结论：D部分覆盖缺口与无间隙覆盖和仅通用药物间隙覆盖的高血压和高脂血症患者使用药物减少有关。到2020年逐步消除缺口的提议将使这些患者受益；然而，低价值药物的使用也可能增加。
Background: Prior studies of the Medicare Part D coverage gap are limited in generalizability and scope.Objective: To determine the effect of the coverage gap on drugs used for asymptomatic (antihypertensive and lipid-lowering drugs) and symptomatic (pain relievers, acid suppressants, and antidepressants) conditions in elderly patients with hypertension and hyperlipidemia.Design: Quasi-experimental study using pre-post design and contemporaneous control group.Setting: Medicare claims files from 2005 and 2006 for 5% random sample of Medicare beneficiaries.Patients: Part D plan enrollees with hypertension or hyperlipidemia aged 65 years or older who had no coverage, generic-only coverage, or both brand-name and generic coverage during the gap in 2006. Patients who were fully eligible for the low-income subsidy served as the control group.Measurements: Monthly 30-day supply prescriptions available, medication adherence, and continuous medication gaps of 30 days or more for antihypertensive or lipid-lowering drugs; monthly 30-day supply prescriptions available for pain relievers, acid suppressants, or antidepressants before and after coverage gap entry.Results: Patients with no gap coverage had a decrease in monthly antihypertensive and lipid-lowering drug prescriptions during the coverage gap. Nonadherence also increased in this group (anti-hypertensives: odds ratio [OR], 1.60 [95% CI, 1.50 to 1.71]; lipid-lowering drugs: OR, 1.59 [CI, 1.50 to 1.68]). The proportion of patients with no gap coverage who had continuous medication gaps in lipid-lowering medication use and antihypertensive use increased by an absolute 7.3% (OR, 1.38 [CI, 1.29 to 1.46]) and 3.2% (OR, 1.35 [CI, 1.25 to 1.45]), respectively, because of the coverage gap. Decreases in use were smaller for pain relievers and antidepressants and larger for acid suppressants in patients with no gap coverage. Patients with generic-only coverage had decreased use of cardiovascular medications but no change in use of drugs for symptomatic conditions. No measures changed in the brand-name and generic coverage groups. Results of sensitivity analyses were consistent with the main findings.Limitation: Because this study was nonrandomized, unobserved differences may still exist between study groups.Conclusion: The Part D coverage gap was associated with decreased use of medications for hypertension and hyperlipidemia in patients with no gap coverage and generic-only gap coverage. The proposed phasing out of the gap by 2020 will benefit such patients; however, use of low-value medications may also increase.